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The Volume-Outcomes Effect in Hepato-Pancreato-Biliary Surgery: Hospital Versus Surgeon Contributions and Specificity of the Relationship
Abstract
Although the relationship between hepato-pancreato-biliary (HPB) procedure volume and outcomes is established, the relative importance of hospital and surgeon effects and the specificity of the volume-outcomes effect remain ill-defined. We sought to comprehensively characterize the hospital and surgeon volume-outcomes relationships in high-risk HPB surgery.
The 1998 to 2005 State Inpatient Databases for Florida, Maryland, and New York were used to identify patients undergoing complex HPB surgery and to quantify hospital and surgeon procedure volumes. The effects of hospital and surgeon procedure volumes on casemix-adjusted inpatient mortality were analyzed using multilevel logistic regression models.
For hepatic resection, hospital procedure volume predicted mortality (high versus low volume, odds ratio [OR] 0.48, p=0.04), but surgeon volume did not (p=0.42). For pancreatic resection, in contrast, both hospital (OR 0.32, p < 0.001) and surgeon (OR 0.30, p < 0.001) procedure volume predicted mortality. The hospital volume effect for pancreatic resection was largely explained by surgeon volume. In both procedure groups, volume-outcomes effects were very specific. Only volumes of the primary procedure were predictive of mortality; volumes of related HPB procedures and overall HPB volume demonstrated no independent effect on mortality.
In HPB surgery, the relative contributions of hospital versus surgeon volume vary according to the specific procedure in question. In addition, the association between hospital or surgeon volume and in-hospital mortality is very specific to the procedure in question. High-volume expertise in one area of HPB surgery does not translate into improved outcomes for related procedures. These data may have implications for quality assessment and improvement, patient referral, and HPB surgical training.
... The quality assessment of surgical procedures is becoming one of the priorities for different stakeholders involved in the healthcare system. Such assessment is crucial for any type of surgical procedures but for highly complex surgical procedures, such as hepatobiliary surgery, is even more crucial considering the associated morbidity and mortality risks [1][2][3]. As supported by a long-standing body of the literature, the centralization of complex surgery serves to increase the quality of care following the principle that • The twenty Italian administrative regions [10]. ...
... However, controversies exist among experts. Nathan et al. [3] showed that the protective effect of hospital hepatic resection volume persisted after case-mix adjustment for competing risk factors, while that was not the case considering the surgeon hepatic resection volume. Indeed, high-and lowvolume surgeons had comparable in-hospital mortality rates after hepatectomy [3]. ...
... Nathan et al. [3] showed that the protective effect of hospital hepatic resection volume persisted after case-mix adjustment for competing risk factors, while that was not the case considering the surgeon hepatic resection volume. Indeed, high-and lowvolume surgeons had comparable in-hospital mortality rates after hepatectomy [3]. It is, anyway, a matter of fact that the experience of the surgeon represents a very important factor. ...
Purpose
Whether hospital volume affects outcome of patients undergoing hepatobiliary surgery, and whether the centralization of such procedures is justified remains to be investigated. The aim of this study was to analyze the outcome of liver surgery in Italy in relationship of hospital volume.
Methods
This is a nationwide retrospective observational study conducted on data collected by the National Italian Registry “Piano Nazionale Esiti” (PNE) 2023 that included all liver procedures performed in 2022. Outcome measure were case volume and 30-day mortality. Hospitals were classified as very high-volume (H-Vol), intermediate-volume (I-Vol), low-volume (L-Vol) and very low-volume (VL-VoL). A review on centralization process and outcome measures was added.
Results
6,126 liver resections for liver tumors were performed in 327 hospitals in 2022. The 30-day mortality was 2.2%. There were 14 H-Vol, 19 I-Vol, 31 L-Vol and 263 VL-Vol hospitals with 30-day mortality of 1.7%, 2.2%, 2.6% and 3.6% respectively (P < 0.001); 220 centers (83%) performed less than 10 resections, and 78 (29%) centers only 1 resection in 2022. By considering the geographical macro-areas, the median count of liver resection performed in northern Italy exceeded those in central and southern Italy (57% vs. 23% vs. 20%, respectively).
Conclusions
High-volume has been confirmed to be associated to better outcome after hepatobiliary surgical procedures. Further studies are required to detail the factors associated with mortality. The centralization process should be redesigned and oversight.
... [3][4][5][6] Complex hepatopancreaticobiliary (HPB) operations, such as pancreaticoduodenectomy (PD), are a notable case study with average charges approaching $100,000 and trends in regionalization of care to well-equipped high-volume centers. [7][8][9][10][11][12] Variation in reimbursement and incomplete estimation of hospital costs from nonspecific chargemasters have limited any insight into real-world prices paid and the role regionalization may play. 13 To facilitate price-sharing by patients and competitive purchasing by employers and insurers, the Centers for Medicare and Medicaid Services (CMS) enacted the price ...
... 43 The influence of market concentration on compliance and reimbursement evokes trends in the regionalization of HPB surgical care to fewer high-volume centers, which has not only been studied as a determinant of lower mortality but also as a way to achieve cost savings of up to 40% with increasing center experience. [7][8][9][10]44 However, we found no evidence of downward pressure on commercial or cash rates and instead found higher adjusted Medicare reimbursements for PD-related hospital care at the highest-volume centers. Together, these findings suggest that both compliance with price transparency mandates, and real-world reimbursements of complex HPB surgical care are more consistently associated with operational features and market factors than HPB surgical volume. ...
The Centers for Medicare and Medicaid Services (CMS) price transparency rule tries to facilitate cost-conscious decision-making. For surgical services, such as pancreaticoduodenectomy (PD), factors mediating transparency and real-world reimbursement are not well described.
The Leapfrog Survey was used to identify United States hospitals performing PD. Financial and operational data were obtained from Turquoise Health and CMS Cost Reports. Chi-square tests and modified Poisson regression evaluated associations with reimbursement disclosure. Two-part logistic and gamma regression models estimated effects of hospital factors on commercial, Medicare, and self-pay reimbursements for PD.
Of 452 Leapfrog hospitals, 295 (65%) disclosed PD hospital or procedure reimbursements. Disclosing hospitals were larger (beds > 200: 81.0% vs. 71.3%, p = 0.04), reported higher net margins (0.7% vs. − 2.1%, p = 0.04), more likely for-profit (26.1% vs. 6.4%, p < 0.001), and teaching-affiliated (82.0% vs. 65.6%, p < 0.001). Nonprofit status conferred hospitalization reimbursement increases of 8683–12,329, while moderate market concentration predicted savings up to 4589–644 for procedures. Top Leapfrog volume ratings predicted an increase of up to $7795 for only Medicare hospitalization reimbursement.
Nondisclosure of hospital and procedural reimbursements for PD remains a major issue. Transparency was noted in hospitals with higher margins, size, and academic affiliation. Factors associated with higher reimbursement were non-profit status, academic affiliation, and more equitable market share. Reimbursement inconsistently tracked with PD quality or volume measures. Policy changes may be required to incentivize reimbursement disclosure and translate transparency into increased value for patients.
... In contrast, when the influence of pancreatic resection volume was examined, a significant correlation was found between individual surgeon volume and a lower in-hospital mortality rate. 27 The authors conclude that quality improvement efforts must be procedure specific. For some procedures, such as liver resections, the intervention should be primarily targeted at the hospital level, whereas for others, such as pancreatic resections, the target should extend to individual surgeon caseloads. ...
... Following a comprehensive review of the literature, it became apparent that the need to offer quality care differs according to the procedures used. 27,39 For example, complex liver surgery, including liver transplantation, depends on the centre volume of cases with little or no impact from the individual surgeon caseloads. In contrast, complex pancreatic surgery, which mostly follows standardised procedures, relies more on the individual surgeon's caseload or expertise rather than the centre volume. ...
The concept of center approach to treat patients with complex disorders, such a those with hepato-pancreato-biliary (HPB) diseases, is widely used, although the requirements needed to achieve high quality outcomes remains unclear. We therefore conducted a literature review, which highlighted the paucity of information linking center structure or process to outcome data outside of caseloads, specialization, and quality of training. We then conducted an international survey among the largest 107 HPB centers with experts in HPB surgery and found that most responders work in rather virtual HPB centers without dedicated space and assigned beds and personal. We finally analyzed our experience with the Swiss HPB center, previously reported in this Journal 15 years ago, disclosing that budget priorities set by the hospital administration may prevent the development of a full integrated center, for example by inconsistent assignment of the center beds to HBP patients or removal of dedicated intermediate care beds. We propose criteria for essential requirements for a HPB center to deliver high quality outcomes, with the concept of “center of reference” limited to actual, in opposition to virtual, centers.
Lay summary
After a comprehensive literature review and a large international survey, we present the requirements for HPB center to deliver quality outcomes. The worldwide survey showed that there is a need for “re-designing” HPB centers, as only one third of surveyed centers meet most of the criteria.
... From two studies no effect sizes could be extracted [85,92]. Five studies reported significant effects for both hospital and surgeon volume [93][94][95][96][97], while one study failed to demonstrate significant effects, although a tendency to decreased mortality was observed for high volume hospitals and surgeons [98]. ...
... Interestingly, the two studies that failed to show a surgeon volume effect were adjusted for the amount of supervision and training, respectively [86,88]. Findings that are in accordance with other studies support the importance of training and experience [7,97,107,108]. ...
Background
How the extent of confounding adjustment impact (hospital) volume-outcome relationships in published studies on pancreatic cancer surgery is unknown.
Methods
A systematic literature search was conducted for studies that investigated the relationship between volume and outcome using a risk adjustment procedure by querying the following databases: PubMed, Cochrane Central Register of Controlled Trials, Livivo, Medline and the International Clinical Trials Registry Platform (last query: 2020/09/16). Importance of risk-adjusting covariates were assessed by effect size (odds ratio, OR) and statistical significance. The impact of covariate adjustment on hospital (or surgeon) volume effects was analyzed by regression and meta-regression models.
Results
We identified 87 studies (75 based on administrative data) with nearly 1 million patients undergoing pancreatic surgery that included in total 71 covariates for risk adjustment. Of these, 33 (47%) had statistically significant effects on short-term mortality and 23 (32%) did not, while for 15 (21%) factors neither effect size nor statistical significance were reported. The most important covariates for short term mortality were patient-specific factors. Concerning the covariates, single comorbidities (OR: 4.6, 95% CI: 3.3 to 6.3) had the strongest impact on mortality followed by hospital volume (OR: 2.9, 95% CI: 2.5 to 3.3) and the procedure (OR: 2.2, 95% CI: 1.9 to 2.5). Among the single comorbidities, coagulopathy (OR: 4.5, 95% CI: 2.8 to 7.2) and dementia (OR: 4.2, 95% CI: 2.2 to 8.0) had the strongest influence on mortality. The regression analysis showed a significant decrease hospital volume effect with an increasing number of covariates considered (OR: 0.06, 95% CI: 0.10 to −0.03, P < 0.001), while such a relationship was not observed for surgeon volume (P = 0.35).
Conclusions
This analysis demonstrated a significant inverse relationship between the extent of risk adjustment and the volume effect, suggesting the presence of unmeasured confounding and overestimation of volume effects. However, the conclusions are limited in that only the number of included covariates was considered, but not the effect size of the non-included covariates.
... Hepatic (liver) resection is the main cornerstone for primary and secondary liver tumors treatments showing compelling long-term oncological outcomes compared with other interventional or medical therapy in several hepatobiliary and oncological diseases [1][2][3][4]. In order to plan for liver resection, the considerations include the lesion's nature and its location within the liver, the patient's anatomy, and the quality and volume of the hepatic tissue remaining following the resection, ensuring an adequate future hepatic remnant [5][6][7]. ...
... Perioperative outcomes for liver resection had improvements because of better surgical techniques that take advantage of the segmental anatomy of the liver, enhanced techniques for bleeding control, and improved intensive care. Hepatic resection that is performed in high-volume centers by very well-trained hepatobiliary surgeons is associated with more favorable outcomes [5][6][7]. ...
Aim:
This study aimed to determine the indications and demographic profile of hepatic resection at Sher-I-Kashmir Institute of Medical Sciences (SKIMS), the performed types of hepatic resection, as well as assess the details of the operation and perioperative complications of hepatic resection.
Methods:
This is a prospective, retrospective observational study. The retrospective study period was from January 2005 to August 2015 and the prospective study period was from 2015 till 2017. Prospective patients were clinically evaluated by medical history and clinical examination and also underwent various investigations. The patients were scored on Child-Pugh and American Society of Anesthesiology (ASA) scores for risk stratification and prepared for surgery, which included segmentectomy to major liver resection. The retrospective data were obtained from the Medical Records Department (MRD). Statistical analysis was done on SPSS software 25.0 version (Armonk, NY: IBM Corp.).
Results:
This study included 122 patients with a male to female ratio of 1:1.59. The patients' age was between 1 and 73 years. The patients' most common complaint was right upper quadrant abdominal pain. The main established clinical diagnosis was oriental cholangiohepatitis (OCH) (36.9%) followed by carcinoma of gallbladder (CaGB) which accounted for 37 cases (30.4%). Liver metastases including solitary masses and multiple lesions were 10 cases (8.2%). Fifty-five patients underwent left lateral segmentectomy (45.1%) and mostly for OCH. Standard wedge resection was done in 30.7% of cases and for all cases of CaGB. The mean blood loss was 146.5 ml. A total of 37 patients had complications. Wound infection was the most common complication, occurring in 10 patients (8.2%).
Conclusion:
Patients with hepatobiliary pathology, necessitating liver resection are now routinely admitted to the Department of Surgical Gastroenterology in SKIMS, Srinagar. Patients are carefully evaluated and operated with a confirmed definitive diagnosis. The overall surgical outcome does not differ from India's best centers.
... Pancreatic resection was used as the index procedure given its relatively high morbidity and mortality, as well as data suggesting variation in outcomes relative to access to care. [36][37][38] In addition, we used the diversity index, which was a validated tool utilized by the Census Bureau to measure residential segregation. 28 Of note, patients from the lowest racially integrated counties had 16% lower odds to experience a TO following pancreatic resection compared with patients from high-diversity communities. ...
... [48][49][50] Pancreatic resection is also a surgical procedure that is highly sensitive to the volume-outcome relationship, as well as the overall quality of the hospital in which the procedure is performed. 21,38,51 As such, disparities in 90-day mortality following pancreatectomy may be attributed to differences in access to high-quality hospitals. For example, Sarrazin et al. reported that Medicare beneficiaries who were from highly segregated areas were more likely to be hospitalized for acute myocardial infarction in a high-mortality hospital. ...
IntroductionResidential racial desegregation has demonstrated improved economic and education outcomes. The degree of racial community segregation relative to surgical outcomes has not been examined.Patients and Methods
Patients undergoing pancreatic resection between 2013 and 2017 were identified from Medicare Standard Analytic Files. A diversity index for each county was calculated from the American Community Survey. Multivariable mixed-effects logistic regression with a random effect for hospital was used to measure the association of the diversity index level with textbook outcome (TO).ResultsAmong the 24,298 Medicare beneficiaries who underwent a pancreatic resection, most patients were male (n = 12,784, 52.6%), White (n = 21,616, 89%), and had a median age of 72 (68–77) years. The overall incidence of TO following pancreatic surgery was 43.3%. On multivariable analysis, patients who resided in low-diversity areas had 16% lower odds of experiencing a TO following pancreatic resection compared with patients from high-diversity communities (OR 0.84, 95% CI 0.72–0.98). Compared with patients who resided in the high-diversity areas, individuals who lived in low-diversity areas had higher odds of 90-day readmission (OR 1.16, 95% CI 1.03–1.31) and had higher odds of dying within 90 days (OR 1.85, 95% CI 1.45–2.38) (both p < 0.05). Nonminority patients who resided in low-diversity areas also had a 14% decreased likelihood to achieve a TO after pancreatic resection compared with nonminority patients in high-diversity areas (OR 0.86, 95% CI 0.73–1.00).Conclusion
Patients residing in the lowest racial/ethnic integrated counties were considerably less likely to have an optimal TO following pancreatic resection compared with patients who resided in the highest racially integrated counties.
