The current recommendation is that pancreatic resections be performed at hospitals doing >10 pancreatic resections annually.
To evaluate the extent of regionalization of pancreatic resection and the factors predicting resection at high-volume centers (>10 cases/year) in Texas.
Using the Texas Hospital Inpatient Discharge Public Use Data File, we evaluated trends in the percentage of patients undergoing pancreatic resection at high-volume centers (>10 cases/year) from 1999 to 2004 and determined the factors that independently predicted resection at high-volume centers.
A total of 3,189 pancreatic resections were performed in the state of Texas. The unadjusted in-hospital mortality was higher at low-volume centers (7.4%) compared to high-volume centers (3.0%). Patients resected at high-volume centers increased from 54.5% in 1999 to 63.3% in 2004 (P = 0.0004). This was the result of a decrease in resections performed at centers doing less than five resections/year (35.5% to 26.0%). In a multivariate analysis, patients who were >75 (OR = 0.51), female (OR = 0.86), Hispanic (OR = 0.58), having emergent surgery (OR = 0.39), diagnosed with periampullary cancer (OR = 0.68), and living >75 mi from a high-volume center (OR = 0.93 per 10-mi increase in distance, P < 0.05 for all OR) were less likely to be resected at high-volume centers. The odds of being resected at a high-volume center increased 6% per year.
Whereas regionalization of pancreatic resection at high-volume centers in the state of Texas has improved slightly over time, 37% of patients continue to undergo pancreatic resection at low-volume centers, with more than 25% occurring at centers doing less than five per year. There are obvious demographic disparities in the regionalization of care, but additional unmeasured barriers need to be identified.
"Studies on cancer treatment in the surgical literature suggest certain cancers should be treated at HVCs or TFs., , , , , ,  Such studies have resulted in a number of national initiatives to improve the delivery of cancer care. The American College of Surgeons, through the development of the National Surgical Quality Improvement Program (NSQIP), has demonstrated since 1991 that the systematic collection, analysis and feedback of risk-adjusted surgical data, including that on hospital volumes, leads to improved outcomes. "
[Show abstract][Hide abstract] ABSTRACT: Patient chances for cure and palliation for a variety of malignancies may be greatly affected by the care provided by a treating hospital. We sought to determine the effect of volume and teaching status on patient outcomes for five gynecologic malignancies: endometrial, cervical, ovarian and vulvar carcinoma and uterine sarcoma.
The Florida Cancer Data System dataset was queried for all patients undergoing treatment for gynecologic cancers from 1990-2000.
Overall, 48,981 patients with gynecologic malignancies were identified. Endometrial tumors were the most common, representing 43.2% of the entire cohort, followed by ovarian cancer (30.9%), cervical cancer (20.8%), vulvar cancer (4.6%), and uterine sarcoma (0.5%). By univariate analysis, although patients treated at high volume centers (HVC) were significantly younger, they benefited from an improved short-term (30-day and/or 90-day) survival for cervical, ovarian and endometrial cancers. Multivariate analysis (MVA), however, failed to demonstrate significant survival benefit for gynecologic cancer patients treated at teaching facilities (TF) or HVC. Significant prognostic factors at presentation by MVA were age over 65 (HR = 2.6, p<0.01), African-American race (HR = 1.36, p<0.01), and advanced stage (regional HR = 2.08, p<0.01; advanced HR = 3.82, p<0.01, respectively). Surgery and use of chemotherapy were each significantly associated with improved survival.
No difference in patient survival was observed for any gynecologic malignancy based upon treating hospital teaching or volume status. Although instances of improved outcomes may occur, overall further regionalization would not appear to significantly improve patient survival.
PLoS ONE 01/2009; 4(1):e4049. DOI:10.1371/journal.pone.0004049 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A secondary cache SRAM is an indispensable CPU partner in a high-performance system. The main objectives are: 1) pipeline burst operation; 2) 32b 500MHz (2GB/s) I/Os, and 3) point-to-point communication with a CPU, as well as shortened latency and reduced noise and power caused by high-speed, high-bandwidth I/O operation. A pre-fetched pipeline scheme enables the cycle time for an internal memory core (I-cycle) to be extended by N times that of an external bus cycle (E-cycle). This is modified to an SRAM to achieve both 4b pipeline-burst cache operation and 500MHz I/O frequency. In this case, I-cycle time of 8ns is four times E-cycle time (2ns)
Digest of Technical Papers - IEEE International Solid-State Circuits Conference 01/1997; DOI:10.1109/ISSCC.1997.585461
[Show abstract][Hide abstract] ABSTRACT: Surgeon specialization has been shown to result in improved outcomes but may not be the sole measure of surgical quality in hepato-pancreatico-biliary (HPB) surgery. We attempted to determine which factors predominate in optimal patient outcomes between volume, surgeon, and hospital resources.
All non-transplant pancreatic (n = 7195) and liver operations (n = 4809) from the Nationwide Inpatient Sample (NIS) were examined from 1998-2005. Surgeons and hospitals were divided into two groups, transplant (TX) or non-transplant (non-TX), using the unique surgeon and hospital identifier of NIS. A logistic regression model examined the relationship between factors while accounting for patient and hospital factors.
We identified 4,355 primary surgeons (165 TX, 4,190 non-TX) who performed HPB surgery in 675 hospitals across 12 different states. Non-TX surgeons performed the majority of pancreatic (97%) and liver procedures (81%). There was no difference in mortality after HPB surgery depending on surgeon specialty (p = 0.59). Factors for inpatient death after HPB surgery included increasing age, male gender, and public insurance (p < 0.05). In addition, surgery performed at a TX center had a 21% lower odds of perioperative mortality.
Non-TX surgeons performed the majority of pancreatic and liver surgery in the US. Hospital factors like support of transplantation but not surgical specialty, appeared to impact operative mortality. Future regulatory benchmarks should consider these types of center-based facilities and resources to assess patient outcomes.
Journal of Gastrointestinal Surgery 07/2008; 12(9):1534-9. DOI:10.1007/s11605-008-0566-z · 2.80 Impact Factor
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