Rouse A, Wilson R, Stevens A
Department of Public Health and Epidemiology, University of Birmingham, Edgbaston.
J Public Health Med. 2001 Mar;23(1):65-8. doi: 10.1093/pubmed/23.1.65.
Governments, insurers, quality assurance agencies and others have used the higher volume = better quality relationship as a basis for health policy. This relationship is probably real enough to justify these policies. However, even if it were not real, there are other reasons why these and other organizations such as the National Health Service (NHS) may favour high-volume providers. This paper attempts to answer the question: 'If, for common elective procedures, the NHS instituted a high-volume purchasing policy that requires consultant firms to perform a minimum of "50 procedures a year", what proportion of consultant firms would be affected?' The aims of this study were to estimate the proportion of NHS consultant firms that perform common elective procedures less than 50 times a year and to estimate the proportion of firms that would have to stop providing these procedures if a '50 procedures a year' purchasing policy were introduced.
A descriptive analysis was carried out and modelling was performed on data stored in an NHS health episode statistics database of patients treated in West Midlands NHS facilities. For each of 12 common elective procedures we assumed that a volume threshold of at least 50 a year were set, and calculated the proportion of NHS consultant firms undertaking each procedure who performed less than 50 of those procedures each year and the proportion of firms who would have had to stop providing each procedure.
All firms performing some procedures, e.g. cataract extraction, did so at least 50 times a year. By contrast, no firm repaired more than 50 recurrent inguinal hernias a year. If a volume threshold of at least 50 procedures a year were set for a basket of 12 common elective procedures, then about 40 per cent of firms would no longer be eligible to provide a procedure. Even if a lower 'one a month' threshold were set, about 20 per cent of firms would still not be eligible to provide that procedure.
Introduction of a high-volume policy would affect a considerable number of firms, as many NHS consultant firms perform some common elective procedures infrequently. Some consultants would see the introduction of a high-volume policy as an opportunity to further specialize and super-specialize. Others would see it as a policy that restricts them to providing a narrower range of procedures, makes their professional practice less interesting, and reduces their professional autonomy. Postgraduate training institutions need to consider the possibility and implications of high-volume policies, as many junior doctors would probably need to learn to provide a narrower range of skills than at present.
政府、保险公司、质量保证机构及其他各方已将手术量越高 = 质量越好的关系作为卫生政策的依据。这种关系或许足够真实，可为这些政策提供正当理由。然而，即便这种关系不成立，国家医疗服务体系（NHS）等这些组织及其他组织偏爱高手术量提供者还有其他原因。本文试图回答这个问题：“对于常见的择期手术，如果NHS制定一项高手术量采购政策，要求咨询公司每年至少进行‘50例手术’，那么会有多大比例的咨询公司受到影响？”本研究的目的是估计每年进行常见择期手术少于50次的NHS咨询公司的比例，以及如果引入“每年50例手术”的采购政策，将不得不停止提供这些手术的公司比例。
进行了描述性分析，并对存储在西米德兰兹郡NHS设施接受治疗患者的NHS健康事件统计数据库中的数据进行了建模。对于12种常见择期手术中的每一种，我们假设设定每年至少50例的手术量阈值，并计算每年进行每种手术但手术量少于50例的NHS咨询公司的比例，以及不得不停止提供每种手术的公司比例。
所有进行某些手术（如白内障摘除术）的公司，每年至少进行50次。相比之下，没有公司每年修复超过50例复发性腹股沟疝。如果为12种常见择期手术设定每年至少50例的手术量阈值，那么约40%的公司将不再有资格提供某一手术。即使设定较低的“每月1例”阈值，仍约有20%的公司没有资格提供该手术。
引入高手术量政策将影响相当数量的公司，因为许多NHS咨询公司很少进行某些常见择期手术。一些顾问会将引入高手术量政策视为进一步专业化和超专业化的机会。另一些人则会将其视为一项限制他们只能提供范围更窄的手术、使他们的专业实践变得不那么有趣并降低他们专业自主权的政策。研究生培训机构需要考虑高手术量政策的可能性及其影响，因为许多初级医生可能需要学习提供比目前范围更窄的技能。