... There is a well-established association between surgeon and hospital volume and short-and long-term outcomes for hepatopancreatobiliary (HPB) operations, resulting in broad consensus for HPB operations to occur at high-volume centers [1][2][3]. However, controversy remains as to the optimal location and hospital setting in which to establish high-volume HPB centers [4][5][6]. ...
Background
Owing to the well-established volume-outcome relationship, hepatopancreatobiliary (HPB) surgery is commonly regionalized to academic, teaching hospitals. However, regionalization is associated with decreased access for some populations in need, as well as geographic and financial barriers for patients. If high surgeon and institutional volumes can be achieved, the community, non-teaching HPB surgical practice could help alleviate some issues associated with regionalization. The HPB experience of a community surgeon immediately after surgical oncology training was reviewed, hypothesizing that high volumes with acceptable short-term outcomes could be achieved, although a learning curve may be observed.
Materials and methods
Electronic medical records from 2013 to 2023 were reviewed. Data included patient demographics, perioperative details, pathology, complications, and deaths over 90 postoperative days. Perioperative quality metrics were assessed for trends over time in pancreaticoduodenectomy (PD) and liver resection subgroups.
Results
A total of 295 patients underwent 176 (59.7%) pancreatic and 119 (40.3%) hepatobiliary operations. The most common operations were PD (n=87; 49.4%) and partial hepatic lobectomy (n=56; 41.1%). In the pancreas group, morbidity was 25% (n=44), and mortality was 4.5% (n=8). In the hepatobiliary group, morbidity and mortality were 19.3% (n=23) and 5.0% (n=6), respectively. Within the PD and liver resection subgroups, operative time, estimated blood loss, and hospital length of stay (LOS) trended downward over time, with LOS decreasing significantly.
Conclusion
High HPB volumes with acceptable short-term outcomes can be achieved by a solo practitioner in the community, non-teaching setting. For PDs and liver resections, perioperative metrics trended downward over time, illustrating the learning curve encountered after training.
... SES can also impact HCC-related outcomes including treatment complications, and mortality [48,[54][55][56] . Patients with lower SES experience higher HCC mortality irrespective of race and ethnicity. ...
Hepatocellular carcinoma (HCC) poses a significant public health challenge within the US, exerting an increasingly substantial influence on cancer-related deaths. However, the HCC burden is not uniformly distributed, with significant disparities related to race, ethnicity, and socioeconomic status. This manuscript comprehensively reviews the multifaceted origins of HCC disparities, exploring their roots in the sociocultural environment, socioeconomics, the physical/built environment, and the healthcare/political systems. The sociocultural environment highlights the unique challenges faced by racial and ethnic minority populations, including language barriers, cultural beliefs, and limited healthcare access. The socioeconomics and the physical/built environment section emphasize the impact of neighborhood poverty, geographic disparities, and healthcare infrastructure on HCC outcomes. The healthcare and political systems play a pivotal role in driving HCC disparities through practice guidelines, healthcare policies, insurance coverage, and access to care. Inconsistent practice guidelines across specialties and variations in insurance coverage contribute to disparities in HCC surveillance and treatment. In conclusion, addressing HCC disparities requires a multifaceted, patient-centered approach that includes cultural competence, infrastructure enhancements, policy changes, and improved access to care. Collaborative efforts among healthcare professionals, researchers, policymakers, and institutions are essential to reducing the burden of HCC on marginalized communities and ensuring equitable care for all individuals affected by this complex disease.
... The NIS is a publicly available data set sourced from the SID, involving most states in the US, and encompassing 5 million to 8 million inpatient discharges from about 20% of US hospitals prior to a 2012 overhaul (18). The NIS has been utilized to consider the effects of SV on outcomes in other procedures (8,19,20), as has the SID (21)(22)(23). We included the NIS because it represents a national sample, and the SID was included for comparison. ...
Background
Increased surgeon volume is associated with decreased complications for many surgeries, including thyroidectomy. We sought to use two national databases to assess for associations between surgeon volume and complications in patients undergoing lateral neck dissection for thyroid or parathyroid malignancy.
Methods
Lateral neck dissections for thyroid and parathyroid cancer from the Nationwide Inpatient Sample and State Inpatient Database were analyzed. The primary outcome was any inpatient complication common to thyroidectomy, parathyroidectomy, or lateral neck dissection. The principle independent variable was surgeon volume. Multivariable analysis was then performed on this retrospective cohort study.
Results
The 1,094 Nationwide Inpatient Sample discharges had a 28% (305/1,094) complication rate. After adjustment, surgeons with volumes between 3–34 neck dissections/year demonstrated a surgeon volume-complication rate association [adjusted odds ratio: 1.03; 95% confidence interval (CI): 1.01–1.05]. The 1,235 State inpatient Database discharges had a 21% (258/1,235) overall complication rate, and no association between surgeon volume and complication rates (P=0.25).
Conclusions
This retrospective review of 2,329 discharges for patients undergoing lateral neck dissection for thyroid or parathyroidectomy demonstrated somewhat conflicting results. The Nationwide Inpatient Sample demonstrated increasing complication rates for increasing surgeon volume among intermediate volume surgeons, while the State Inpatient Database demonstrated no surgeon volume-complication association. Given these disparate results, and further limitations with these databases, conclusions regarding surgical volume and clinical decision making based on these data should be assessed cautiously.
... These results are consistent with previous literature, suggesting the relationship of hospital volume with the occurrence of postoperative mortality [9,10]. The reasons that could explain the correlation between high hospital volume and better surgical outcomes are several, including a more specialized medical team, a standardization of care and a higher experience with treatment of complications [2,[11][12][13][14]. ...
Hepatobiliary resections are among the most complex and technically challenging surgical procedures. Even though robust evidence showed that complex surgical procedures such as hepatobiliary surgery have better short- and long-term outcomes and lower mortality rate when performed in high-volume centers, the minimal criteria of centers that can perform hepatobiliary activity are not clearly defined. We conducted a retrospective population study of patients who underwent hepatobiliary surgery for malignant disease in a single Italian administrative region (Veneto) from 2010 to 2021 with the aim to investigate the hospitals annual surgical volume for hepatobiliary malignant diseases and the effect of hospital volume on in-hospital, 30- and 90-day postoperative mortality. The centralization process of hepatobiliary surgery in Veneto is rapidly increasing over the past 10 years (rate of performed in highly specialized centers increased from 62% in 2010 to 78% in 2021) and actually it is really established. The crude and adjusted (for age, sex, Charlson Index) mortality rate after hepatobiliary surgery resulted significantly lower in centers with high-volume activity compared to them with low-volume activity. In the Veneto region, the "Hub and Spoke" model led to a progressive centralization of liver and biliary cancer treatment. High surgical volume has been confirmed to be related to better outcomes in terms of mortality rate after hepatobiliary surgical procedures. Further studies are necessary to clearly define the minimal criteria and associated numerical cutoffs that can help define the characteristics of centers that can perform hepatobiliary activities.
... A forest plot of studies that reported on the association between surgeon technical skill and postoperative complications is shown in Figure 4. Egger's test indicated no significant publication bias (P = .86). 50,51 or specialty. 49,52 Surgical quality measures include evaluation of a procedure's end result, typically evaluated by review of medical records, operative narrative, or post hoc imaging results. ...
Background:
A systematic literature review and meta-analysis was conducted to assess the association between intraoperative surgical skill and clinical outcomes.
Methods:
Peer-reviewed, original research articles published through August 31, 2021 were identified from PubMed and Embase. From the 1,513 potential articles, seven met eligibility requirements, reporting on 151 surgeons and 17,932 procedures. All included retrospective assessment of operative videos. Associations between surgical skill and outcomes were assessed by pooling odds ratios (OR) using random-effects models with the inverse variance method. Eligible studies included pancreaticoduodenectomy, gastric bypass, laparoscopic gastrectomy, prostatectomy, colorectal, and hemicolectomy procedures.
Results:
Meta-analytic pooling identified significant associations between the highest vs. lowest quartile of surgical skill and reoperation (OR: 0.44; 95% confidence interval [CI]: 0.23, 0.83), hemorrhage (OR: 0.66; 95% CI, 0.65, 0.68), obstruction (OR: 0.33; 95% CI, 0.30, 0.35), and any medical complication (OR: 0.23, 95% CI, 0.19, 0.27). Nonsignificant inverse associations were noted between skill and readmission, emergency department visit, mortality, leak, infection, venous thromboembolism, and cardiac and pulmonary complications.
Conclusions:
Overall, surgeon technical skill appears to predict clinical outcomes. However, there are surprisingly few articles that evaluate this association. The authors recommend a thoughtful approach for the development of a comprehensive surgical quality infrastructure that could significantly reduce the challenges identified by this study.
... Minimally invasive liver surgery has been increasingly adopted in the past two decades, even for major hepatectomies [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] . The impact of transplant activity in a centre on outcomes after liver surgery has been poorly investigated 21 . ...
Background:
This nationwide retrospective study was undertaken to evaluate impact of hospital volume and influence of liver transplantation activity on postoperative mortality and failure to rescue after liver surgery.
Methods:
This was a retrospective study of patients who underwent liver resection between 2011 and 2019 using a nationwide database. A threshold of surgical activities from which in-hospital mortality declines was calculated. Hospitals were divided into high- and low-volume centres. Main outcomes were in-hospital mortality and failure to rescue.
Results:
Among 39 286 patients included, the in-hospital mortality rate was 2.8 per cent. The activity volume threshold from which in-hospital mortality declined was 25 hepatectomies. High-volume centres (more than 25 resections per year) had more postoperative complications but a lower rate of in-hospital mortality (2.6 versus 3 per cent; P < 0.001) and failure to rescue (5 versus 6.3 per cent; P < 0.001), in particular related to specific complications (liver failure, biliary complications, vascular complications) (5.5 versus 7.6 per cent; P < 0.001). Liver transplantation activity did not have an impact on these outcomes.
Conclusion:
From more than 25 liver resections per year, rates of in-hospital mortality and failure to rescue declined. Management of specific postoperative complications appeared to be better in high-volume centres.
... 6 These findings suggest that complex HPB surgeries should be regionalized to high-volume tertiary institutions and National Cancer Institute-designated cancer centers for better outcomes. 7,8,9 However, other studies have discovered that low-volume hospitals produce mortality and morbidity statistics that are consistent with those of high-volume hospitals. 10,11,12,13,14 Additionally, for patients in many areas of the country, HPB surgical care at specialized high-volume centers can be difficult to access due to travel and socioeconomic factors. ...
There is a national trend towards regionalizing complex hepatopancreaticobiliary (HPB) surgeries to high-volume institutions. Due to geographic and socioeconomic constraints, however, many patients in the United States continue to undergo HPB surgery at local community hospitals. This study evaluated complex HPB surgeries performed by a single surgeon at a low-volume community hospital from May 2007 to June 2021. A retrospective review of medical records (n=163) was done to collect data on patient demographics and outcomes. Surgical outcomes of HPB procedures were compared to published data from high-volume centers. Overall mortality within 30 days of the procedure was 1% (n=1). Using Clavien-Dindo classification, the major complication rate was 10%, including 8% grade III and 2% grade IV complications. Reoperation (2%) and readmission (3%) were rare in this population. Median length of stay was 7 days and median estimated blood loss was 500 milliliters. Surgical outcomes from the community hospital were comparable to high-volume centers. For pancreatic cancer patients treated at the community hospital, Kaplan-Meier curves revealed comparable 5-year survival time to national data. Complex HPB procedures can be safely performed at a low-volume hospital in Hawai'i with outcomes comparable to large tertiary centers.
... At the turn of the 21 st century, published data emerged to show that high volume centers performed PDs with significantly reduced overall morbidity [1][2][3][4][5][6][7][8], thirty-day mortality [1,8] readmission rates [3], cost [3,9], duration of hospital stay [3,9] and 5-year survival rates[1, 8,10]. These data supported the principle of centralization -a concept that seemed predictable and intuitive on first glance. ...
Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors' opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.
... In addition, considering that the operations included in the overall complex oncologic operative volume are often performed by different specialists, these findings indicate that overall hospital characteristics may have a more pronounced impact on outcomes than does surgeon volume alone. [20][21][22] The favorable impact of combined complex operative volume on outcomes in hospitals that are low volume for the complex operation of interest may be explained by several factors. First, once a hospital becomes high volume for a complex oncologic operation, the surgeons may develop standardized clinical pathways to care for complex patients and manage their complications; the favorable effects of these pathways may benefit patients undergoing other complex operations. ...
Background:
Centralization for complex cancer surgery may not always be feasible owing to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts postoperative outcomes at hospitals that are low-volume for a specific high-risk cancer operation.
Study design:
Patients who underwent pneumonectomy, esophagectomy, gastrectomy, hepatectomy, pancreatectomy, or proctectomy were identified from the National Cancer Database (2004-2017). For every operation, 3 separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low volume for the individual cancer operation but high volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation.
Results:
LVH was significantly (all p ≤ 0.01) predictive for 30-day mortality compared with HVH across all operations: pneumonectomy (9.5% vs 7.9%), esophagectomy (5.6% vs 3.2%), gastrectomy (6.8% vs 3.6%), hepatectomy (5.9% vs 3.2%), pancreatectomy (4.7% vs 2.3%), and proctectomy (2.4% vs 1.3%). Patients who underwent surgery at MVH and HVH demonstrated similar 30-day mortality: esophagectomy (3.2 vs 3.2%; p = 0.993), gastrectomy (3.2% vs 3.6%; p = 0.637), hepatectomy (3.8% vs 3.2%; p = 0.233), pancreatectomy (2.8% vs 2.3%; p = 0.293), and proctectomy (1.2% vs 1.3%; p = 0.843). Patients who underwent pneumonectomy at MVH demonstrated lower 30-day mortality compared with HVH (5.4% vs 7.9%; p = 0.045).
Conclusion:
Patients who underwent complex operations at MVH had similar postoperative outcomes to those at HVH. MVH provide a model for the centralization of complex cancer surgery for patients who do not receive their care at HVH.
... 62 There is evidence to suggest surgeon experience and surgeon volume are significant prognostic factors independent of hospital volume. 75 But as noted, surgeon experience is rarely reported in the contemporary literature and is rarely included in models of centralization. 76,77 Some low-volume centers in Australia and New Zealand achieve clinical outcomes comparable to HV/VHV centers despite only performing 3 to 19 pancreatic cancer resections annually. ...
Background
Pancreatic cancer remains a highly fatal disease with a 5-year overall survival of less than 10%. In seeking to improve clinical outcomes, there is ongoing debate about the weight that should be given to patient volume in centralization models. The aim of this systematic review is to examine the relationship between patient volume and clinical outcome after pancreatic resection for cancer in the contemporary literature.
Methods
The Google Scholar, PubMed, and Cochrane Library databases were systematically searched from February 2015 until June 2021 for articles reporting patient volume and outcomes after pancreatic cancer resection.
Results
There were 46 eligible studies over a 6-year period comprising 526,344 patients. The median defined annual patient volume thresholds varied: low-volume 0 (range 0–9), medium-volume 9 (range 3–29), high-volume 19 (range 9–97), and very-high-volume 28 (range 17–60) patients. The latter 2 were associated with a significantly lower 30-day mortality (P < .001), 90-day mortality (P < .001), overall postoperative morbidity (P = .005), failure to rescue rate (P = .006), and R0 resection rate (P = .008) compared with very-low/low-volume hospitals. Centralization was associated with lower 30-day mortality in 3 out of 5 studies, while postoperative morbidity was similar in 4 out of 4 studies. Median survival was longer in patients traveling greater distance for pancreatic resection in 2 out of 3 studies. Median and 5-year survival did not differ between urban and rural settings.
Conclusion
The contemporary literature confirms a strong relationship between patient volume and clinical outcome for pancreatic cancer resection despite expected bias toward more complex surgery in high-volume centers. These outcomes include lower mortality, morbidity, failure-to-rescue, and positive resection margin rates.
