Does the physician or the hospital matter in delivering quality health care?

This is the question I'm struggling with in my current work. Numerous studies have demonstrated better results at high-volume hospitals with cardiovascular surgery, major cancer resections, and other high-risk procedures.[1],[2] And this has sparked the debate - is it the hospital, or the physicians who work in the hospital that make the hospital what it is?

What is interesting is that centralising specialist services drives quality through both a “hospital” effect, but also a “physician” effect. Teasing this out is difficult. Physicians who see more of a particular diagnosis or perform a specific procedure tend to achieve higher quality outcomes.[3], [4], [5] Hospital-based services (e.g., intensive care, pain management, respiratory care, and nursing care) play an increasingly greater role in quality as the average length of stay lengthens.[6]

So this is how I would apply it to myself - if I have a condition that is highly technical, but requires a short length of stay (e.g. carotid endarterctomy? hope i never get one...) in a hospital, I'm more concerned about the quality of the doctor. The longer my post-op care will be, I'm probably going to let the quality of the hospital be a bigger driver in my decision.

In the end we all look for the great doctor in the great hospital, right? But without clear definitions of what quality is in the first place, it's hard to figure out where to go anyways...

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[1] Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med. 1979;301:1364-9.

[2] Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer

surgery. JAMA. 1998;280:1747-51.

[3] Hillner BE, Smith TJ, Desch CE. Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care. J Clin Oncol 2000;18:2327-40.

[4] Hannan EL, Popp AJ, Tranmer B, Feustel P, Waldman J, Shah D. Relationship between provider volume and mortality for carotid endarterectomies in New York State. Stroke 1998;29:2292-7.

[5] Hannan EL, Siu AL, Kumar D, Kilburn H Jr, Chassin MR. The decline in coronary artery bypass graft surgery mortality in New York State: the role of surgeon volume. JAMA 1995;273:209-13.

[6] Dudley RA, Johansen KL, Brand R, Rennie DJ, Milstein A. Selective referral to high volume hospitals: estimating potentially avoidable deaths. JAMA 2000;283:1159-66.