Denise Grady penned an excellent New York Times piece this week about the relationship between volume and quality in health outcomes. She tells the story of a relative diagnosed with rectal cancer whose small hometown surgeon explained that he could remove the tumor but she would lose control of her bowels after the procedure. Not satisfied with that solution, she traveled further away from her home to find a physician more experienced with her specific condition. Today she's in good health and doesn't need a colostomy bag.

Grady wasn't surprised to learn the literature supports her relative's experience:

[A] study published in 2007...found that people with rectal cancer survived longer and were more likely to have operations that saved the sphincter at teaching hospitals than at community ones—even though the university hospitals were more likely to take on difficult cases with large tumors. Another study... suggested that women with advanced breast cancer received more comprehensive therapy and survived somewhat longer when treated at teaching hospitals rather than at community ones.

The authors of the above study recently published another article dealing with the overarching issue: they argue that physicians have an ethical obligation to tell patients if they are more likely to have better outcomes at different hospitals as part of the informed consent process. As illustrated in the 2007 article, volume can be a major indicator of quality.

This is not the first time that the positive correlation between volume and quality has come across this blogger's desk ; the most succinct description is offered by health care economist (and Obama adviser) David Cutler in his book Your Money Or Your Life. He tells us, "In California, for example, two-thirds of bypass surgeries are performed in hospitals that do fewer than five hundred operations per year; one-third are treated in hospitals that do fewer than the minimum number recommended by the American College of Cardiology." Yikes! He also writes in the endnotes that very few Canadian hospitals are allowed to perform bypass surgery—so nearly all Canadian cardiac patients receive their care in a high-volume hospital.

Of course, the volume-makes-perfect idea can be perverted, too. Consider the Elyria, Ohio cardiologists who love performing angioplasties. A candidate for bypass surgery? Angioplasty. Mild symptoms that could perhaps be treated with pharmaceuticals? Angioplasty. Runny nose? Angioplasty (okay, just kidding). But you get the drift.

Atul Gawande's book Better contains a great chapter describing how honesty about a program's strengths and weaknesses doesn't necessarily mean that patients flee elsewhere. He describes Cystic Fibrosis physicians at Cincinnati Children's Hospital giving the pediatric patients' parents a slideshow describing how their care was not the best in country, but they were determined to improve. Rather than moving to a new city with better CF outcomes, the parents decided to stay with the team that had been treating their children and help improve the quality of care with the physicians.

This debate is far from over; as more consumer information enters the health world, patients might start making these decisions on their own, bypassing the informed consent process. That's unlikely to occur anytime soon, however.

The physician community will have to decide for themselves whether this transparency should be part of the informed consent process. If they choose not to act, you can bet insurers and other payers will start considering how to make this information more readily available. After all, who would want their family member to receive care that we know in advance will be substandard?