... Posteriormente, en 2004, el grupo Leapfrog, para la mejora de la calidad, propone un sistema de derivació n a centros de referencia basado en la evidencia y a la CP como grupo de procedimientos que se beneficiarían de este sistema 33 . En este contexto, la relació n entre resultados en CP con volumen del centro y experiencia del cirujano fue asentá ndose entre la comunidad científica, gracias a diversos estudios en este sentido, incluyendo metaaná lisis [33][34][35][36][37][38][39][40][41][42] . Poco a poco, el concepto de centro de referencia se ha ido asentando en la mentalidad de todas las esferas sanitarias. ...
Introduction
The main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.
Method
Descriptive, retrospective and single-center study, corresponding to the period 2006−2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.
Results
631 patients were analyzed. The values obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02).
Conclusions
The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.
... There is a potential confounding relationship between hospital and surgeon volume as high volume surgeons tend to operate at high volume hospitals. However, the individual impacts of surgeon versus hospital volume are unclear; multiple studies demonstrate conflicting results regarding whether surgeon or hospital volume is more strongly associated with the volume-outcome effect (2,16,17). ...
Objective:
The purpose of this narrative review is to present the data to date on the volume-outcome association in pancreas cancer surgery and describe the prevalence of and barriers to regionalized pancreas cancer care in western health systems.
Background:
Numerous studies have demonstrated an association between increasing hospital or surgeon volume and improved patient morbidity and mortality in patients undergoing surgery for pancreas cancer. However, since the initial promotion of minimum volume standards, regionalization has remained difficult to establish.
Methods:
A PubMed literature search for years 1995-2020 was conducted to target original research on the volume-outcome association in pancreas cancer and the prevalence of associated regionalized care systems. Peer reviewed original research studies were selected based on their study design and potential to inform meaningful conclusions from the data.
Conclusions:
Increasing hospital or surgeon volume is associated with improved short and long-term survival in pancreas cancer patients undergoing surgical resection. Despite the knowledge that increasing hospital and surgeon volume is associated with improved operative mortality and long term survival in pancreas cancer, the majority of patients undergo surgery at low volume hospitals with low volume surgeons. Barriers to regionalization are complex and involve the interaction of many conflicting factors and processes on human, health system, and national levels. Better understanding of the barriers to regionalization in pancreas cancer care is needed before this model of care becomes feasible.
Introduction
Regionalizing hepatic resections to high‐volume hospitals (HVH) has improved outcomes, yet widened disparities in access. We sought to evaluate the association of hospital volume with quality care outcomes and overall survival (OS) between minor and major hepatectomy for primary liver cancer.
Methods
The National Cancer Database identified patients with primary liver cancer who underwent minor/major hepatectomy (2009–2019). HVHs were defined by the top quartile in annual case volume (vs. the bottom three quartiles). Quality care outcomes (time to resection, margin status, length of stay, 30‐day readmission, 30‐day mortality, 90‐day mortality) and OS were assessed using multivariable regression.
Results
Overall, 6,988 patients underwent minor hepatectomy and 4880 major hepatectomy. No differences in quality care outcomes or OS based on hospital volume for minor hepatectomy were observed (all p > 0.05). Treatment at HVHs for major hepatectomy was associated with decreased odds of 30‐day and 90‐day mortality events (all p < 0.05). Median OS was 40.2 months [IQR 21.7–66.6] at HVHs versus 33.5 [IQR 17.0–58.7] at low‐volume hospitals which remained independently predictive of improved OS on multivariable analysis (HR 0.86, 95% CI 0.79–0.93).
Conclusion
These results support regionalization to HVHs for major hepatectomy; however, minor hepatectomy can be safely performed at hospitals regardless of volume.
Background
Behavioral health disorders (BHD) can often be exacerbated in the setting of cancer. We sought to define the prevalence of BHD among cancer patients and characterize the association of BHD with surgical outcomes.
Methods
Patients diagnosed with lung, esophageal, gastric, liver, pancreatic, and colorectal cancer between 2018-2021 were identified within Medicare Standard Analytic Files. Data on BHD defined as substance abuse, eating disorder, or sleep disorder were obtained. Post-operative textbook outcome (TO)(i.e., no complications, prolonged length of stay, 90-day readmission, or 90-day mortality), as well as in-hospital expenditures and overall survival were assessed.
Results
Among 694,836 cancer patients, 46,719 (6.7%) patients had at least one BHD. Patients with BHD were less likely to undergo resection (no BHD: 23.4% vs. BHD: 20.3%; p<0.001). Among surgical patients, individuals with BHD had higher odds of a complication (OR 1.32 [1.26-1.39]), prolonged length of stay (OR 1.36 [1.29-1.43]), and 90-day readmission (OR 1.57 [1.50-1.65]) independent of social vulnerability or hospital volume status, resulting in lower odds to achieve a TO (OR 0.66 [0.63-0.69]). Surgical patients with BHD also had higher in-hospital expenditures (no BHD: 17,432; p<0.001). Of note, patients with BHD had worse long-term post-operative survival (median, no BHD: 46.6 [45.9-46.7] vs. BHD: 37.1 [35.6-38.7] months) even after controlling for other clinical factors (HR 1.26 [1.22-1.31], p<0.001).
Conclusion
BHD was associated with lower likelihood to achieve a postoperative TO, higher expenditures, as well as worse prognosis. Initiatives to target BHD are needed to improve outcomes of cancer patients undergoing surgery.
We sought to determine the impact of historical redlining on travel patterns and utilization of high-volume hospitals (HVHs) among patients undergoing complex cancer operations.
The California Department of Health Care Access and Information database was utilized to identify patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for cancer between 2010 and 2020. Patient ZIP codes were assigned Home Owners’ Loan Corporation grades (A: ‘Best’; B: ‘Still Desirable’; C: ‘Definitely Declining’; and D: ‘Hazardous/Redlined’). A clustered multivariable regression was used to assess the likelihood of patients undergoing surgery at an HVH, bypassing the nearest HVH, and total real driving time and travel distance.
Among 14,944 patients undergoing high-risk cancer surgery (ES: 4.7%, n = 1216; PN: 57.8%, n = 8643; PD: 14.4%, n = 2154; PR: 23.1%, n = 3452), 782 (5.2%) individuals resided in the ‘Best’, whereas 3393 (22.7%) individuals resided in redlined areas. Median travel distance was 7.8 miles (interquartile range [IQR] 4.1–14.4) and travel time was 16.1 min (IQR 10.7–25.8). Overall, 10,763 (ES: 17.4%; PN: 76.0%; PA: 63.5%; PR: 78.4%) patients underwent surgery at an HVH. On multivariable regression, patients residing in redlined areas were less likely to undergo surgery at an HVH (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.54–0.82) and were more likely to bypass the nearest hospital (OR 1.80, 95% CI 1.44–2.46). Notably, Medicaid insurance, minority status, limited English-language proficiency, and educational level mediated the disparities in access to HVH.
Surgical disparities in access to HVH among patients from historically redlined areas are largely mediated by social determinants such as insurance and minority status.
Background: This study aims to compare the outcomes of high-volume, medium-volume, and low-volume hospitals performing hepatic resections using a network meta-analysis.
Methods: A literature search until June 2023 was conducted across major databases to identify studies comparing outcomes in high-volume, medium-volume, and low-volume hospitals for liver resection. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area values, odds ratio, and mean difference with 95% credible intervals were reported for postoperative mortality, failure-to-rescue, morbidity, length of stay, and hospital costs.
Results: Twenty studies comprising 248,707 patients undergoing liver resection were included. For the primary mortality outcome, overall and subgroup analyses were performed: group I: high-volume = 5 to 20 resections/year; group II: high-volume = 21 to 49 resections/year; group III: high-volume ≥50 resections/year. Results demonstrated a significant association between hospital volume and mortality (overall-high-volume versus medium-volume: odds ratio 0.66, 95% credible interval 0.49-0.87; high-volume versus low-volume: odds ratio 0.52, 95% credible interval 0.41-0.65; group I-high-volume versus low-volume: odds ratio 0.34, 95% credible interval 0.22-0.50; medium-volume versus low-volume: odds ratio 0.56, 95% credible interval 0.33-0.92; group II-high-volume versus low-volume: odds ratio 0.67, 95% credible interval 0.45-0.91), as well as length of stay (high-volume versus low-volume: mean difference -1.24, 95% credible interval -2.07 to -0.41), favoring high-volume hospitals. No significant difference was observed in failure-to-rescue, morbidity, or hospital costs across the 3 groups.
Conclusion: This study supports a positive relationship between hospital volume and surgical outcomes in liver resection. Patients from high-volume hospitals experience superior outcomes in terms of lower postoperative mortality and shorter lengths of stay than medium-volume and low-volume hospitals.
Mental health encompasses cognitive, emotional, and behavioral well-being with mental disorders defined by clinically significant disturbances in cognition, emotion regulation, or behavior. Mental health disorders are diverse and may vary within diagnoses, impacting healthcare and outcomes individually. Mental illness (MI) primarily affects cognition and emotion, including depression, anxiety, and bipolar disorder, while behavioral health disorders (BHD) primarily affect behavior, including substance abuse, eating disorders, and sleep disorders. MI and BHD prevalence is higher in cancer patients, affecting surgical and oncology outcomes. MI correlates with less chemotherapy, poorer surgical outcomes, and increased complications, readmissions, and mortality. MI also leads to increased post-discharge healthcare expenses. Suicidal ideation (SI) risk factors include mental health diagnoses, race, marital status, and gender, while intensive cancer treatment is associated with SI risk. Access to mental healthcare can be limited, particularly in shortage areas. Expanding access through incentive-based programs, collaborative care models, and telehealth systems may mitigate disparities in mental health care access and improve outcomes for cancer patients with comorbid mental illness.
Both textbook outcome (TO) and hospital volume have been identified as quality metrics following cancer surgery. We sought to examine whether TO or hospital volume is more important relative to long-term survival following surgical resection of hepatocellular carcinoma (HCC).
Patients who underwent surgery for HCC between 2004 and 2018 were identified using the National Cancer Database. TO was defined as R0 margin resection, no extended length of stay, no 30-day readmissions, and no 90-day mortality. The impact of TO and hospital case volume on long-term survival was determined using multivariable Cox regression.
Among 24,895 patients who underwent HCC resection, 9.0% (n = 2,252), 79.5% (n = 19,787), and 11.5% (n = 2,856) of patients were operated on at low-, medium-, and high-volume hospitals, respectively. Treatment at high-volume hospitals and achievement of a post-operative TO were independently associated with improved 5-year overall survival (OS). Pairwise comparison demonstrated that patients treated at high-volume hospitals who did not achieve a TO still had a better 5-year OS versus individuals treated at low-volume hospitals who did achieve a TO (5-year OS, no TO vs. TO: low-volume hospitals, 26.5% vs. 48.6%; high volume hospitals: 62.6% vs. 74.9%, respectively; p < 0.001). Overall, resection of HCC at a high-volume hospital was independently associated with a 54% reduction in mortality.
Long-term survival following HCC resection was largely associated with hospital case volume rather than TO. The effect of TO on long-term outcomes was largely mediated by hospital case volume highlighting the importance of centralization of care for patients with HCC.
Introduction:
Regionalization of complex surgical procedures may improve healthcare quality. We sought to define the impact of regionalization on access to high-volume hospitals for complex oncologic procedures in the state of California.
Methods:
The California Department of Health Care Access and Information Database (2012-2016) identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR). Geospatial analysis was conducted to determine travel patterns. Clustered multivariable regression was performed to assess the probability of receiving care at a high-volume center.
Results:
Among 25,070 patients (ES: n = 1216, 4.9%; PN: n = 13,247, 52.8%; PD: n = 3559, 14.2%; PR: n = 7048, 28.1%), 6575 (26.2%) individuals resided within 30 min, 11,046 (44.1%) resided within 30-60 min, 7125 (28.4%) resided within 60-90 min, and 324 (1.3%) resided beyond a 90-min travel window from a high-volume center. Median travel distance was 13.4 miles (interquartile range [IQR] 6.0-28.7). On multivariable regression, patients residing further away were more likely to bypass a low-volume center to undergo care at a high-volume hospital (odds ratio 1.32, 95% confidence interval 1.12-1.55) versus individuals residing closer to high-volume centers. Approximately one-third (29.7%) of patients lived beyond a 1-h travel window to the nearest high-volume hospital, of whom 5% traveled over 90 min. While hospital mortality rates across different travel time windows did not differ, surgery at a high-volume center was associated with an overall 1.2% decrease in in-hospital mortality.
Conclusions:
Regionalization of complex cancer surgery may be associated with a significant travel burden for a large subset of patients with complex cancer.
Background:
Utilization of minimally-invasive distal pancreatectomy (MIDP) for pancreatic adenocarcinoma has increased. While unplanned conversion to an open procedure during MIDP is associated with inferior short-term outcomes, the long-term consequences of conversion have not been adequately examined.
Methods:
Patients with pancreatic adenocarcinoma undergoing MIDP were selected from the National Cancer Database (2010-2015) and subdivided based on the occurrence of unplanned conversion. Post-operative outcomes and overall survival (OS) were examined. Conversion was additionally compared to a matched group of planned open resections.
Results:
Among 592 patients undergoing attempted MIDP, unplanned conversion occurred in 23.1%. Despite increased 90-day mortality among patients experiencing conversion, there was no difference in median OS between groups (25.0 vs 27.8 months, p = 0.095). For patients undergoing conversion, post-operative outcomes and long-term survival were similar when compared to a propensity-matched group of patients undergoing planned open resection. On multivariable analysis, treatment at an academic facility (OR 0.63) and a robotic approach (OR 0.50) were both significantly associated with completed MIDP.
Conclusion:
Despite inferior post-operative outcomes compared to successful MIDP, unplanned conversion did not result in significantly reduced long term survival. MIDP can be attempted selectively but treatment at experienced centers via a robotic approach should be considered.
Objective:
We sought to define the impact of community privilege on variations in travel patterns and access to care at high-volume hospitals for complex surgical procedures.
Background:
With increased emphasis on centralization of high-risk surgery, social determinants of health (SDOH) play a critical role in preventing equitable access to care. Privilege is a right, benefit, advantage, or opportunity that positively impacts all SDOH.
Methods:
The California Office of State-wide Health Planning Database identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for a malignant diagnosis between 2012 and 2016 and was merged using ZIP codes with the Index of Concentration of Extremes, a validated metric of both spatial polarization and privilege obtained from the American Community Survey. Clustered multivariable regression was performed to assess the probability of undergoing care at a high-volume center, bypassing the nearest and high-volume center, and total real driving time and travel distance.
Results:
Among 25,070 patients who underwent a complex oncologic operation (ES: n=1,216, 4.9%; PN: n=13,247, 52.8%; PD: n=3,559, 14.2%; PR: n=7,048, 28.1%), 5,019 (20.0%) individuals resided in areas with the highest privilege (i.e., White, high-income homogeneity), whereas 4,994 (19.9%) individuals resided in areas of the lowest privilege (i.e., Black, low-income homogeneity). Median travel distance was 33.1 miles (interquartile range [IQR] 14.4-72.2) and travel time was 16.4 minutes (IQR 8.3-30.2). Roughly, three-quarters of patients (overall: 74.8%, ES: 35.0%; PN: 74.3%; PD: 75.2%; LR: 82.2%) sought surgical care at a high-volume center. On multivariable regression, patients residing in the least advantaged communities were less likely to undergo surgery at a high-volume hospital (overall: odds ratio [OR] 0.65, 95% confidence interval [CI] 0.52-0.81). Of note, individuals in the least privileged areas had longer travel distances (28.5 miles, 95%CI 21.2-35.8) and times (10.4 m, 95%CI 7.6-13.1) to reach the destination facility, as well as over 70% greater odds of bypassing a high-volume hospital to undergo surgical care at a low-volume center (OR 1.74, 95% CI 1.29-2.34) versus individuals living in the highest privileged areas.
Conclusions and relevance:
Privilege had a marked effect on access to complex oncologic surgical care at high-volume centers. This highlights the need to focus on privilege as a key social determinant of health that influences patient access to and utilization of healthcare resources.
Background
The purpose of this study is to evaluate the trends of hepatobiliary surgeries performed at military hospitals and to discuss potential implications on resident training and military readiness. While there is data to suggest centralization of surgical specialty services leads to improved patient outcomes, the military does not currently have a specific centralization policy. Implementation of such a policy could potentially impact resident training and readiness of military surgeons. Even in the absence of such a policy, there may still be a trend toward centralization of more complex surgeries like hepatobiliary surgeries. The present study evaluates the numbers and types of hepatobiliary procedures performed at military hospitals.
