Dutch surgeons' views on the volume-outcome mechanism in surgery: A qualitative interview study.

Objective: To contribute to a better understanding of volume-outcome relationships in surgery by exploring Dutch surgeons' views on the underlying mechanism.

Design: A qualitative study based on face-to-face semi structured interviews and an inductive content analysis approach.

Setting: Interviews were conducted in eight hospitals in the Netherlands (2 university, 4 teaching and 2 general).

Participants: Twenty surgeons (gastrointestinal, vascular and trauma).

Main outcome measure(s): Dutch surgeons' views on volume-outcome relationships in surgery and the underlying mechanism.

Results: The majority of surgeons believed volume is related to outcomes after surgery. Interviewees highlighted the importance of both focus and skills when describing the underlying mechanism. Focus was visible on three levels: hospital, surgeon and team. Focus on a hospital level referred to investing in specific infrastructure and dedicated personnel. Surgeons described both the benefits and downsides of surgeons' increased focus to a certain surgical subspeciality. And their experiences on the importance of working with fixed, procedure-specific teams. The positive influence of caseload on technical and nontechnical skills was acknowledged, as well as the benefits of combining skills by operating together. Although a basic skill set should be maintained, this does not necessarily require high volume.

Conclusions: Focus and skills are important explanatory factors in volume-outcome relationships according to Dutch surgeons. This suggests that both high- and low-volume providers should enable specialized, fixed teams for complex surgeries and focus on maintenance of both their technical and nontechnical skills. By uncovering the underlying mechanism, imperfect quality indicators such as volume can be supplemented or replaced.