Surgical experience should not be defined by workload

On p 1381 Kee et al investigate the influence of hospital and surgeon workload on survival with colorectal cancer in Northern Ireland, using a province-wide colorectal cancer register. The authors determined the outcome of all cases ascertained and managed surgically between 1990 and 1994, with a median follow up of 54 months. Surgeon caseload had no significant effect on mortality after Dukes’s stage was adjusted for. There was, however, a significant impact on survival from the overall hospital workload, with cases treated in hospitals with a low workload (<33 cases per year) having slightly better survival at 2 years than those treated in hospitals with a higher workload. No evidence was found for a linear trend. The authors conclude that any definition of an expert on the basis of workload is rather fragile, and the lack of routinely collected case mix data presents major challenges for clinical audit and governance in the future.