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Selective Use Of References?In their paper on the volume of coronary artery bypass graft (CABG) surgeries (Jan/Feb 07), Chad Wilson and colleagues find that since 1992 the number of small specialty cardiac hospitals has increased steadily. As a consequence, the proportion of CABG operations performed at low-volume hospitals has increased, while the proportion at high-volume hospitals has decreased. Convinced that hospitals with lower surgical volume have higher operative mortality, the authors fear that the change in surgery distribution might increase the overall CABG mortality rate. In their Note 4, the authors provide three references in support of their categorical statement that low-volume hospitals have high mortality rates. But they do not explain that each of the references points out that the difference in mortality between low- and high-volume hospitals is modest (or small) and not a reliable indicator of differences in quality of care. Furthermore, they appear to be unaware that the strength of the relationship between surgical volume and mortality has been found to greatly diminish with time, as technical and other aspects of the procedure have evolved.1 Robert Sade reminds us that "the primary obligation of physicians is to serve the medical interests of their patients." 2 If, for any reason, investigators ignore important evidence that might influence policy decisions, they will not be acting in their patients’ best interests.
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