Evolution of the Surgeon-Volume, Patient-Outcome Relationship
Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA. Annals of surgery
(Impact Factor: 8.33).
07/2009; 250(1):159-65. DOI: 10.1097/SLA.0b013e3181a77cb3
Higher surgeon volume is associated with improved patient outcomes. This finding has prompted recommendations for increasing specialization and referrals to high-volume surgeons, yet their implementation in clinical practice has not been measured.
We performed cross-sectional analyses using 1999 and 2005 discharge information from the Health Care Utilization Project National Inpatient Sample to measure whether the number of procedures performed by high-volume surgeons increased over time. Procedures included those demonstrated to have strong surgeon volume-outcome associations in the literature. International Classification of Diseases, Ninth Revision codes were employed for colorectal procedures, esophagectomy, gastrectomy, pancreatectomy, thyroidectomy, coronary artery bypass graft surgery, and carotid endarterectomy. Bivariate analyses and hierarchical generalized linear models were employed to measure association between surgeon volume and length of stay (LOS) and mortality or complications.
There was a significant increase in the proportion of procedures performed by high-volume surgeons over time, with the most dramatic increases seen for gastrectomy (54%), pancreatectomy (31%), and thyroidectomy (23%). Having a procedure performed by a high-volume surgeon was associated with patient race and insurance status. Overall, unadjusted mortality and LOS were significantly lower for high-volume surgeons compared with low-volume surgeons in 1999 and 2005. In multivariable hierarchical generalized linear models, only differences in LOS by surgeon volume remained significant in both years.
The proportion of procedures performed by high-volume surgeons increased over a 6-year period, as evidence mounted in support of a surgeon volume-outcome association. Efforts are still needed to improve access among underserved subsets of the population and eliminate apparent disparities based on patient race and insurance status.
Available from: PubMed Central
- "Compared with classic regression models, HLM provides a corrected standard error for nested data and can provide the proportion of the variation in the outcome accounted for by specific predictor variables. In our data, multiple patients could be treated by a single surgeon for a DRF, and HLM is advantageous in that it can account for clustered data in which predictor variables, such as surgeon characteristics, are nonindependent.38,39 "
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Distal radius fractures (DRFs) are one of the most common injuries among the elderly, resulting in significant expense and disability. The specific aims of this study are (1) to examine rates of therapy following DRFs and (2) to identify those factors that influence utilization of therapy and time span between DRF treatment and therapy among a national cohort of elderly patients.
We examined national use of physical and occupational therapy among all Medicare beneficiaries who suffered DRFs between January 1, 2007, and October 1, 2007, and assessed the effect of treatment, patient-related, and surgeon-related factors on utilization of therapy.
Overall, 20.6% of patients received either physical or occupational therapy following DRF. Use of therapy varied by DRF treatment, and patients who underwent open reduction and internal fixation were more likely to receive therapy compared with patients who received closed reduction. Patients who received open reduction and internal fixation were also referred to therapy earlier compared with patients who received external fixation, percutaneous pinning, and closed reduction. Surgeon specialization is associated with greater use of postoperative therapy. Patient predictors of therapy use include younger age, female sex, higher socioeconomic status, and fewer comorbidity conditions.
Use of therapy following DRF varies significantly by both patient- and surgeon-related factors. Identifying patients who benefit from postinjury therapy can allow for better resource utilization following these common injuries.
Available from: sciencedirect.com
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ABSTRACT: Despite its short existence, vascular surgery has already grown out of the scope of a mono-specialty. Meanwhile emerging interests of other competing specialties push into the field of vascular care. Continuous technological innovation drives the need for sub-specialisation to provide disease-centred expertise; however, treatment success equally depends on balanced patient-centred care. Vascular surgeons are amidst this controversy and are currently challenged by their own demand to offer all aspects of vascular care - as "the vascular specialist". This article discusses the natural driving forces towards sub-specialisation and appraises advantages and limitations with respect to the future of integrated vascular care.
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ABSTRACT: Vascular surgical specialisation is associated with improved outcomes. We aimed to assess the effect of anaesthetic specialisation on outcome following major vascular surgery.
Retrospective cohort study.
Patients undergoing major vascular surgery (lower limb revascularisation, elective and ruptured abdominal aortic aneurysm repair, endovascular aneurysm repair and carotid endarterectomy) over a five-year period were identified from a prospective database. The primary outcomes were death within 30 days and death within two years of surgery. Potential risk factors for mortality were assessed using multivariate logistic regression modelling.
The analysis cohort comprised 1155 patients followed up for a median of 583 days. Mortality within two years of surgery was 16%. For the overall cohort, care from vascular anaesthetists was independently associated with reduced 30-day (odds ratio 0.22; 95% CI 0.12-0.62) and medium-term mortality (0.31; 95% CI 0.18-0.55). For elective patients (n=851), vascular anaesthesia reduced two-year mortality (odds ratio 0.29; 95% CI 0.15-0.58; P=0.0004) though not 30-day mortality (odds ratio 0.55; 95% CI 0.15-1.95; P=0.35). For emergency patients, care by a vascular anaesthetist influenced neither 30-day mortality (odds ratio 0.33; 95% CI 0.08-1.41; P=0.13) nor medium-term mortality (odds ratio 0.45; 95% CI 0.17-1.21; P=0.11).
Anaesthetic specialisation reduced early- and medium-term mortality rates following major vascular surgery. If replicated by prospective studies, these results suggest that vascular surgery services would benefit from specialised anaesthetic support.
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