What Constitutes a “High-Volume” Hospital for Pancreatic Resection?

Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
Journal of the American College of Surgeons (Impact Factor: 5.12). 05/2008; 206(4):622.e1-9. DOI: 10.1016/j.jamcollsurg.2007.11.011
Source: PubMed


Annual institution resection volume has been proposed for defining centers of excellence, with various cut-offs for defining "high-volume" centers used. This study aimed to define an objective, evidence-based operative volume threshold associated with improved postoperative outcomes after pancreatic resection.
This retrospective analysis of patients who underwent pancreatic resection in the Nationwide Inpatient Sample, a 20% representative sample of patients in the US between 1998 and 2003, was performed using multivariable logistic regression. Different models of annual hospital resection volume were analyzed and the goodness of fit of each "high-volume" model to postoperative mortality was compared through use of the pseudo r(2).
Based on analysis of 7,558 patients who underwent pancreatic resection, median annual institution resection volume was 15 (range 1 to 254), and overall in-hospital mortality was 7.6%. The best model of "high-volume" centers was an annual institution resection volume of 19 or more, as determined by goodness of fit (r(2) of 5.29%). But there was little difference in data variance explained between this best model and other "high-volume" models. The model without any volume variable had a goodness-of-fit r(2) of 3.57%, suggesting that volume explains less than 2% of data variance in perioperative death after pancreatic resection.
Very little difference was observed in the explanatory powers of models of "high-volume" centers. Although volume has an important impact on mortality, volume cut-off is necessary but insufficient for defining centers of excellence. Volume appears to function as an imperfect surrogate for other variables, which may better define centers of excellence.

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    • "cancer patients to be cared for at regional cancer centers and a significant number of patients receive their pancreatic cancer care at community institutions [7]. Some studies note that volume is an imperfect surrogate for quality at best [8]. Low-and medium-volume centers can definitely provide excellent complex cancer care given adequate resources and experienced practitioners [9]. "
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    ABSTRACT: Background. The treatment of pancreatic cancer and other periampullary neoplasms is complex and challenging. Major high-volume cancer centers can provide excellent multidisciplinary care of these patients but almost two-thirds of pancreatic cancer patients are treated at low volume centers. There is very little published data from low volume community cancer programs in regards to the treatment of periampullary cancer. In this study, a review of comprehensive periampullary cancer care at two low volume hospitals with comparison to national standards is presented. Methods. This is a retrospective review of 70 consecutive patients with periampullary neoplasms who underwent surgery over a 5-year period (2006-2010) at two community hospitals. Results. There were 51 successful resections of 70 explorations (73%) including 34 Whipple procedures. Mortality rate was 2.9%. Comparison of these patients to national standards was made in terms of operative mortality, resectability rate, administration of adjuvant therapy, clinical trial participation and overall survival. The results in these patients were comparable to national standards. Conclusions. With adequate commitment of resources and experienced surgical and oncologic practitioners, community cancer centers can meet national tertiary care standards in terms of pancreatic and periampullary cancer care.
    International Journal of Surgical Oncology 12/2011; 2011:936516. DOI:10.1155/2011/936516
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    ABSTRACT: In a case controlled analysis, we attempted to determine if the volume-survival benefit persists in liver resection (LR) after eliminating differences in background characteristics. Using the Nationwide Inpatient Sample (NIS), we identified all LR (n = 2,949) with available surgeon/hospital identifiers performed from 1998-2005. Propensity scoring adjusted for background characteristics. Volume cut-points were selected to create equal groups. A logistic regression for mortality was then performed with these matched groups. At high volume (HV) hospitals, patients (n = 1423) were more often older, white, private insurance holders, elective admissions, carriers of a malignant diagnosis, and high income residents (p < 0.05). Propensity matching eliminated differences in background characteristics. Adjusted in-hospital mortality was significantly lower in the HV group (2.6% vs. 4.8%, p = 0.02). Logistic regression found that private insurance and elective admission type decreased mortality; preoperative comorbidity increased mortality. Only LR performed by HV surgeons at HV centers was independently associated with improved in-hospital mortality (HR, 0.43; 95% CI, 0.22-0.83). A socioeconomic bias may exist at HV centers. When these factors are accounted for and adjusted, center volume does not appear to influence in-hospital mortality unless LR is performed by HV surgeons at HV centers.
    Journal of Gastrointestinal Surgery 08/2008; 12(10):1709-16; discussion 1716. DOI:10.1007/s11605-008-0627-3 · 2.80 Impact Factor
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