Hospitals with skilled teams doing large amounts of heart, blood vessel, hip and prostate surgery have 25 to 41 percent fewer deaths in these often risky operations than less busy hospitals.
This conclusion -- one of the most startling ever documented about the vast differences in surgical results between different hospitals -- was reached by a group of California health policy specialists who studied surgical results on 842,622 patients at 1,498 American hospitals.
The report's authors and the authors of an accompanying editorial in today's New England Journal of Medicine concluded that some kinds of surgery ought to be "regionalized." That is, they explained, they should be done in far fewer hospitals by teams that not only specialized in certain procedures but also do enough of them to become truly skillful.
The main differences in deaths occurred between hospitals doing more than 200 and hospitals doing fewer than 200 of several types of operations each year.
"What this means to the average patient facing an operation," one surgeon, not one of the report's authors, said yesterday, "is that you very well ought to ask your doctor to tell you how much of that surgery is done at such-and-such hospital. If he can't or won't discuss it, you are justified to being wary."
The study was made by Drs. Harold Luft, John Bunker and Alain Enthoven of Stanford University and the University of California at San Francisco.
They pored over 1974-1975 data supplied by hundreds of hospitals to the Commission on Professional and Hospital Activities, a national data-gathering service in Ann Arbor, Mich.
They adjusted the figures to take into account the fact that some hospitals had sicker patients.
This done, they found that in open-haert surgery and coronary artery bypass surgery -- an operation being done in increasing numbers on heart disease patients -- death rates in high-volume hospitals were 38 percent lower than rates in low volume hospitals.
The differences were about the same for various kinds of blood vessel surgery and for trans-urethral operations, the most difficult type of prostrate surgery.
There was less difference depending on volume for a second group of procedures, including collectomy (colon surgery), biliary tract surgery without gall bladder removal, hip replacement by an artificial hip, grafting to repair aneurysms in the abdomnal aorta (the main artery leading from the heart), certain types of ulcer surgery and complicated gall bladder surgery.
However, here, too, there were differences according to volume. For example, the report said, "if all total hip replacements were performed in hospitals doing 50 or more procedures a year, 32 percent of all in-hospital deaths" of such patients "could be averted."
In a third group generally simple procedures there were no differences between high-volume and low-volume hospitals. These included simple vagotomy (vagus nerve surgery) for ulcers and uncomplicated gall bladder removal.
The report's authors say there should be comparable studies on differences in morbidity, or illness following surgery, and on differences in results between individual surgeons.
Based on such data, they said, there ought to be community planning to concentrate some procedures to save lives and improve surgical results.
In an editorial, Dr. William Longmire, a noted surgeon at the University of California at Los Angeles, and Dr. Sherman Mellinkoff, medical dean there, largely agree.
Some regionalization has occurred, they say, since 56 percent of all open-heart operations are done in only 8 percent of hospitals that do such surgery.
On the other hand, 44 percent of such surgery is scattered among 92 percent of hospitals doing it.
A study group named by Washington-area health planning agencies learned this year that in 1978 most Washington hospitals doing heart surgery did too little for safety and efficiency and some indeed had high death rates.
Only three hospitals -- Washington Hospital Center, Fairfax Hospital and Children's Hospital -- were doing enough heart surgery to assure skilled care, according to standards set by a national commission.
One result of that study is that Prince George's General Hospital, which had local health planning agency permission to start heart surgery, has refrained from doing so.
"But now," said Raleigh Cline, that hospital's administrator, "we think good planning ought to see some closing of programs that don't meet good standards. We haven't seen that yet."