Trends and Disparities in Regionalization of Pancreatic Resection
ABSTRACT 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.
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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
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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
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ABSTRACT: A strong volume-outcome relationship has been demonstrated for pancreatic resection, and regionalization of care to high-volume centers (>11 resections/year) has been recommended. However, it is unclear if volume alone should be the sole criteria for regionalization. The objective of this study is to evaluate variability in outcomes among high-volume hospitals (>11 resections/year). We used the Texas Hospital Inpatient Discharge Database from 1999 through 2005 to evaluate variability in outcomes after pancreatic resection among high-volume hospitals in Texas. The outcome variables of interest were mortality, length of stay, discharge to a skilled nursing facility, operation within 24 hours of hospital admission, and total hospital charges. Unadjusted and adjusted models were performed. A total of 12 high-volume hospitals were in Texas. The number of resections at each hospital ranged from 78-608 cases for the 7-year time period studied. In unadjusted models, there was significant variability in mortality (range, 0.7%-7.7%, P < .0001), duration of stay (range of medians, 9-21 days, P < .0001), the need for ongoing nursing care at discharge (range, 0.7%-41.4%, P < .0001), operation within 24 hours of admission (range, 41%-96%, P < .0001), and total hospital charges (median range, $38,318-$110,860, P < .0001). There were significant differences in the demographics, risks of mortality, and illness severity among the 12 high-volume hospitals. Therefore, multivariate models were used to control for age group, sex, race/ethnicity, risk of mortality, illness severity, admission status, diagnosis, procedure, and insurance status. In the multivariate models, the particular hospital at which the pancreatic surgery was performed was a significant independent predictor of every outcome variable except mortality. For pancreatic resection, there is significant variability in outcomes even among high-volume providers. Individual hospitals likely account for much of the variability not explained by hospital volume. Although the structure measure of hospital volume is easy to measure, these data suggest that it is not a reliable single measure of quality or outcomes after pancreatic surgery.Surgery 08/2008; 144(2):133-40. DOI:10.1016/j.surg.2008.03.041