Effect of Surgical Volume on Morbidity and Mortality of Abdominal Hysterectomy for Endometrial Cancer
ABSTRACT To estimate the effects of surgeon and hospital volume on perioperative morbidity and mortality in women who underwent hysterectomy for endometrial cancer.
Patients who underwent abdominal hysterectomy for endometrial cancer between 2003 and 2007 and who recorded in an inpatient, acute-care database were examined. Procedure-associated intraoperative, perioperative, and postoperative medical complications, as well as hospital readmission, length of stay, intensive care unit (ICU) use, and mortality were examined. Surgeons and hospitals were stratified into volume-based tertiles and outcomes analyzed using multivariable, generalized estimating equations.
A total of 6,015 women were identified. After adjustment for case-mix variables and hospital volume, perioperative surgical complications (15.2% compared with 11.7%) (odds ratio [OR] 0.57; 95 confidence interval [CI] 0.38-0.85), medical complications (31.4% compared with 22.0%) (OR 0.57; 95% CI 0.37-0.88), and ICU utilization (8.9% compared with 3.5%) (OR 0.47; 95% CI 0.28-0.80) were lower in patients treated by high-volume surgeons. Surgeon volume had no independent effect on the rates of operative injury (OR 0.82; 95% CI 0.32-2.08), transfusion (OR 2.33; 95% CI 0.93-5.36), length of stay (OR 0.60; 95% CI 0.25-1.41), or readmission (OR 1.05; 95% CI 0.51-2.14). Whereas patients treated at high-volume hospitals were less likely to require ICU care (9.3% compared with 4.3%) (OR 0.44; 95% CI 025-0.77), hospital volume had no independent effect on any of the other primary outcomes of interest (P>.05 for all).
Perioperative surgical complications, medical complications, and ICU requirements are lower in patients treated by high-volume surgeons. Hospital volume had little independent effect on outcomes.
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ABSTRACT: The volume of surgical procedures performed by hospitals and surgeons has a strong influence on outcomes for a number of surgeries. We examined the influence of surgeon and hospital case volume on morbidity, mortality, and resource utilization for women with endometrial cancer undergoing laparoscopic hysterectomy. Perspective, a nationwide inpatient database developed to measure utilization and quality, was used to examine women with endometrial cancer who underwent laparoscopic hysterectomy with or without lymphadenectomy from 2000 to 2010. Perioperative morbidity, mortality, and cost were compared using Chi-square tests and multivariable generalized estimating equations. A total of 4,137 patients were identified. The overall complication rate was 9.8% for low-volume vs. 10.4% for high-volume surgeons [multivariable odds ratio (OR) = 0.71; 95% confidence interval (CI), 0.41-1.22]. The rates of intraoperative complications, surgical-site complications, medical complications, transfusion, and reoperation were similar for patients treated by low- and high-volume surgeons (p > 0.05 for all). The adjusted estimate for hospital cost for patients treated by high- compared with low-volume surgeons was 219 USD (95% CI, -790 to 1,228 USD). The odds ratio for any complication in high- compared with low-volume hospitals was 1.24 (95% CI, 0.78-1.96). The average cost for patients treated in high- compared with low-volume facilities was -815 USD (95% CI, -1,641 to 11 USD). Neither physician nor hospital volume had a statistically significant effect on perioperative mortality. Laparoscopic hysterectomy for endometrial cancer is well tolerated and associated with an acceptable morbidity profile. Surgeon and hospital volume appear to have little effect on perioperative morbidity, mortality, and resource utilization.Annals of Surgical Oncology 03/2012; 19(3):948-58. DOI:10.1245/s10434-011-2090-8 · 3.94 Impact Factor