Methods
This study is a retrospective review of de-identified data from Military Health System Mart (M2) from 2014 to 2020. The M2 database contains patient data from all Defense Health Agency treatment facilities, encompassing all branches of the United States Military. Variables collected include number and types of hepatobiliary procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each medical facility. Linear regression was used to evaluate significant trends in numbers of surgeries over time.
Results
Fifty-five military hospitals performed hepatobiliary surgeries from 2014 to 2020. A total of 1,087 hepatobiliary surgeries were performed during this time; cholecystectomies, percutaneous procedures, and endoscopic procedures were excluded. There was no significant decrease in overall case volume. The most commonly performed hepatobiliary surgery was “unlisted laparoscopic liver procedure.” The military training facility with the most hepatobiliary cases was Brooke Army Medical Center.
Conclusion
The number of hepatobiliary surgeries performed in military hospitals has not significantly decreased over the years 2014–2020, despite a national trend toward centralization. Centralization of hepatobiliary surgeries in the future may impact residency training as well as military medical readiness.
Background:
We previously demonstrated the importance of combined complex surgery volume on short-term outcomes of high-risk cancer operations. This study investigates the impact of combined common complex cancer operation volume on long-term outcomes at hospitals with low cancer-specific operation volumes.
Patients and methods:
A retrospective cohort of National Cancer Data Base (2004-2019) patients undergoing surgery for hepatocellular carcinoma, non-small cell lung cancers, or pancreatic, gastric, esophageal, or rectal adenocarcinomas was utilized. Three separate cohorts were established: low-volume hospitals (LVH), mixed-volume hospitals (MVH) with low-volume individual cancer operations and high-volume total complex operations, and high-volume hospitals (HVH). Survival analyses were performed for overall, early-, and late-stage disease.
Results:
The 5 year survival was significantly better at MVH and HVH compared with LVH, for all operations except late-stage hepatectomy (HVH survival > LVH and MVH). The 5 year survival probability was similar between MVH and HVH for operations on late-stage cancers. Early and overall survival for gastrectomy, esophagectomy, and proctectomy were equivalent between MVH and HVH. While early and overall survival for pancreatectomy were benefited by HVH over MVH, the opposite was true for lobectomy/pneumonectomy, which were benefited by MVH over HVH; however, none of these differences were likely to have an effect clinically. Only hepatectomy patients demonstrated statistical and clinical significance in 5 year survival at HVH compared with MVH for overall survival.
Conclusions:
MVH hospitals performing sufficient complex common cancer operations demonstrate similar long-term survival for specific high-risk cancer operations to HVH. MVH provide an adjunctive model to the centralization of complex cancer surgery, while maintaining quality and access.
Background
Hospital volume affects outcomes of patients who underwent resection for hepatocellular carcinoma (HCC). We sought to assess the impact of minimally invasive hepatectomy (MIH) volume on short- and long-term outcomes among patients with HCC.Methods
Patients who underwent MIH for HCC from 2010 to 2018 were identified from the National Cancer Database. Multivariable modeling with restricted cubic splines (RCS) was utilized to identify the MIH hospital volume threshold. Textbook outcome (TO) was defined as no conversion to open resection, negative margins after resection (R0), no extended length-of-stay, no readmission, and no 90-day mortality.ResultsAmong 3268 patients who underwent MIH for HCC, median age was 65.0 (IQR 59.0–72.0) and the majority was male (n = 2308, 70.6%). MIH hospital volume ranged from 1 to 87 cases, with a median of 13 (IQR 7–23). Overall, 2151 (60.9%) patients achieved TO after resection. While particularly high rates of achievement were found for no 90-day mortality (n = 3106, 95.0%), no readmission (n = 3153, 96.5%), and R0 resection (n = 3,017, 92.3%), other TO components including no conversion to open (n = 2778, 85.0%) and no prolonged LOS (n = 2584, 79.1%) were achieved less frequently. Patients treated at high-volume centers (≥50 MIH cases) were more likely to experience TO (high volume centers, n = 334, 68.7% vs. low volume centers, n = 1656, 59.5%, p < 0.001) and better long-term survival (5-year OS; high volume centers, 64.7% vs. low volume centers, 54.6%, p < 0.001).ConclusionsMIH hospital volume was associated with a higher likelihood of achieving TO and improved long-term survival among patients undergoing resection of HCC.
Background:
Available evidence on the volume-outcome relationship after pancreatic surgery is limited due to the narrow focus of interventions, volume indicators and outcomes considered as well as due to methodological differences of the included studies. Therefore, we aim to evaluate the volume-outcome relationship following pancreatic surgery following strict study selection and quality criteria, to identify aspects of methodological variation and to define a set of key methodological indicators to consider when aiming for comparable and valid outcome assessment.
Methods:
Four electronic databases were searched to identify studies on the volume-outcome relationship in pancreatic surgery published between the years 2000-2018. Following a double-screening process, data extraction, quality appraisal, and subgroup analysis, results of included studies were stratified and pooled using random effects meta-analysis.
Results:
Consistent associations were found between high hospital volume and both postoperative mortality (OR 0.35, 95% CI: 0.29-0.44) and major complications (OR 0.87, 95% CI: 0.80-0.94). A significant decrease in the odds ratio was also found for high surgeon volume and postoperative mortality (OR 0.29, 95%CI: 0.22-0.37).
Discussion:
Our meta-analysis confirms a positive effect for both hospital and surgeon volume indicators for pancreatic surgery. Further harmonization (e.g. surgery types, volume cut-offs/definition, case-mix adjustment, reported outcomes) are recommended for future empirical studies.
Background
The interplay of patient-, procedural, and provider-level factors on the ability to achieve a textbook outcome(TO) remain poorly defined.
Methods
The Medicare Standard Analytical Files from 2013-2017 were used to identify beneficiaries who underwent pancreatic surgery. Multivariable logistic regression with mixed effects was used to examine the role of the individual surgeon relative to patient- and procedural-factors to achieve a TO.
Results
Among 20,902 patients who underwent pancreatic resection, median age was 72 years (IQR:68–77); roughly one-half of the cohort was female(47,4%) and the majority was White (89.3%). After controlling for patient- and procedure-related characteristics, there was 35% variation in odds of experiencing a TO relative to the specific individual surgeon who performed the operation (OR:1.35, 95%CI:1.29–1.41). Patients who underwent pancreatectomy by a bottom TO quartile surgeon had a higher observed/expected ratio for each component of TO including post-operative complication (OR:2.62, 95%CI:2.11–3.25), prolonged LOS (OR:3.36, 95%CI:2.67–4.22), 90-day readmission (OR:2.08, 95%CI:1.68–2.56), and 90-day mortality (OR:3.29, 95% CI:2.35–4.63) compared with patients treated by a high TO quartile surgeon.
Conclusion
The likelihood of achieving a TO after pancreatic resection was markedly influenced by the individual treating surgeon even after controlling for patient- and procedure-level factors.
Mortality after pancreatoduodenectomy has improved over time. This progress is likely related to advancements in failure to rescue (FTR-the percentage of patients who die after developing a major complication). Several factors associated with FTR include patient-specific risks, development of certain postoperative complications, surgeon-specific factors, hospital-specific factors, rescue techniques, and regional differences. Efforts should be made to explore additional factors such as the influence of safety culture in the postoperative setting. Improvement in FTR may be better explored through randomized controlled postoperative management trials. In stable patients, management of complications by interventional radiology is preferred over reoperation.
Background/Aim: Since the first pancreaticoduodenectomy (PD) surgeries, mortality, morbidity and length of hospital stay decreased, in return, the number of uncomplicated cases and dissected lymph nodes increased over the years. The aim of our study was to determine the effect of hospital volume on survival, postoperative hospital stay, fistula rate, morbidity rate and the number of lymph nodes dissected. Methods: In this retrospective cohort study, 213 patients who were operated with the diagnosis of periampullary tumor between January 2008 and January 2016 were included in the study. The patients were divided into four groups according to the years of surgery: Group A (n=31, 2008-2009), Group B (n=46, 2010-2011), Group C (n=50, 2012-2013) and Group D (n=86, 2014-2016). The groups were compared with each other in terms of the following factors; Pancreatic fistula rates, postoperative hospital stay, mortality rates, morbidity rates, number of dissected lymph nodes. Results: It has been observed that there is a relation between pancreatic tissue quality and duct size with fistulas (P=0.0016 and P=0.017, respectively). It is seen that as the amount of number lymph nodules increases, the quality of staging improves (P=0.009). Rates of mortality and morbidity are decreased, as the hospital volume increased (P=0.037), The same effect of hospital volume is observed in length of hospital stay and fistula rates, both improved (P=0.017 and P
Background
Liver transplantation has increased in volume and provides substantial survival benefit. However, there remains a need for value-based assessment of this costly procedure.
Methods
Model for end stage liver disease era adult recipients were identified using United Network for Organ Sharing Standard Transplant Analysis file data (n = 75,988) and compared across time periods (period A: February 2002 to January 2007; B: February 2007 to January 2013; C: February 2013 to January 2019). Liver centers were divided into volume tertiles for each period (small, medium, large). Value for the index transplant episode was defined as percentage graft survival ≥1 year divided by mean posttransplant duration of stay.
Results
All centers increased value over time due to ubiquitous improvement in 1-year graft survival. However, large centers demonstrated the most significant value change (large +17% vs small +7.0%, P < .001) due to a –8.5% reduction in large centers duration of stay from period A to C, while small centers duration of stay remained unchanged (–0.1%). Large centers delivered higher value despite more complex care: older recipients (54.8 ± 10.3 vs 53.0 ± 11.4 years P < .001), fewer model for end stage liver disease exceptions (34.0% vs 38.2%, P < .001), higher rates of candidate portal vein thrombosis (10.1% vs 8.5%, P < .001) and prior abdominal surgery (43.4% vs 37.4%, P < .001), and more marginal donor utilization (donor risk index 1.45 ± 0.38 vs 1.36 ± 0.33, P < .001). Mahalanobis metric matching demonstrated that compared with small centers, large centers progressively shortened recipient duration of stay per transplant in each period (A: –0.36 days, P = .437; B: –2.14 days, P < .001; C: –2.49 days, P < .001).
Conclusion
There is value in liver transplant volume. Adoption of value-based practices from large centers may allow optimization of health care delivery for this costly procedure.
There is extensive research demonstrating significant variation in the utilization of surgery and outcomes from surgery, including differences in mortality, complications, readmission, and failure to rescue. Literature suggests that these variations exist across as well as within small area geographies in the United States. There is also significant evidence of variation in access and outcomes from surgery that is attributable to race. Emerging research is demonstrating that there may be some variation attributable to a patient's social determinants of health and their lived averment. Those affected must work together to determine rate of utilization and how much variation is acceptable.
Objective:
To evaluate the effect of a liver transplantation (LT) program on the outcomes of resectable hepatocellular carcinoma (HCC).
Summary background data:
Surgical treatment of HCC includes both hepatic resection (HR) and LT. However, the presence of cirrhosis and the possibility of recurrence make the management of this disease complex and probably different according to the presence of a LT program.
Methods:
Patients undergoing HR for HCC between January 2005 and December 2019 were identified from a national database of HCC. The main study outcomes were major surgical complications according to the Comprehensive Complication Index (CCI), post-hepatectomy liver failure (PHLF), 90-day mortality, overall survival (OS), and disease-free survival (DFS). Secondary outcomes were salvage liver transplantation (SLT) and post-recurrence survival (PRS).
Results:
A total of 3202 patients were included from 25 hospitals over the study period. Three out of 25 (12%) had a LT program. The presence of a LT program within a center was associated with a reduced probability of PHLF (OR=0.38) but not with OS and DFS. There was an increased probability of SLT when HR was performed in a transplant hospital (OR=12.05). Among transplant-eligible patients, those who underwent LT had a significantly longer PRS.
Conclusions:
This study showed that the presence of a LT program was associated with decreased PHLF rates and an increased probability to receive SLT in case of recurrence.
Background:
To ensure that highly advanced hepatobiliary-pancreatic surgery (HBPS) is performed safely, the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) board certification system for expert surgeons established a safety committee to monitor surgical safety.
Methods:
We investigated postoperative mortality rates based on summary reports of numbers and outcomes of highly advanced HBPS submitted annually by the board-certified training institutions from 2012 to 2019. We also analyzed summary reports on mortality cases submitted by institutions with high 90-day post-HBPS mortality rates and recommended site visits and surveys as necessary.
Results:
Highly advanced HBPS was performed in 121,518 patients during the 8-year period. Thirty-day mortality rates from 2012 to 2019 were 0.92%, 0.8%, 0.61%, 0.63%, 0.70%, 0.59%, 0.48%, and 0.52%, respectively (p < .001). Ninety-day mortality rates were 2.1%, 1.82%, 1.62%, 1.28%, 1.46%, 1.22%, 1.19%, and 0.98%, respectively (p < .001). Summary reports were submitted by 20 hospitals between 2015 and 2019. Mortality rates before and after the start of report submission and audit were 5.72% and 2.79%, respectively, (odds ratio 0.690, 95% confidence interval 0.487-0.977; p = .037).
Conclusions:
Development of a system for designation of board-certified expert surgeons and safety management improved the mortality rate associated with highly advanced HBPS.
Introduction
Identification of early stage gallbladder cancer (GBC) is difficult with simple cholecystectomy being considered curative for T1a GBC but T1b requires radical cholecystectomy due to chances of lymph node metastasis. However there is no consensus regarding the optimal treatment strategy for T1b disease.
Methodology
A retrospective review of a prospectively maintained database of GBC patients operated at our institute from March 2010 to March 2021 was conducted. Only patients with proven gallbladder adenocarcinoma on final histopathology report were included.
Results
A total of 1245 patients of suspected GBC who underwent surgery during this period with 76 patients of T1b stage were analysed. We divided the group into a node positive cohort (n = 16, 9 received neoadjuvant treatment due to uptake in periportal nodes and 7 patients were pN1) and a node negative cohort (n = 60). The median nodal harvest was 8 nodes (2–24 nodes). Considering the radiological and pathological parameters, the rate of lymph node positivity was 21% (16/76). The overall major morbidity was 5.2% and there was no mortality. After a median follow up of 47.5 months, 3-year OS and DFS of the node negative and positive cohort was 96.7%, 91.7% and 75% and 62.5% (p = 0.058). The node positive cohort had 43% recurrences whereas the node negative cohort had 8.3% with all recurrences limited to periportal lymph nodes, distant nodes or liver metastasis.
Conclusion
Nodal positivity for T1b gall bladder cancer ranges around 21% and radical surgery with complete peri –portal lymphadenectomy should be considered as standard of care.
IntroductionIncreasing hospital or surgeon volume is associated with improved outcomes among patients with pancreatic cancer. Promotion of regionalized care is based on this volume-outcome association. However, other research has exposed nuances and complexities inherent to this association that should be considered when promoting regionalized care models. We herein provide a critical review of the literature on the volume-outcome association and a discussion of areas of ongoing controversy.MethodsA PubMed literature search was conducted for the years 1995–2020. Peer reviewed original research studies were selected for critical review based on study design, potential to draw meaningful conclusions from the data, and discussion of current knowledge gaps.ResultsBased on the cumulative published literature, hospital/surgeon volume and patient mortality are inversely related. However, it remains unclear whether volume is a proxy for other more causative variables inherent in high-volume centers. Interpretation of the volume-outcome association is made more difficult to interpret due to the large variation in the definition of high volume, difficulty in isolating the individual impact of surgeon versus hospital volume, challenges in quantifying health system processes related to volume, and the fact that some low-volume centers consistently achieve excellent clinical results. Implementation of true regionalized care models has been rare, likely reflecting both health system and patient level challenges.Conclusion
The volume-outcome association has been consistently demonstrated to be important to the care of patients with pancreas cancer. The underlying mechanism of this association to explain the overall benefit is likely multifactorial. Better understanding of what drives the volume-outcome association may increase access to optimized care for a broader range of hospital systems and patients.
