Learning from Small-Volume Congenital Heart Programs

The relationship between surgical volume and clinical outcomes in congenital heart surgery has been frequently studied and interpreted to indicate that higher volume programs are associated with superior outcomes after congenital heart surgery. Volume-based assumptions have been used to support the notion that volume-specific stratification of case mix would improve overall outcomes in the United States with specific attention to programs with annualized volumes of 75-200 STS index cases/year. Although not intended, some have perceived these recommendations to indicate that programs performing 75-200 annualized index cases/year offer surgical outcomes of lesser quality than higher volume programs. Nevertheless, some programs performing 75-200 annualized index cases/year consistently perform exceptionally well. Because the inherent advantages - and challenges - associated with being a program in this size range have not been frequently examined, this manuscript focuses on describing these attributes. We hypothesize that better understanding of the determinants of high (or low) performance in this size range could have significant impact on delivery of care in the United States.