Exploring Dutch surgeons' views on volume-based policies: a qualitative interview study.

Objective In many countries, the evidence for volume-outcome associations in surgery has been transferred into policy. Despite the large body of research that exists on the topic, qualitative studies aimed at surgeons' views on, and experiences with, these volume-based policies are lacking. We interviewed Dutch surgeons to gain more insight into the implications of volume-outcome policies for daily clinical practice, as input for effective surgical quality improvement. Methods Semi-structured interviews were conducted with 20 purposively selected surgeons from a stratified sample for hospital type and speciality. The interviews were recorded, transcribed verbatim and underwent inductive content analysis. Results Two overarching themes were inductively derived from the data: (1) minimum volume standards and (2) implications of volume-based policies. Although surgeons acknowledged the premise 'more is better', they were critical about the validity and underlying evidence for minimum volume standards. Patients often inquire about caseload, which is met with both understanding and discomfort. Surgeons offered many examples of controversies surrounding the process of determining thresholds as well as the ways in which health insurers use volume as a purchasing criterion. Furthermore, being held accountable for caseload may trigger undesired strategic behaviour, such as unwarranted operations. Volume-based policies also have implications for the survival of low-volume providers and affect patient travel times, although the latter is not necessarily problematic in the Dutch context. Conclusions Surgeons in this study acknowledged that more volume leads to better quality. However, validity issues, undesired strategic behaviour and the ways in which minimum volume standards are established and applied have made surgeons critical of current policy practice. These findings suggest that volume remains a controversial quality measure and causes polarization that is not conducive to a collective effort for quality improvement. We recommend enforcing thresholds that are based on the best achievable level of consensus and assessing additional criteria when passing judgement on quality of care.