Background and PurposeThere is limited high-level evidence to guide locally advanced pancreas cancer (LAPC) management. Recent work shows that surgeons’ preferences in LAPC management vary broadly. We sought to examine whether surgeon volume was associated with attitudes regarding LAPC management.Methods
An electronic survey was distributed by email to an international cohort of pancreas surgeons to evaluate practice patterns regarding LAPC management. Clinical vignette-based questions evaluated surgeons’ attitudes regarding patient eligibility and the proclivity to offer exploration. Surgeons were classified into “low-“ or “high-volume” categories according to thresholds of self-reported annual pancreatectomy volume. Surgeon’s attitudes regarding LAPC management and inclination to consider exploration were compared across annual volume categories.ResultsA total of 153 eligible responses were received from 4 continents, for an estimated response rate of 10.6%. Median duration of practice was 12 years (IQR 6–20). Most respondents reported >25 cases/year (89, 58.2%), of which 34 (22.2%) reported >50. Compared to surgeons with <25 cases/year, surgeons with >25 cases/year practiced longer (median 15 vs. 7.5 years, P<0.001) and were more likely to “always” recommend neoadjuvant chemotherapy (83.2% vs. 56.3%, P=0.001). Surgeons performing >50 cases/year were more likely to offer arterial resection (70.6% vs. 43.7%, P=0.006). The willingness to offer (or defer) exploration did not differ across any categories of surgeons’ annual case volume.Conclusions
In an international survey of pancreas surgeons, the proclivity to consider exploration for LAPC was not associated with multiple categories of surgeon volume. Better evidence is needed to define the optimal management approach to LAPC.
Purpose:
We sought to determine whether colorectal cancer surgery can be done safely at rural hospitals. The current study compared outcomes among rural patients who underwent colon resection at rural and nonrural hospitals.
Methods:
Medicare beneficiaries who underwent colon resection for cancer between 2013 and 2017 were identified using the Medicare Inpatient Standard Analytic Files. Patients and hospitals were designated as rural based on rural-urban continuum codes. Risk-adjusted postoperative outcomes and hospitalization spending were compared among patients undergoing resection at rural versus nonrural hospitals.
Results:
Among 3,937 patients who resided in a rural county and underwent colon resection for cancer, mean age was 76.3 (SD: 7.1) years and 1,432 (36.4%) patients underwent operative procedure at a rural hospital. On multivariable analyses, no differences in postoperative outcomes were noted among Medicare beneficiaries undergoing colon resection for cancer at nonrural versus rural hospitals. Specifically, the risk-adjusted probability of experiencing a postoperative complication at a nonrural hospital was 15.4% (95% CI: 14.1%-16.8%) versus 16.3% (95% CI: 14.2%-18.3%) at a rural hospital (OR 1.08, 95% CI: 0.85-1.38); 30-day mortality (nonrural: 2.9%, 95% CI: 2.2-3.6 vs rural: 3.5%, 95% CI: 2.4-4.5) was also comparable. In addition, price standardized, risk-adjusted expenditures were similar at nonrural (18,037-19,010, 95% CI: 19,390) hospitals.
Conclusion:
Among rural Medicare beneficiaries who underwent a colon resection for cancer, there were no differences in postoperative outcomes among nonrural versus rural hospitals. These findings serve to highlight the importance of policies and practice guidelines that secure safe, local surgical care, allowing rural clinicians to accommodate strong patient preferences while delivering high-quality surgical care.
Background:
The relationship between hospital Magnet status recognition and postoperative outcomes following complex cancer surgery remains ill-defined. We sought to characterize Textbook Outcome (TO) rates among patients undergoing (HP) surgery for cancer in Magnet versus non-Magnet centers.
Methods:
Medicare beneficiaries undergoing HP surgery between 2015 and 2017 were identified. The association of postoperative TO (no complications/extended length-of-stay/90-day mortality/90-day readmission) with Magnet designation was examined after adjusting for competing risk factors.
Results:
Among 10,997 patients, 21.3% (n = 2337) patients underwent surgery at Magnet hospitals (non-Magnet centers: 78.7%, n = 8660). On multivariable analysis, patients undergoing HP surgery had comparable odds of achieving a TO at Magnet versus non-Magnet hospitals (hepatectomy: odds ratio [OR]: 1.05, 95% confidence interval [CI]: 0.94-1.17; pancreatectomy-OR: 0.88, 95% CI: 0.74-1.06). Patients treated at hospitals with a high nurse-to-bed ratio had higher odds of achieving a TO irrespective of whether they received surgery at Magnet (high vs. low nurse-to-bed ratio; OR: 1.38; 95% CI: 1.01-1.89) or non-Magnet centers (OR: 1.26; 95% CI: 1.10-1.45). Similarly, hospital HP volume was strongly associated with higher odds of TO following HP surgery in both Magnet (Leapfrog compliant vs. noncompliant; OR: 1.24, 95% CI: 1.06-1.44) and non-Magnet centers (OR: 1.18; 95% CI: 1.11-1.26).
Conclusion:
Hospital Magnet designation was not an independent factor of superior outcomes after HP surgery. Rather, hospital-level factors such as nurse-to-bed ratio and HP procedural volume drove outcomes.
Although numerous studies suggest that there is an inverse relation between hospital volume of surgical procedures and surgical mortality, the relative importance of hospital volume in various surgical procedures is disputed.
Using information from the national Medicare claims data base and the Nationwide Inpatient Sample, we examined the mortality associated with six different types of cardiovascular procedures and eight types of major cancer resections between 1994 and 1999 (total number of procedures, 2.5 million). Regression techniques were used to describe relations between hospital volume (total number of procedures performed per year) and mortality (in-hospital or within 30 days), with adjustment for characteristics of the patients.
Mortality decreased as volume increased for all 14 types of procedures, but the relative importance of volume varied markedly according to the type of procedure. Absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals ranged from over 12 percent (for pancreatic resection, 16.3 percent vs. 3.8 percent) to only 0.2 percent (for carotid endarterectomy, 1.7 percent vs. 1.5 percent). The absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals were greater than 5 percent for esophagectomy and pneumonectomy, 2 to 5 percent for gastrectomy, cystectomy, repair of a nonruptured abdominal aneurysm, and replacement of an aortic or mitral valve, and less than 2 percent for coronary-artery bypass grafting, lower-extremity bypass, colectomy, lobectomy, and nephrectomy.
In the absence of other information about the quality of surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital.
Although initiatives to regionalize cancer surgery are already under way, the relative importance of volume in cancer surgery is disputed.
We examined surgical mortality with 8 cancer resections in the US population to better quantify the influence of hospital volume.
Using information from the all-payer Nationwide Inpatient Sample (1995-1997), we examined mortality with 8 cancer resections (N = 195 152). After dividing patients into 3 evenly sized volume groups based on hospital procedure volume (low, medium, and high), we used regression techniques to describe relationships between hospital volume and in-hospital mortality, adjusting for patient characteristics.
Trends toward lower operative risks at high-volume hospitals were observed for 7 of the 8 procedures. However, differences between low- and high high-volume hospitals were statistically significant for only 3 operations (esophagectomy, 15.0% vs 6.5%; pancreatic resection, 13.1% vs 2.5%; and pulmonary lobectomy, 10.1% vs 8.9%, respectively). Although they did not reach statistical significance, absolute differences in mortality between low- and high-volume hospitals were greater than 1% for the following 3 procedures: gastrectomy, 8.7% vs 6.9%; cystectomy, 3.6% vs 2.5%; and pneumonectomy, 10.6% vs 8.9%, respectively. Mortality reductions for nephrectomy and colectomy were small. In general, in terms of absolute differences in mortality, the effect of volume was greatest in elderly patients.
Operative mortality decreases with increasing hospital volume for several cancer resections. However, volume may be most important in patients who are older and at higher risk.
To determine whether the improved outcome of a surgical procedure in high volume hospitals is specific to the volume of the same procedure.
Analysis of secondary data in Ontario, Canada.
Patients having an oesophagectomy, colorectal resection for cancer, pancreaticoduodenectomy, major lung resection for cancer, or repair of an unruptured abdominal aortic aneurysm between 1994 and 1999.
Odds ratio for death within 30 days of surgery in relation to the hospital volume of the same surgical procedure and the hospital volume of the other four procedures. Estimates were adjusted for age, sex, and comorbidity and accounted for hospital level clustering.
With the exception of colorectal resection, 30 day mortality seemed to be inversely related not only to the hospital volume of the same procedure but also to the hospital volume of most of the other procedures. In some cases the effect of the volume of a different procedure was stronger than the effect of the volume of the same procedure. For example, the association of mortality from pancreaticoduodenectomy with hospital volume of lung resection (odds ratio for death in hospitals with a high volume of lung resection compared with low volume 0.36, 95% confidence interval 0.23 to 0.57) was much stronger than the association of mortality from pancreaticoduodenectomy with hospital volume of pancreaticoduodenectomy (0.76, 0.44 to 1.32).
The inverse association between high volume of procedure and risk of operative death is not specific to the volume of the procedure being studied.
Strong associations between provider (i.e., hospital or surgeon) procedure volumes and patient outcomes have been demonstrated for many types of cancer operation. We performed a population-based cohort study to examine these associations for ovarian cancer resections.
We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to identify 2952 patients aged 65 years or older who had surgery for a primary ovarian cancer diagnosed from 1992 through 1999. Hospital- and surgeon-specific procedure volumes were ascertained based on the number of claims submitted during the 8-year study period. Primary outcome measures were mortality at 60 days and 2 years after surgery, and overall survival. Length of hospital stay was also examined. Patient age at diagnosis, race, marital status, comorbid illness, cancer stage, and median income and population density in the area of residence were used to adjust for differences in case mix. All P values are two-sided.
Neither hospital- nor surgeon-specific procedure volume was statistically significantly associated with 60-day mortality following primary ovarian cancer resection. However, differences by hospital volume were seen with 2-year mortality; patients treated at the low-, intermediate-, and high-volume hospitals had 2-year mortality rates of 45.2% (95% confidence interval [CI] = 42.1% to 48.4%), 41.1% (95% CI = 38.1% to 44.3%), and 40.4% (95% CI = 37.4% to 43.4%), respectively. The inverse association between hospital procedure volume and 2-year mortality was statistically significant both before (P = .011) and after (P = .006) case-mix adjustment but not after adjustment for surgeon volume. Two-year mortality for patients treated by low-, intermediate-, and high-volume surgeons was 43.2% (95% CI = 40.7% to 45.8%), 42.9% (95% CI = 39.5% to 46.4%), and 39.5% (95% CI = 36.0% to 43.2%), respectively; there was no association between 2-year mortality and surgeon procedure volume, with or without case-mix adjustment. After case-mix adjustment, neither hospital volume (P = .031) nor surgeon volume (P = .062) was strongly associated with overall survival.
Hospital- and surgeon-specific procedure volumes are not strong predictors of survival outcomes following surgery for ovarian cancer among women aged 65 years or older.
Specialty-specific hospitals and hospitals with a high volume of complex procedures have been shown to have better outcomes. We sought to determine whether a high volume of unrelated complex procedures or procedures in the same specialty area (urology) could translate into better outcomes after major urologic cancer surgery.
We performed a cross-sectional analysis of administrative discharge abstract data from the Nationwide Inpatient Sample of the Health Care Utilization Project for years 1998 to 2002. Comparison of outcome after three major urologic cancer-related surgical procedures (radical cystectomy [RC], radical nephrectomy [RN], and radical prostatectomy [RP]) at hospitals by procedure-specific volume, specialized urology status, and Leapfrog criteria was obtained to determine in-hospital mortality after the procedure. All patients in the database with a diagnosis of bladder, kidney, or prostate cancer being admitted for RC, RN, or RP between 1998 and 2002 were included.
Neither specialized urology status nor meeting Leapfrog volume criteria for unrelated procedures was associated with lower odds of in-hospital mortality after any of the procedures examined. High-volume hospitals (for RC and RP) and moderate-volume hospitals (for RP) were associated with lower odds of mortality. None of the examined hospital volume-related factors was associated with lower odds of mortality after RN.
In-hospital mortality after two of three major urologic cancer procedures is affected only by procedure-specific volumes. Generalized process measures existing in hospitals performing a high volume of general urologic procedures or unrelated complex procedures may be less important determinants of procedure-specific outcomes in patients.
To determine whether the improved outcome of a surgical procedure in high volume hospitals is specific to the volume of the same procedure.
Analysis of secondary data in Ontario, Canada.
Patients having an oesophagectomy, colorectal resection for cancer, pancreaticoduodenectomy, major lung resection for cancer, or repair of an unruptured abdominal aortic aneurysm between 1994 and 1999.
Odds ratio for death within 30 days of surgery in relation to the hospital volume of the same surgical procedure and the hospital volume of the other four procedures. Estimates were adjusted for age, sex, and comorbidity and accounted for hospital level clustering.
With the exception of colorectal resection, 30 day mortality seemed to be inversely related not only to the hospital volume of the same procedure but also to the hospital volume of most of the other procedures. In some cases the effect of the volume of a different procedure was stronger than the effect of the volume of the same procedure. For example, the association of mortality from pancreaticoduodenectomy with hospital volume of lung resection (odds ratio for death in hospitals with a high volume of lung resection compared with low volume 0.36, 95% confidence interval 0.23 to 0.57) was much stronger than the association of mortality from pancreaticoduodenectomy with hospital volume of pancreaticoduodenectomy (0.76, 0.44 to 1.32).
The inverse association between high volume of procedure and risk of operative death is not specific to the volume of the procedure being studied.
Background
Hepatic resection has become common in the United States for both primary and secondary hepatic tumors.
Hypothesis
Variation in outcomes after hepatic resection is related to patient characteristics, the indication for operation, and hospital procedural volume.
Design
Observational study using a nationally representative database.
Patients
All patients in the Nationwide Inpatient Sample for 1996 and 1997 with a primary procedure code for hepatic resection (N = 2097).
Main Outcome Measures
Outcomes included in-hospital mortality and length of stay. Risk-adjusted analyses were performed using hierarchical multivariate models.
Results
Overall mortality for the 2097 patients was 5.8%. The most common indications for hepatic resection were secondary metastases (52%), primary hepatic malignancy (16%), biliary tract malignancy (10%), and benign hepatic tumor (5%). High-volume hospitals had a mortality rate of 3.9% vs 7.6% at low-volume hospitals (P<.001). In the multivariate analysis adjusting for patient case-mix, high-volume hospitals had a 40% lower risk of in-hospital mortality compared with low-volume hospitals (odds ratio, 0.60; 95% confidence interval, 0.39-0.92; P = .02). Other predictors of mortality in the multivariate analysis included age older than 65 years, hepatic lobectomy (vs wedge resection), primary hepatic malignancy (vs metastases), and the severity of underlying liver disease.
Conclusions
Hospital procedural volume is an important predictor of mortality after hepatic resection. Patients who require resection of primary and secondary liver tumors should be offered referral to a high-volume center.
Hypothesis
High-volume centers provide superior quality care and therefore have a lower incidence of postoperative complications.
Design
Observational statewide administrative database.
Setting
State of Maryland, nonfederal acute-care hospital (n = 52), performing liver resection (n = 35).
Patients
All patients discharged after undergoing hepatic resection from 1994 to 1998 (N = 569).
Main Outcome Measures
Two sequential analyses using multiple logistic regression of in-hospital mortality were performed to determine the relative importance of preoperative case-mix and postoperative complications.
Results
The overall in-hospital mortality rate was 4.8% and was significantly lower in high-volume hospitals (2.8%) than in low-volume hospitals (10.2%) (P<.001). After adjusting for case-mix in the multivariate analysis, low hospital volume was associated with a 3-fold increase in mortality (odds ratio, 3.1; 95% confidence interval [CI], 1.2-7.6; P = .02). Having surgery at a low-volume hospital was associated with increased rates of several postoperative complications: reintubation (relative risk [RR], 2.5; 95% CI, 1.8-3.4), pulmonary failure (RR, 2.3; 95% CI, 1.6-3.5), pneumonia (RR, 0.35; 95% CI, 1.0-5.6), acute renal failure (RR, 2.0; 95% CI, 1.1-3.7), acute myocardial infarction (RR, 2.6; 95% CI, 1.2-5.9), and aspiration (RR, 1.4; 95% CI, 0.9-2.0). When considering all other factors using statistical methods, hospital volume was no longer associated with mortality.
