EDITORIALS Taking Action on the Volume–Quality Relationship: How Long Can We Hide Our Heads in the Colostomy Bag?

There is remarkably consistent evidence that the more expe-rience doctors or health care systems have with a procedure, the better the results. At last count, 123 of 128 published studies showed some evidence of a “volume–quality ” relationship (1,2). For oncology, the evidence is mostly consistent and often pro-vides striking examples of markedly better outcomes with higher volume (3). There is even some evidence that outcomes can be improved with standardized care and clinical practice guidelines, among other things (4). In this issue of the Journal, Hodgson et al. (5) identified 7257 patients with stage I–III rectal cancer from 1994 through 1997 in the California Cancer Registry to study the relationship of hos-pital volume with colostomy rates, 30-day mortality, and 2-year survival. The results look like a dose–response curve in chemo-therapy: the higher the volume, the better the results, as show