Understanding and reducing variation in surgical mortality.

Surgical mortality varies widely across hospitals and surgeons, more so than would be predicted by chance alone or differences in case mix. Although a large body of research has suggested the importance of procedure volume, clinical mechanisms underlying variation in surgical mortality remain largely unknown. Payers, policy makers, and professional organizations have implemented a variety of large-scale strategies aimed at improving outcomes. Selective referral, process compliance, and outcomes measurement reflect different philosophies on how best to improve surgical quality and have distinct advantages and disadvantages. The optimal strategy may depend on both the clinical context (e.g., which procedure) and political realities.