Conclusions
Patients who undergo hepatic resection at low-volume hospitals are at a higher risk of postoperative complications and death than those who have the same operation at high-volume hospitals. The empirical difference between outcomes at high- and low-volume hospitals seems to be due to a variation in postoperative complications.
Background
Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain.
Methods
Using information from the national Medicare claims data base for 1998 through 1999, we examined mortality among all 474,108 patients who underwent one of eight cardiovascular procedures or cancer resections. Using nested regression models, we examined the relations between operative mortality and surgeon volume and hospital volume (each in terms of total procedures performed per year), with adjustment for characteristics of the patients and other characteristics of the providers.
Results
Surgeon volume was inversely related to operative mortality for all eight procedures (P=0.003 for lung resection, P<0.001 for all other procedures). The adjusted odds ratio for operative death (for patients with a low-volume surgeon vs. those with a high-volume surgeon) varied widely according to the procedure — from 1.24 for lung resection to 3.61 for pancreatic resection. Surgeon volume accounted for a large proportion of the apparent effect of the hospital volume, to an extent that varied according to the procedure: it accounted for 100 percent of the effect for aortic-valve replacement, 57 percent for elective repair of an abdominal aortic aneurysm, 55 percent for pancreatic resection, 49 percent for coronary-artery bypass grafting, 46 percent for esophagectomy, 39 percent for cystectomy, and 24 percent for lung resection. For most procedures, the mortality rate was higher among patients of low-volume surgeons than among those of high-volume surgeons, regardless of the surgical volume of the hospital in which they practiced.
Conclusions
For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently.
Administrative databases are increasingly used for studying outcomes of medical care. Valid inferences from such data require the ability to account for disease severity and comorbid conditions. We adapted a clinical comorbidity index, designed for use with medical records, for research relying on International Classification of Diseases (ICD-9-CM) diagnosis and procedure codes. The association of this adapted index with health outcomes and resource use was then examined with a sample of Medicare beneficiaries who underwent lumbar spine surgery in 1985 ( n = 27,111). The index was associated in the expected direction with postoperative complications, mortality, blood transfusion, discharge to nursing home, length of hospital stay,and hospital charges. These associations were observed whether the index incorporated data from multiple hospitalizations over a year's time, or just from the index surgical admission. They also persisted after controlling for patient age. We conclude that the adapted comorbidity index will be useful in studies of disease outcome and resource use employing administrative databases.
Background
and
objective: We reviewed retrospectively the anaesthetic management and perioperative course of eight right hepatectomies for living liver donation.
Recent studies have demonstrated the relationship between clinical outcomes of complex surgical procedures and provider volume.
Hepatic resection is one such high-risk surgical procedure. The aim of this analysis was to determine whether mortality and
cost of performing hepatic resection are related to surgical volume while also examining outcomes by extent of resection and
diagnosis, variables seen with this procedure. Maryland discharge data were used to study surgical volume, length of stay,
charges, and mortality for 606 liver resections performed at all acute-care hospitals between January 1990 and June 1996.
One high-volume provider accounted for 43.6% of discharges, averaging 40.6 cases per year. In comparison, the remainder of
resections were performed at 35 other hospitals, averaging 1.5 cases per year. Data were stratified into these high- and low-volume
groups, and adjusted outcomes were compared. The mortality rate for all procedures in the low-volume group was 7.9% compared
to 1.5% for the high-volume provider (P <0.01, relative risk = 5.2). No overall differences were observed between low- and high-volume providers in total hospital
charges. When analyzing by procedure type and diagnosis, lower mortality was seen in the high-volume center for both minor
and major resections, as well as resections for metastatic disease. It was concluded that hepatic resection can be performed
more safely and at comparable cost at high-volume referral centers.
Objective:
To examine the association of surgeon and hospital case volumes with the short-term outcomes of in-hospital death, total hospital charges, and length of stay for resection of colorectal carcinoma.
Methods:
The study design was a cross-sectional analysis of all adult patients who underwent resection for colorectal cancer using Maryland state discharge data from 1992 to 1996. Cases were divided into three groups based on annual surgeon case volume--low (< or =5), medium (5 to 10), and high (>10)--and hospital volume--low (<40), medium (40 to 70), and high (> or =70). Poisson and multiple linear regression analyses were used to identify differences in outcomes among volume groups while adjusting for variations in type of resections performed, cancer stage, patient comorbidities, urgency of admission, and patient demographic variables.
Results:
During the 5-year period, 9739 resections were performed by 812 surgeons at 50 hospitals. The majority of surgeons (81%) and hospitals (58%) were in the low-volume group. The low-volume surgeons operated on 3461 of the 9739 total patients (36%) at an average rate of 1.8 cases per year. Higher surgeon volume was associated with significant improvement in all three outcomes (in-hospital death, length of stay, and cost). Medium-volume surgeons achieved results equivalent to high-volume surgeons when they operated in high- or medium-volume hospitals.
Conclusions:
A skewed distribution of case volumes by surgeon was found in this study of patients who underwent resection for large bowel cancer in Maryland. The majority of these surgeons performed very few operations for colorectal cancer per year, whereas a minority performed >10 cases per year. Medium-volume surgeons achieved excellent outcomes similar to high-volume surgeons when operating in medium-volume or high-volume hospitals, but not in low-volume hospitals. The results of low-volume surgeons improved with increasing hospital volume but never equaled those of the high-volume surgeons.
Administrative databases are increasingly used for studying outcomes of medical care. Valid inferences from such data require the ability to account for disease severity and comorbid conditions. We adapted a clinical comorbidity index, designed for use with medical records, for research relying on International Classification of Diseases (ICD-9-CM) diagnosis and procedure codes. The association of this adapted index with health outcomes and resource use was then examined with a sample of Medicare beneficiaries who underwent lumbar spine surgery in 1985 (n = 27,111). The index was associated in the expected direction with postoperative complications, mortality, blood transfusion, discharge to nursing home, length of hospital stay, and hospital charges. These associations were observed whether the index incorporated data from multiple hospitalizations over a year's time, or just from the index surgical admission. They also persisted after controlling for patient age. We conclude that the adapted comorbidity index will be useful in studies of disease outcome and resource use employing administrative databases.
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
The authors examined the effect of hospital and surgeon volume on perioperative mortality rates after pancreatic resection for the treatment of pancreatic cancer.
Discharge abstracts from 1972 patients who had undergone pancreaticoduodenectomy or total pancreatectomy for malignancy in New York State between 1984 and 1991 were obtained from the Statewide Planning and Research Cooperative System. Logistic regression analysis was used to determine the relationship between hospital and surgeon experience to perioperative outcome.
More than 75% of patients underwent resection at minimal-volume (fewer than 10 cases) or low-volume (10-50 cases) centers (defined as hospitals in which a minimal number of resections were performed in a given year), and these hospitals represented 98% of the institutions treating peripancreatic cancer. The two high-volume hospitals (more than 81 cases) demonstrated a significantly lower perioperative mortality rate (4.0%) compared with the minimal- (21.8%) and low-volume (12.3%) hospitals (p < 0.001). The perioperative mortality rate was 15.5% for low-volume (fewer than 9 cases) surgeons (defined as surgeons who had performed a minimal number of resections in any hospital in a given year) (n = 687) compared with 4.7% for high-volume (more than 41 cases) pancreatic surgeons (n = 4) (p < 0.001). Logistic regression analysis demonstrated that perioperative death is significantly (p < 0.05) related to hospital volume, but the surgeon's experience is not significantly related to perioperative deaths when hospital volume is controlled.
These data support a defined minimum hospital experience for elective pancreatectomy for malignancy to minimize perioperative deaths.
The effects of regionalization of tertiary care were studied by analyzing cost and outcome for pancreaticoduodenectomies in a state in which the majority of these high-risk procedures were performed in one hospital.
Using Maryland inpatient discharge data via a retrospective study, the authors compared cost and outcome data for a hospital with more than one half of the cases in the state to all other hospital providers as a group and with smaller groupings according to the volume of procedures performed.
Hospital mortality, length of stay, and costs were significantly less at the high-volume regional medical center when compared with all other hospitals. Mortality and cost increased as volume decreased when hospitals were grouped according to volume.
An academic medical center, functioning as a high-volume regional provider, can deliver tertiary care services with improved outcomes at lower costs than community hospitals.
To determine whether hospital volume is associated with clinical and economic outcomes for patients with pancreatic cancer who underwent pancreatic resection, palliative bypass, or endoscopic or percutaneous stent procedures in Maryland between 1990 and 1995.
Previous studies have demonstrated that outcomes for patients undergoing a Whipple procedure improve with higher surgical volume, but only 20% to 35% of patients with pancreatic cancer qualify for curative resection. Most patients undergo palliative procedures instead with a surgical bypass or biliary stent.
Analysis of hospital discharge data from all nonfederal acute care hospitals in Maryland identified all patients with pancreatic cancer who underwent a pancreatic resection, palliative bypass, or stent procedure between 1990 and 1995. Hospitals (n = 48) were categorized as high-, medium-, and low-volume providers according to their average annual volume of these procedures. Multivariate regression was used to examine the association between hospital volume and in-hospital mortality rate, length of stay, and hospital charges, after adjusting for differences in case mix and surgeon volume.
Increased hospital volume is associated with markedly decreased in-hospital mortality rates and a decreased or similar length of stay for all three types of procedures and with decreased or similar hospital charges for resections and stents. After adjustment for case mix differences, the relative risk (RR) of in-hospital death after pancreatic resection was 19.3 and 8 at the low- and medium-volume hospitals, respectively, versus the high-volume hospital; after bypasses, the RR of death was 2.7 and 1.9, respectively; and after stents, the RR was 4.3 and 4.8, respectively.
Patients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.
Reports of better results at national referral centers than at low-volume community hospitals have prompted calls for regionalizing pancreaticoduodenectomy (the Whipple procedure). We examined the relationship between hospital volume and mortality with this procedure across all US hospitals.
Using information from the Medicare claims database, we performed a national cohort study of 7229 Medicare patients more than 65 years old undergoing pancreaticoduodenectomy between 1992 and 1995. We divided the study population into approximate quartiles according to the hospital's average annual volume of pancreaticoduodenectomies in Medicare patients: very low (< 1/y), low (1-2/y), medium (2-5/y), and high (5+/y). Using multivariate logistic regression to account for potentially confounding patient characteristics, we examined the association between institutional volume and in-hospital mortality, our primary outcome measure.
More than 50% of Medicare patients a undergoing pancreaticoduodenectomy received care at hospitals performing fewer than 2 such procedures per year. In-hospital mortality rates at these low- and very-low-volume hospitals were 3- to 4-fold higher than at high-volume hospitals (12% and 16%, respectively, vs 4%, P < .001). Within the high-volume quartile, the 10 hospitals with the nation's highest volumes had lower mortality rates than the remaining high-volume centers (2.1% vs 6.2%, P < .01). The strong association between institutional volume and mortality could not be attributed to patient case-mix differences or referral bias.
Although volume-outcome relationships have been reported for many complex surgical procedures, hospital experience is particularly important with pancreaticoduodenectomy. Patients considering this procedure should be given the option of care at a high-volume referral center.
Background:
Commonly performed elective gastrointestinal surgical procedures are carried out with low morbidity and mortality in hospitals throughout the United States. Complex operative procedures on the alimentary tract are performed with a relatively low frequency and are associated with higher mortality. Volume and experience of the surgical provider team have been correlated with better clinical and economic outcomes for one complex gastrointestinal surgical procedure, pancreaticoduodenectomy. This study evaluated whether provider volume and experience were important factors influencing clinical and economic outcomes for a variety of complex gastrointestinal surgical procedures in one state.
Study design:
Complex high-risk gastrointestinal surgical procedures were defined as those with statewide in-hospital mortality of > or = 5%, frequency of greater than 200 per year in the state, and requiring special surgical skill and expertise. Six procedures met these criteria. Using publicly available discharge data, all patients discharged from Maryland hospitals from July 1989 to June 1997 with a primary procedure code for one of the six study procedures were selected. Hospitals were classified into one of six groups based on the average number of study procedures per year: 10 or less; 11 to 20; 21 to 50; 51 to 100; 101 to 200; and 201 or more procedures per year. A hospital was included if at least one procedure was performed there during the study period. No providers fell within the 51 to 100, and 101 to 200 groups, so all analyses were performed for the remaining four volume groups that were classified, respectively, as minimal (10 or fewer procedures), low (11 to 20 procedures), medium (21 to 50 procedures), and high-volume groups (201 or more procedures). Poisson regression was used to assess the relationship between in-hospital mortality and hospital volume after case-mix adjustment. Multiple linear regression models were used to assess differences in average length-of-stay and average total hospital charges among hospital volume groups. We further analyzed mortality, length-of-stay, and charges at the procedural level to understand these subgroups of complex gastrointestinal patients. We also examined the relationship between provider volume and outcomes for malignant versus benign diagnosis groups.
Results:
Complex gastrointestinal surgical procedures were performed on 4,561 patients in Maryland from July 1989 through June 1997. The study population averaged 61.6 years of age, was 55% male, 71% Caucasian, and had predominantly Medicare as a payment source. After case-mix adjustment, patients who underwent complex gastrointestinal surgical procedures at the medium-, low-, and minimal-volume provider groups had a 2.1, 3.3, and 3.2 times greater risk of in-hospital death, respectively, than patients at the high-volume provider (p < 0.001 for all comparisons); longer lengths-of-stay, 16.1, 15.7, and 15.5 days at the low-, medium-, and minimal-volume groups, respectively, versus 14.0 days for the high-volume provider (p < 0.001 for all comparisons). Similarly, adjusted charges at the high-volume provider were, on average, 14% less than those of the low-volume group, which had the next lowest charges. Although mortality rates differed by procedure type, for each procedure, mortality increased as provider volume decreased, following the pattern found in the aggregate analysis. After case-mix adjustment, the risk of in-hospital death for patients with malignant diagnoses was significantly higher for the medium-, low-, and minimal-volume groups compared with patients at the high-volume provider, relative risk of 3.1, 4.0, and 4.2, respectively, (p < 0.001 for all comparisons).
Conclusions:
This study demonstrates that increased hospital experience is associated with a marked decrease in hospital mortality. The decreased mortality at the high-volume provider was also associated with shorter lengths-of-stay and lower hospital char
Several studies have reported lower perioperative mortality rates with pancreaticoduodenectomy at high-volume hospitals than at low-volume hospitals. We sought to determine whether volume is also related to survival after hospital discharge.
Using information from the Medicare claims database, we performed a retrospective cohort study of all 7229 patients over age 65 undergoing pancreaticoduodenectomy in the United States between 1992 and 1995. We divided the study population into approximate quartiles according to their hospital's average annual volume of pancreaticoduodenectomies in Medicare patients: very low (< 1/y), low (1-2/y, medium (2-5/y), and high (5+/y). To adjust for potentially confounding variables, we used a Cox proportional hazards model to examine relationships between hospital volume and mortality, our primary outcome measure.
Overall, 3-year survival was higher at high-volume centers (37%) than at medium- (29%), low- (26%), and very low volume hospitals (25%) (log-rank P < .0001). After excluding perioperative deaths and adjusting for case-mix, patients undergoing surgery at high-volume hospitals remained less likely to experience late mortality than patients at very low volume centers (adjusted hazard ratio 0.69, 95% CI 0.62-0.76). Relationships between hospital volume and survival after discharge were not restricted to patients with cancer diagnoses; patients with benign disease had similar improvements in late survival after surgery at high-volume centers.
Hospital volume strongly influences both perioperative risk and long-term survival after pancreaticoduodenectomy. Our data suggest that both patient selection and differences in quality of care may underlie better outcomes at high-volume referral centers.
Given the strong "volume-outcome" relations observed with many surgical procedures, concentrating surgery in high-volume hospitals could substantially reduce the number of surgical deaths. We explored the potential benefits of regionalizing 10 high-risk procedures for the 38 million Americans enrolled in Medicare.
Number of lives saved in 1 year.