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ABSTRACT: To estimate the influence of surgical volume on outcome and resource utilization for laparoscopic hysterectomy for benign indications. Patients who underwent laparoscopic hysterectomy from 2000 to 2010 and recorded in a commercial database were analyzed. Patients were stratified into tertiles according to the number of procedures performed by their surgeons and at their hospital. The influence of surgeon and hospital volume on perioperative morbidity and resource utilization was examined using multivariable regression models. A total of 124,615 patients were identified. The overall complication rate decreased from 6.2% for low-volume surgeons to 4.2% for high-volume surgeons (P<.001). Patients operated on by high-volume surgeons were 25% (risk ratios [RRs] 0.75, 95% confidence interval [CI] 0.68-0.82) less likely to experience a complication. In multivariable models intraoperative complications, surgical-site complications, medical complications, prolonged hospitalization, and transfusion rates were lower for high-volume surgeons. Overall morbidity was 5.8% for women treated at low-volume hospitals compared with 4.7% at high-volume centers (P<.001). Women treated at high-volume centers were 18% (RR 0.82, 95% CI 0.75-0.90) less likely to experience a complication. Procedure costs for high-volume surgeons were $867 lower than for low-volume surgeons, and treatment at a high-volume center reduced costs by $966 per procedure. Performance of laparoscopic hysterectomy by high-volume surgeons and at high-volume hospitals is associated with modest reductions in morbidity and lower costs. II.Obstetrics and Gynecology 04/2012; 119(4):709-16. DOI:10.1097/AOG.0b013e318248f7a8 · 4.37 Impact Factor
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ABSTRACT: Increasingly, consumers are accessing the Internet seeking health information. Consumers are also using online doctor review websites to help select their physician. Such websites tally numerical ratings and comments from past patients. To our knowledge, no study has previously analyzed whether doctors with positive online reputations on doctor review websites actually deliver higher quality of care typically associated with better clinical outcomes and better safety records. For a number of procedures, surgeons who perform more procedures have better clinical outcomes and safety records than those who perform fewer procedures. Our objective was to determine if surgeon volume, as a proxy for clinical outcomes and patient safety, correlates with online reputation. We investigated the numerical ratings and comments on 9 online review websites for high- and low-volume surgeons for three procedures: lumbar surgery, total knee replacement, and bariatric surgery. High-volume surgeons were randomly selected from the group within the highest quartile of claims submitted for reimbursement using the procedures' relevant current procedural terminology (CPT) codes. Low-volume surgeons were randomly selected from the lowest quartile of submitted claims for the procedures' relevant CPT codes. Claims were collated within the Normative Health Information Database, covering multiple payers for more than 25 million insured patients. Numerical ratings were found for the majority of physicians in our sample (547/600, 91.2%) and comments were found for 385/600 (64.2%) of the physicians. We found that high-volume (HV) surgeons could be differentiated from low-volume (LV) surgeons independently by analyzing: (1) the total number of numerical ratings per website (HV: mean = 5.85; LV: mean = 4.87, P<.001); (2) the total number of text comments per website (HV: mean = 2.74; LV: mean = 2.30, P=.05); (3) the proportion of glowing praise/total comments about quality of care (HV: mean = 0.64; LV: mean = 0.51, P=.002); and (4) the proportion of scathing criticism/total comments about quality of care (HV: mean = 0.14; LV: mean = 0.23, P= .005). Even when these features were combined, the effect size, although significant, was still weak. The results revealed that one could accurately identify a physician's patient volume via discriminant and classification analysis 61.6% of the time. We also found that high-volume surgeons could not be differentiated from low-volume surgeons by analyzing (1) standardized z score numerical ratings (HV: mean = 0.07; LV: mean = 0, P=.27); (2) proportion of glowing praise/total comments about customer service (HV: mean = 0.24; LV: mean = 0.22, P=.52); and (3) proportion of scathing criticism/total comments about customer service (HV: mean = 0.19; LV: mean = 0.21, P=.48). Online review websites provide a rich source of data that may be able to track quality of care, although the effect size is weak and not consistent for all review website metrics.Journal of Medical Internet Research 04/2012; 14(2):e50. DOI:10.2196/jmir.2005 · 4.67 Impact Factor