Title: The Organization of Health Care Services for Children and Youth: Synthesis of the Evidence to Help Guide the Integration and Consolidation of Pediatric Health Services
Investigator Name: Dr. Terry Klassen
Project Completion Date: May 2003
Research Category: Synthesis
Institution: University of Alberta
Project Number: 6795-15-2001/4450003
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Summary
Over thirty years ago, the volume-outcome relationship was put forth as an explanation for varying health outcomes. The volume-outcome relationship refers to the concept that the more often a procedure is performed or a type of patient is treated, the physician and hospital will gain proficiency and expertise in their treatment. In an attempt to explain the volume-outcome relationship, two theories have been developed. The "practice makes perfect" theory states that repetition of procedure and type of patient improves outcome. The "selective referral" theory states that patients are referred to physicians with superior outcomes and the increased patient referral increases a physician's volume of patients. In order to accurately determine how volume influences outcome, the patients' risk for poor outcomes must be standardized or adjusted. We systematically reviewed 106 studies that examined how volume or regionalization of health services affected patient outcomes or utilization of health services.
A medical librarian conducted electronic searches in the five
following bibliographic databases: Medline, EMBASE, Cinhal, HealthStar,
and Web of Science. Two reviewers independently screened the search
output and the full text of potentially relevant studies was obtained.
Two reviewers applied the inclusion criteria to 1,213 studies.
Studies were included if they examined a volume-outcome relationship
or evaluated the impact of regionalization of services in a pediatric
population. The study must have included a comparison group and
have measured objective outcomes such as mortality, length of stay,
or admission rates. Third, the participants had to be either: facilities
or healthcare workers delivering pediatric health services, or
any provider of child health (including governmental, non-governmental,
or private organizations). Eighty-seven studies were deemed relevant.
An additional ten studies were identified from conference proceedings
or reference lists of included studies. Writing to authors of included
studies identified another nine studies. Quality was assessed independently
by two reviewers. Two techniques were used to evaluate studies
for their methodological rigor, Downs and Black's checklist for
randomized and non-randomized studies of health care interventions
and the degree of risk adjustment for different levels of case-mix.
Data was extracted by one reviewer and checked for accuracy and
completeness by a second. Due to great amounts of heterogeneity,
a quantitative analysis could not be undertaken.
The clinical areas studied were: appendicitis (n=2), cancer (11),
cardiac (12), level of care (23), neonatal (28), NICU (8), PICU
(7), transplant (3), trauma (7), and miscellaneous (5). The median
quality index was 21 (inter-quartile range 18,22), and the majority
of studies were conducted in the United States. The quality of
the studies improved over time.
There was inconclusive evidence for a volume-outcome relationship
for the management of appendicitis. Survival in children diagnosed
with cancer tended to increase when they were treated at high volume
oncology treatment centres, however this was dependent on the type
of cancer being studied. Children also tended to have better outcomes
when treated in pediatric oncology centres versus other types of
treatment institutions. Volume was also positively associated with
outcome for children requiring organ transplants. A volume-outcome
relationship existed for children undergoing a breadth of cardiac
surgeries; regionalization of cardiac care also improved health
outcomes. Increased level of care resulted in improved survival
for low birth weight and high-risk neonates. For NICU and PICU
settings, volume was not related to improved outcome, however patients
treated in institutions with a high level of resources had better
health outcomes than their counterparts treated in basic hospitals.
Increased volume did not improve outcome in the trauma settings,
however it is unclear if increased resource availability or treatment
in pediatric trauma centre affects patient outcome.
The volume-outcome relationship appears to exist in most settings
examined, but seems to be dependent on the procedure being performed
or the particular pediatric speciality. Children with a high risk
of dying appear to fare better in high volume and/or high level
of hospital. The critically ill pediatric population (i.e., admission
to an intensive care) or severely ill or premature neonates have
improved outcome when treated in resource intensive hospitals.
There is also a volume-outcome relationship for most pediatric
surgical procedures examined.
Based on the evidence reviewed, the outcome for surgical procedures
is generally more favourable in high volume hospitals. However,
this does not apply to all surgical procedures, and is more evident
in complex and rare operations. Because resource availability appears
to be a larger predictor of health outcome than volume, severely
ill children fare better in institutions with an increased level
of resources. Finally, the outcome for high-risk pregnancies and
premature babies is improved when delivered in Level III hospitals.
For trauma management and delivery of babies, a well-developed
transportation system is required to shuttle patients to the hospital
that matches their required level of resource.
The views expressed herein do not
necessarily represent the views of Health Canada
In addition to the above summary, the full report can be accessed
in the following ways:
- The print version of the full report can be obtained in the
language of submission from the Health Canada Library through
inter-library loan.
- An electronic version of the report in the language of submission is available upon request from Health Canada by contacting the Research Management and Dissemination Division.
This research has been conducted with a financial contribution
from Health Canada's Health Policy Research Program. For permission
to reproduce all or part of the research report, please contact
the Principal Investigator directly at the following address:  terry.klassen@ualberta.ca.
The Health Policy Research Program (HPRP)
funds research that provides an evidence base for health Canada's
policy decisions. The HPRP is
a strategic and targeted program with a broad socio-economic orientation
and connections to national and international endeavours. The research
can be primary, secondary or synthesis research, a one-time contribution
to a developing research endeavour, or a workshop, seminar or conference.
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