Current number of deaths occurring with each procedure multiplied by the average mortality reductions that plausibly could be achieved with regionalization.
The current number of surgical deaths was obtained from the 1995 MEDPAR file of the Medicare claims database. Expected mortality rate reductions with regionalization, estimated from published volume-outcome studies, were tested over a wide range in sensitivity analysis.
Of 381,000 Medicare patients undergoing any 1 of the 10 procedures in 1995, approximately 17,000 surgical deaths occurred. The total number of lives saved by regionalization depends on assumptions about the mortality reductions likely to be achieved, varying from 853 (5% reduction) to 4266 (25% reduction). Regionalizing common, intermediate-risk procedures (e.g., cardiovascular procedures) would save far more lives than regionalizing less-common, higher-risk operations (e.g., major cancer resections).
Even with conservative assumptions about reduction in surgical mortality likely to be achieved, the benefits of regionalizing major procedures in Medicare patients could be substantial. Policymakers should focus on common procedures before less-common, high-risk operations.
In the 1980s, new methods such as intra-operative ultrasonography, hemihepatic vascular occlusion and ultrasonically guided subsegmentectomy were introduced in clinical practice for use in hepatic surgery. Because of the progress, surgical resection of hepatocellular carcinomas associated with cirrhosis became safer, and curativity and hepatic functional preservation were promoted. The long-term survival rate after operation has improved. Recently, the use of the procedures of vascular surgery transplant surgery has allowed the indication for hepatectomy to be expanded. Here we describe the transition and progress in hepatic surgery.
This study explores the volume-mortality relationship for 3 groups of cancer procedures to determine whether higher-volume hospitals, higher-volume surgeons, or both are associated with lower in-hospital mortality.
New York's Statewide Planning and Research Cooperative System was used to identify more than 32,000 hospital inpatients with a cancer diagnosis who underwent colectomy, lobectomy of the lung, or gastrectomy between January 1, 1994, and December 31, 1997. The association of in-hospital mortality rates with provider (hospital and surgeon) volume was examined after adjusting for differences in age, demographics, organ metastasis, socioeconomic status, and comorbidities.
For hospital volume for gastrectomy, the highest-volume quartile had an absolute risk-adjusted mortality rate that was 7.1% lower (P <.0001) than the lowest-volume quartile, although the overall mortality rate for the procedure was only 6.2%. For surgeon volume for colectomy, the highest- and lowest- volume quartiles differed by 1.9% (P <.0001), although the procedure mortality rate was only 3.5%. For hospital volume for lung lobectomy, the absolute difference in mortality was 1.7%. Patients undergoing operations performed by high-volume surgeons in high-volume hospitals usually had significantly lower risk-adjusted mortality rates than did patients who had low-volume surgeons or who were in low-volume hospitals, or both.
For all 3 procedure groups, the risk-adjusted in-hospital mortality is significantly lower when the procedures are performed by high-volume providers.
We reviewed retrospectively the anaesthetic management and perioperative course of eight right hepatectomies for living liver donation.
After preoperative psychiatric evaluation, eight ASA I-II individuals donated the right lobe of their liver to a family member. A graft-recipient body weight ratio of 0.8-1.0% was required for patient selection. Indications for liver transplantation were: hepatitis C viral-related cirrhosis in six patients; combined hepatitis C and B viral cirrhosis in one patient; multifocal hepatocellular carcinoma--four lesions, involving both liver lobes--of hepatitis C viral-related cirrhosis in another patient. Indication for adult-to-adult living-donor liver transplantation was retained in the latter because of rapid deterioration of liver disease, rare recipient's blood group and extended, unresectable hepatocellular carcinoma. Hepatitis C viral-related cirrhosis was casually the primary indication for adult-to-adult living-donor liver transplantation in this group. The condition of the donated hepatic lobe was optimized by appropriate drug and perfusion management. Preoperative investigations included: blood tests (full cell count and film, thyroid function tests, pregnancy tests, full virological tests and bacteriological cultures, and immunological typing), chest radiograph, electrocardiogram plus Doppler cardiac ultrasound, spirometry, aminopyrine breath test, liver Doppler examination, magnetic resonance imaging, angiography and cholangiography and a volumetric study of the whole liver and the right lobe. Haemoglobin and lactate concentrations, liver function tests and international normalized ratio were measured before and after operation. The volume and weight of the resected right lobe was calculated. Anaesthesia was induced with propofol 300 mL h(-1) and sufentanil 0.3 microg kg(-1) intravenously; cisatracurium, 0.15 mg kg(-1), was given to facilitate tracheal intubation. Anaesthesia was maintained during normocapnic ventilation of the lungs with oxygen 40% in air, isoflurane 1-1.5 MAC and sufentanil. Routine anaesthetic monitoring included electrocardiography, pulse oximetry, invasive blood pressure, central venous pressure, urine output, state of neuromuscular blockade and core temperature. Periods of hypotension (<80% of the preoperative blood pressure) or haemodynamic instability (requiring inotropic or vasoactive support) were registered. Total blood loss and transfusion (homologous, autologous or cell-saver blood) requirements were measured; volume replacements were derived.
Data are presented as mean (range). There was no morbidity or mortality and no periods of intraoperative hypotension or haemodynamic instability. The operation time averaged 619 (525-780)min. Four donors were extubated in the operating room immediately after surgery; the others were extubated in the intensive care unit, where the mean extubation time was 16.3 (5-25)h after arrival. The estimated blood loss was 967 (550-1,600)mL. No homologous blood was administered; five donors received autologous blood, intraoperatively; three donors received a cell-saver blood transfusion. Intraoperative fluid replacement was with crystalloids, colloids and 4% albumin. Total urine output was 1,472 (700-3100)mL. Although intraoperative hypothermia occurred all subjects were normothermic at the end of operation. The pre- and immediately postoperative haemoglobin concentration averaged 13.6 (9.8-15.6) and 10.5 (6.9-13.0)gdL(-1), respectively. On the first postoperative day, the haemoglobin was 11.7 (8.4-15.1)gdL(-1). The donors' liver function tests were transiently elevated in the initial postoperative period. The intensive care unit discharge time was 2 (1-3) days. The hospital stay was 13 (7-17) days. There was no morbidity or mortality.
The study demonstrates that right-lobe living-donor surgery was well tolerated, without intraoperative hypotension or haemodynamic instability, without perioperative anaesthetic or surgical complications, and with an excellent general outcome.
Hepatic resection has become common in the United States for both primary and secondary hepatic tumors.
Variation in outcomes after hepatic resection is related to patient characteristics, the indication for operation, and hospital procedural volume.
Observational study using a nationally representative database.
All patients in the Nationwide Inpatient Sample for 1996 and 1997 with a primary procedure code for hepatic resection (N = 2097).
Outcomes included in-hospital mortality and length of stay. Risk-adjusted analyses were performed using hierarchical multivariate models.
Overall mortality for the 2097 patients was 5.8%. The most common indications for hepatic resection were secondary metastases (52%), primary hepatic malignancy (16%), biliary tract malignancy (10%), and benign hepatic tumor (5%). High-volume hospitals had a mortality rate of 3.9% vs 7.6% at low-volume hospitals (P<.001). In the multivariate analysis adjusting for patient case-mix, high-volume hospitals had a 40% lower risk of in-hospital mortality compared with low-volume hospitals (odds ratio, 0.60; 95% confidence interval, 0.39-0.92; P =.02). Other predictors of mortality in the multivariate analysis included age older than 65 years, hepatic lobectomy (vs wedge resection), primary hepatic malignancy (vs metastases), and the severity of underlying liver disease.
Hospital procedural volume is an important predictor of mortality after hepatic resection. Patients who require resection of primary and secondary liver tumors should be offered referral to a high-volume center.
A strong association between high hospital procedure volume and survival following colon cancer resection has been demonstrated. However, the importance of surgeon case volume as a determinant of outcome has been less well studied, and it is unclear whether hospital or surgeon volume is the more powerful predictor of outcomes.
A retrospective population-based cohort study utilizing the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database identified 24,166 colon cancer patients aged 65 years and older who had surgery for a primary tumor diagnosed in 1991-1996 in a SEER area. Hospital and surgeon-specific procedure volume was ascertained based on the number of claims submitted over the 6-year study period. Outcome measures were mortality at 30 days and 2 years, overall survival, and the frequency of operations requiring an intestinal stoma. Age, sex, race, comorbid illness, cancer stage, socioeconomic status, emergent hospitalization, and the presence of obstruction/perforation were used to adjust for differences in case-mix.
After adjusting for surgeon procedure volume, high hospital procedure volume remained a strong predictor of low post-operative mortality rates (P < 0.001 for each outcome with and without adjustment for surgeon procedure volume). Surgeon-specific procedure volume was also an important predictor of surgical outcomes (P = 0.002 for 30-day mortality, P = 0.001 for 2-year mortality), although this effect was attenuated after adjusting for hospital volume (P = 0.03 for 30-day mortality, P = 0.02 for 2-year mortality). Hospital volume and surgeon volume were each an important predictor of the ostomy rate. Among high volume institutions and surgeons, individual providers with unusually high ostomy rates could be identified.
Both hospital and surgeon-specific procedure volume predict outcomes following colon cancer resection; but hospital volume may exert a stronger effect. Therefore, efforts to optimize the quality of colon cancer surgery should focus on multidisciplinary aspects of hospital care rather than solely on intraoperative technique.
The title I have chosen is meant to be obtuse, but I hope not gratuitous. I chose the title because I thought it would allow me to focus on 3 aspects that were important to me. First, presumption. It is to some degree presumptuous of me to be speaking from this lectern to this group, characterized so clearly, as the leadership of American surgery. The people who have preceded me in this office have led the leaders, both within the surgical profession and within medicine, in its greater context. I hesitate to refer to specific individuals for fear I will do so inadequately and only highlight my own deficiencies when contrasted with many of them. It appears traditional and appropriate to at least acknowledge the debt one owes to one’s teachers and colleagues as they are the key to one’s own success.
Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain.
Using information from the national Medicare claims data base for 1998 through 1999, we examined mortality among all 474,108 patients who underwent one of eight cardiovascular procedures or cancer resections. Using nested regression models, we examined the relations between operative mortality and surgeon volume and hospital volume (each in terms of total procedures performed per year), with adjustment for characteristics of the patients and other characteristics of the providers.
Surgeon volume was inversely related to operative mortality for all eight procedures (P=0.003 for lung resection, P<0.001 for all other procedures). The adjusted odds ratio for operative death (for patients with a low-volume surgeon vs. those with a high-volume surgeon) varied widely according to the procedure--from 1.24 for lung resection to 3.61 for pancreatic resection. Surgeon volume accounted for a large proportion of the apparent effect of the hospital volume, to an extent that varied according to the procedure: it accounted for 100 percent of the effect for aortic-valve replacement, 57 percent for elective repair of an abdominal aortic aneurysm, 55 percent for pancreatic resection, 49 percent for coronary-artery bypass grafting, 46 percent for esophagectomy, 39 percent for cystectomy, and 24 percent for lung resection. For most procedures, the mortality rate was higher among patients of low-volume surgeons than among those of high-volume surgeons, regardless of the surgical volume of the hospital in which they practiced.
For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently.
To compare surgeon and hospital procedure volume as predictors of outcomes for patients with rectal cancer.
Although a "volume-outcome" relationship exists for several major cancer operations, the impact of procedure volume on outcomes following rectal cancer surgery remains uncertain, and it has not been determined whether hospital or surgeon volume is a more important predictor of outcomes.
A retrospective population-based cohort study utilizing the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database identified 2,815 rectal cancer patients aged 65 and older who had surgery for a primary tumor diagnosed in 1992-1996 in a SEER area. Hospital- and surgeon-specific procedure volume was ascertained based on the number of claims submitted over the 5-year study period. Outcome measures were mortality at 30 days and 2 years, overall survival, and the rate of abdominoperineal resections. Age, sex, race, comorbid illness, cancer stage, and socioeconomic status were used to adjust for differences in case mix.
Neither hospital- nor surgeon-specific procedure volume was significantly associated with 30-day postoperative mortality or rates of rectal sphincter-sparing operations. Although an association between hospital volume and mortality at 2 years was evident, this finding was no longer significant once surgeon-specific volume was controlled for. In contrast, surgeon-specific volume was associated with 2-year mortality and remained an important predictor even after adjustment for hospital volume. Surgeon volume was also better than hospital procedure volume at predicting long-term survival.
Surgeon-specific experience as measured by procedure volume can have a significant impact on survival for patients with rectal cancer.
Hepatic resection is increasingly performed for primary and metastatic tumors. Reports from tertiary care centers show improved outcomes over time with lower operative mortality rates. The objective of this investigation was to characterize trends in the use and outcomes of hepatic resection in the US during a recent 13-year period.
Adult patients with a procedures code for hepatic resection in the Nationwide Inpatient Sample (NIS) from 1988 to 2000 were included. The Nationwide Inpatient Sample is a 20% representative sample of all discharges in the US. Outcomes variables included in-hospital mortality and length of stay. High volume hospitals performed 10 or more (>50th percentile) procedures per year.
During the 13-year period, 16,582 patients underwent hepatic resection. The number of procedures performed increased nearly twofold, from 820 per year in 1988 to 1,420 per year in 2000. Similar changes in use were seen for each indication for operation. The overall mortality rate declined from 10.4% (1988 to 1989) to 5.3% (1999 to 2000) during the study period (p < 0.001). The mortality rate was lower at high volume centers than at lower volume centers (5.8% versus 8.9%, p < 0.001), and the decline in mortality over time was greater at high volume centers (10.1% to 3.9%, p < 0.001) compared with to low volume centers (10.6% to 7.4%, p = 0.01).
The number of hepatic resections performed in the US has increased significantly. Short-term outcomes have also improved over the same time period, with more improvement seen at higher volume centers than in lower volume centers.
To compare the use of conventional statistical models with multilevel regression models in volume-outcome analyses of surgical procedures in an empirical case study.
Using conventional regression models and multilevel regression models, we estimated the effect of hospital volume and surgeon volume on 30-day mortality and length of postoperative hospital stay in persons who had an esophagectomy, pancreaticoduodenectomy, or major lung resection for cancer in Ontario, Canada, from 1994 to 1999.
The point estimates of volume-outcome associations were similar using either method; however, the 95% confidence intervals estimated by multilevel models were wider than those estimated by conventional models. A significant association between volume and mortality was identified in 2 of 18 (11%) comparisons using conventional analysis but in none of the 18 (0%) comparisons using multilevel analysis, and between volume and length of stay in 15 of 18 (83%) comparisons using conventional analysis and in 1 of 18 (6%) comparisons using multilevel analysis.
Conventional and multilevel statistical models can yield substantially different results in the analysis of volume-outcome associations for surgical procedures.
Although relations between procedure volume and operative mortality are well established for high-risk cancer operations, differences in clinical practice between high-volume and low-volume centers are not well understood. The current study was conducted to examine relations between hospital volume, process of care, and operative mortality in cancer surgery.
Using the Medicare claims database (2000-2002), we identified all patients undergoing major resections for lung, esophageal, gastric, liver, or pancreatic cancer (n=71,558). Preoperative, intraoperative, and postoperative processes of care potentially related to operative mortality were identified from inpatient, outpatient, and physician claims files using appropriate International Classification of Diseases--Clinical Modification (ICD-9) and Current Procedural Terminology (CPT) codes. We then assessed variation in the use of each process according to hospital volume, adjusting for patient characteristics and procedure type. Study Participants were US Medicare patients. The main outcome measure was specific processes of care.
Relative to those at low-volume centers (lowest 20th by volume), patients at high-volume hospitals (highest 20th) were significantly more likely to undergo stress tests (odds ratio [OR]: 1.51, 95% confidence interval [CI]: 1.21-1.87), but not other preoperative imaging tests. They were more likely to see medical or radiation oncologists (OR: 1.37, 95% CI: 1.16-1.62), but not other specialists, preoperatively. Although blood transfusions and use of epidural pain management did not vary significantly by volume, patients at high-volume hospitals had significantly longer operations and were more likely to receive perioperative invasive monitoring (OR: 2.56, 95% CI: 1.82-3.60). Differences in measurable processes of care did not explain volume-related differences in operative mortality to any significant degree.
Although high-volume and low-volume hospitals differ with regard to many aspects of perioperative care, mechanisms underlying volume-outcome relations in high-risk cancer surgery remain to be identified.
Although hospital procedure volume is clearly related to operative mortality with many cancer procedures, its effect on late survival is not well characterized.
To examine relationships between hospital volume and late survival after different types of cancer resections.
Using the national Surveillance Epidemiology and End Results (SEER)-Medicare linked database (1992-2002), we identified all patients undergoing major resections for lung, esophageal, gastric, pancreatic, colon, and bladder cancer (n = 64,047). Relationships between hospital volume and survival were assessed using Cox proportional hazards models, adjusting for patient characteristics and use of adjuvant radiation and chemotherapy. Study Participants: U.S. Medicare patients residing in SEER regions. Main Outcome Measures: 5-year survival.
Although there were statistically significant relationships between hospital volume and 5-year survival with all 6 cancer types, the relative importance of volume varied markedly. Absolute differences in 5-year survival probabilities rates between low-volume hospitals (LVHs) and high-volume hospitals (HVHs) ranged from 17% for esophageal cancer resection (17% vs. 34%, respectively) to only 3% for colon cancer resection (45% vs. 48%). Absolute differences in 5-year survival between LVHs and HVHs fell between these ranges for lung (6%), gastric (6%), pancreatic (5%), and bladder cancer (4%). Volume-related differences in late survival could not be attributed to differences in rates of adjuvant therapy.
Along with lower operative mortality, HVHs have better late survival rates with selected cancer resections than their lower-volume counterparts. Mechanisms underlying their better outcomes and thus opportunities for improvement remain to be identified.
High-volume hospitals have lower mortality rates for a wide range of surgical procedures, including cystectomy for bladder cancer. However, the processes of care that mediate this effect are unknown. We sought to identify the processes that underlie the volume-outcome relationship for cystectomy.
Within the Surveillance, Epidemiology, and End Results (SEER)-Medicare data set, we used International Classification of Diseases (ICD)-9 procedure codes to identify 4465 patients who underwent cystectomy for bladder cancer between 1992 and 1999. The preoperative and perioperative processes of care were abstracted from the inpatient, outpatient, and physician files using the procedure and diagnosis codes available through 2002. Logistic models were used to assess the relationship between the process and hospital volume, adjusting for differences in patient characteristics.
Substantial variation was found in the use of specific processes of care across the hospital volume strata. High-volume hospitals had greater rates of preoperative cardiac testing (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.24 to 1.98), intraoperative arterial monitoring (OR 3.73, 95% CI 3.11 to 4.46), and the use of a continent diversion (OR 4.01, 95% CI 3.03 to 5.30), among many others. Patients treated at low-volume hospitals were 48% more likely to die in the postoperative period (4.9% versus 3.5%, adjusted OR 1.48, 95% CI 1.03 to 2.13). Differences in the use of processes of care explained 23% of this volume-mortality effect.
High-volume and low-volume hospitals differ with regard to many processes of care before, during, and after radical cystectomy. Although these practices have partly explained the volume-outcome relationships for cystectomy, the primary mechanisms underlying this effect remain unclear.
Several studies have examined the association between procedure-specific volume and in-hospital mortality and concluded that high-volume hospitals have lower mortality rates when compared with low-volume hospitals. There is a paucity of studies examining the association between unrelated procedure volume and in-hospital mortality. The objective of our study is to examine the procedure-specific volume-outcome association as well as unrelated procedure volume-outcome association for 5 procedures: coronary artery bypass graft (CABG), percutaneous coronary interventions (PCI), elective abdominal aortic aneurysm repair (AAA), pancreatectomy (PAN), and esophagectomy (ESO).
Nationwide Inpatient Sample for years 2000 through 2003 was used. All discharges with primary procedure codes for CABG, PCI, AAA, PAN, and ESO were selected. The average number of procedures performed by the hospitals per year during the study period was computed, and hospitals were categorized as having met or not met the Leapfrog Group-recommended volume thresholds. Procedure specific and unrelated procedure volume-in-hospital mortality association was examined by using multivariable logistic regression analysis. Procedure volume-in-hospital mortality association was adjusted for patient and hospital characteristics.
For all 5 procedures, hospitals that did not meet Leapfrog Group volume thresholds were associated with significantly higher odds for in-hospital mortality when compared with hospitals that met Leapfrog Group volume thresholds (P < 0.05). Hospital volume levels for PAN or ESO did not influence outcomes following CABG, PCI, and AAA. Similarly, hospital volumes for CABG, PCI, and AAA did not influence the outcomes for PAN or ESO.
Hospital volume-in-hospital mortality association appears largely to be specific to the procedure being studied.
An increasing amount of literature concerning blood conservation, restrictive transfusion strategies, pharmacological manipulation of the hemostatic and fibrinolytic systems, minimal invasive surgery, local hemostatic agents and guidelines for blood transfusion, is being published each year. Is 'bloodless (liver) surgery' or rather minimization of perioperative blood loss and transfusion requirement necessary?
To answer this question, we studied key articles and checked cross-references with the support of PubMed and the Cochrane Database of systematic reviews.
At present there is still a need to reduce the use of blood. Pre-donation, set of transfusion triggers, (non-)pharmacological approaches to decrease surgical blood loss, hemodilution techniques, peri- and postoperative cell salvage and postoperative re-transfusion can contribute to the success of a bloodless (liver) surgery program.
We conclude that a multidisciplinary effort has to be made through the entire chain, from the outpatient clinic through discharge from the hospital, with the utmost exertion of all team members in which surgeons play a key role in the adaptation of a bloodless (liver) surgery program to the specific needs of patients.
To analyze in-hospital mortality after pancreatectomy using a large national database.
Pancreatic resections, including pancreaticoduodenectomy, distal pancreatectomy, and total pancreatectomy, remain the only potentially curative interventions for pancreatic cancer. The goal of this study was to define factors affecting outcomes after pancreatectomy for neoplasm.
A retrospective analysis was performed using all patients undergoing pancreatic resections for neoplastic disease identified from the Nationwide Inpatient Sample from 1998 to 2003. Crude in-hospital mortality was analyzed by chi. A multivariable model was constructed to adjust for age, sex, hospital teaching status, hospital surgical volume, year of resection, payer status, and selected comorbid conditions.
In all, 279,445 patient discharges were identified with a primary diagnosis of pancreatic neoplasm. A total of 39,463 (14%) patients underwent resection during that hospitalization. In-hospital mortality was 5.9% with a significant decrease from 7.8% to 4.6% from 1998 to 2003 by trend analysis (P < 0.0001). Resections done at low (<5 procedures/year)- and medium (5-18/year)-volume centers had higher mortality compared with those at high (>18/year)-volume centers (low-volume odds ratio = 3.3; 95% confidence interval, 2.3-4.; medium-volume, odds ratio = 2.1; 95% confidence interval, 1.5-3.0). The proportion of procedures performed at high volume centers increased from 30% to 39% over the 6-year time period (P < 0.0001) by trend test.
This large observational study demonstrates an improvement in operative mortality for patients undergoing pancreatectomy for neoplastic disease from 1998 to 2003. In addition, a greater proportion of pancreatectomies were performed at high-volume centers in 2003. The regionalization of pancreatic surgery may have partially contributed to the observed decrease in mortality rates.
Operations on the liver and pancreas have fallen within the domain of the general surgeon and have been part of general surgery training. The more complex procedures involving these organs are limited in number in most general surgery residencies and do not afford an opportunity for vast experience. Moreover, fellowship programs in hepato-bilio-pancreatic (HPB) surgery and the development of laparoscopic techniques may have further limited the familiarity of general surgery residents with these operations. To determine the experience accrued by finishing general surgery residents, we accessed, through the Residency Review Committee of the Accreditation Council for Graduate Medical Education, the Resident Case Log System used by general surgery residents throughout their training to document operative cases. The number of operations on the gallbladder, bile ducts, pancreas, and liver was examined over the past 16 years (there were missing data for 3 years). Reference years 1995 and 2005 were compared to detect trends. Experience with laparoscopic cholecystectomy has steadily increased and averaged more than 100 cases in 2006. Experience in liver resection, distal pancreatectomy, and partial (Whipple) pancreatectomy has statistically improved from 1995 to 2005, but the numbers of cases are low, generally less than five per finishing resident. Experience in open common bile duct and choledocho-enteric anastomoses has statistically declined from 1995 to 2005, averaging less than four cases per finishing resident. The mode (most frequently performed number) for liver and pancreas resections was either 0 or 1. It is doubtful this experience in HPB surgery engenders confidence in many finishing residents. Attention should be focused on augmenting training in HPB surgery for general surgery residents perhaps through a combination of programmatic initiatives, ex vivo experiences, and minifellowships. Institutional initiatives might consist of defined HPB services with appropriate expertise, infrastructure, process, and outcome measures in which a resident-oriented, competency-based curriculum could be developed.
The Charlson comorbidity index has been widely used for risk adjustment in outcome studies using administrative health data. Recently, 3 International Statistical Classification of Diseases, Tenth Revision (ICD-10) translations have been published for the Charlson comorbidities. This study was conducted to compare the predictive performance of these versions (the Halfon, Sundararajan, and Quan versions) of the ICD-10 coding algorithms using data from 4 countries.
Data from Australia (N = 2000-2001, max 25 diagnosis codes), Canada (N = 2002-2003, max 16 diagnosis codes), Switzerland (N = 1999-2001, unlimited number of diagnosis codes), and Japan (N = 2003, max 11 diagnosis codes) were analyzed. Only the first admission for patients age 18 years and older, with a length of stay of >/=2 days was included. For each algorithm, 2 logistic regression models were fitted with hospital mortality as the outcome and the Charlson individual comorbidities or the Charlson index score as independent variables. The c-statistic (representing the area under the receiver operating characteristic curve) and its 95% probability bootstrap distribution were employed to evaluate model performance.
Overall, within each population's data, the distribution of comorbidity level categories was similar across the 3 translations. The Quan version produced slightly higher median c-statistics than the Halfon or Sundararajan versions in all datasets. For example, in Japanese data, the median c-statistics were 0.712 (Quan), 0.709 (Sundararajan), and 0.694 (Halfon) using individual comorbidity coefficients. In general, the probability distributions between the Quan and the Sundararajan versions overlapped, whereas those between the Quan and the Halfon version did not.
Our analyses show that all of the ICD-10 versions of the Charlson algorithm performed satisfactorily (c-statistics 0.70-0.86), with the Quan version showing a trend toward outperforming the other versions in all data sets.
Higher hospital and surgeon volumes have been associated with improved outcomes after hepatic resection. Subspecialty training has not previously been associated with improved outcomes after hepatic resection. The objective of this study was to determine what effects, if any, surgeon's volume and training had on the outcomes after hepatic resection.
Administrative procedure codes were used to identify all adult patients from the fiscal year 1991-1992 to 2003-2004 who underwent a hepatic resection in two large urban health regions in Canada (Calgary and Capital health regions). The primary outcomes were operative mortality and postoperative complications.
There were 1107 hepatic resections in the stated time period performed by a total of 72 surgeons. There were 66 deaths, resulting in an in-hospital mortality rate of 6.0%, and an overall complication rate of 46%. Statistically significant predictors of operative mortality were: urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing burden of comorbid medical illness. Surgeon training along with patient's sex, the urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing comorbidity were predictive of postoperative complications.
This study found surgeon training to be highly predictive of postoperative complications after hepatic resection.
To quantify the degree to which overall urologic oncology volume either reduces or enhances the effect of single procedure volume on short-term outcomes after urologic oncology surgery.
Urologic oncology procedures for prostate, kidney, and bladder cancer performed between 1988 and 2003 were identified in the Nationwide Inpatient Sample. Procedure-specific volume and urologic oncology volume (excluding the procedure of interest) were determined for each cancer and each hospital. Multivariable logistic regression models were constructed to measure the independent effect of urologic oncology volume (non-index procedures) on operative mortality after prostatectomy, cystectomy, and nephrectomy (index procedures) after adjusting for patient and hospital factors.
Unadjusted operative mortality for prostatectomy, cystectomy, and nephrectomy was 0.2%, 2.8%, and 1.4%, respectively. For prostatectomy and cystectomy, the magnitude of the volume-mortality association was reduced after adjusting for non-index urologic oncology case volume. For example, the relationship between surgical volume and mortality was reduced by 20% for radical prostatectomy and 60% for radical cystectomy.
The volume-outcome effect for index urologic oncology procedures is modified by experience with other non-index specialty-related procedures. Efforts to identify transferable, effective processes of care should focus on a subset of high-volume centers.
Outcome analysis is increasingly being used to develop health-care policy and direct patient referral. For example, the Leapfrog Group health-care quality initiative has proposed "evidence-based hospital" referral criteria for specific procedures including elective abdominal aortic aneurysm repair (AAA-R). These criteria include an annual hospital AAA operative volume exceeding 50 cases and provision of intensive care unit (ICU) care by board-certified intensivists. Outcomes after AAA-R are reportedly influenced by presentation (intact vs. ruptured), operative approach (endovascular vs. open, transperitoneal vs. retroperitoneal), surgeon subspecialty, case volume (hospital and surgeon), and provision of postoperative care by an intensivist. The purpose of this study was to compare our single-center results with those of high-volume centers to assess the validity of the concept that surrogate markers, such as case volume or intensivist involvement, can be used to estimate procedural outcome. A retrospective review was performed of AAA-Rs at one low-volume academic medical center from January 1994 to March 2005. Demographic data, aneurysm diameter and location, operative indications, and repair approach were documented. Postoperative complications, mortality rates, and hospital and ICU length of stay (LOS) were noted and compared to established benchmarks. During the study period, 270 patients underwent AAA-R (annual mean = 27 hospital cases and 13.4 cases/attending vascular surgeon). ICU care was provided by a dedicated vascular surgery service without routine intensivist involvement. Open, elective, infrarenal AAA-R was performed in 161 patients (60%), with a 2.5% hospital mortality rate (30-day, 3.1%). Thirty-three (12%) patients underwent elective endovascular aneurysm repair (EVAR), with no mortality. Both ICU (3.7 vs. 1.4 days, p = 0.03) and hospital (9.2 vs. 2.8 days, p = 0.002) LOS were significantly reduced after EVAR compared to open repair. Hospital LOS was significantly lower after open retroperitoneal repair compared to transperitoneal repair (6.1 vs. 10.3 days, p = 0.001). Thirty-five patients (13%) underwent ruptured AAA-R, with only 34.3% mortality (in-hospital and 30-day). Forty-one patients (15%) underwent repair of complex aortic aneurysms, with 14.1% mortality. There are increasing societal and economic pressures to direct patient referrals to "centers of excellence" for specific surgical procedures. Although our institution meets neither of the Leapfrog Group's proposed criteria, our mortality and LOS for both intact and ruptured infrarenal AAA-R are equivalent or superior to published benchmarks for high-volume hospitals. Individual institutional outcome results such as these suggest that patient referral and care should be based upon actual, carefully verified outcome data rather than utilization of surrogate markers such as case volume and subspecialist involvement in postoperative care.
Importance of hospi-tal volume in the overall management of pancreatic cancer
- Ja Sosa
- Bowman
- Gordon Ta Hm
Sosa JA, Bowman HM, Gordon TA, et al. Importance of hospi-tal volume in the overall management of pancreatic cancer. Ann Surg 1998;228:429–438.
Available at: http://www.hcup-us.ahrq.gov/db/state/siddist/sid_ multivar.jsp
- Healthcare Agency
- Research
- Quality
- Md Rockville
Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.hcup-us.ahrq.gov/db/state/siddist/sid_ multivar.jsp. Accessed April 1, 2008. 25. HCUP Procedure Classes. Healthcare Cost and Utilization Project (HCUP). 1999–2005. Agency for Healthcare Research and Qual-ity, Rockville, MD. Available at: http://www.hcup-us.ahrq.gov/ toolssoftware/procedure/procedure.jsp. Accessed April 1, 2008.
Relationship between hospital volume and late survival after pancreaticoduodenectomy
- Birkmeyer
Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy
- Lieberman
Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy
- Birkmeyer
Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection
- Schrag