Search

PURPOSE: Intensive care unit (ICU) resources are a costly but effective commodity used in the management of critically ill patients with chronic obstructive pulmonary disease (COPD). ICU admission decisions are determined by patient diagnosis and severity of illness, but also may be affected by hospital differences in quality and performance. We investigate the variability in ICU utilization for patients with COPD and its association with hospital characteristics. METHODS: Using a 3M administrative dataset spanning 2008-2013, we conducted a retrospective cohort study of adult patients discharged with COPD at hospitals in three state to determine variability in ICU utilization. Quality metrics were calculated for each hospital using observed-to-expected (O/E) ratios for overall mortality and length-of-stay. Logistic and multi-level multivariate regression models were constructed, estimating the association between hospital quality metrics on ICU utilization, after adjustment for available clinical factors and hospital characteristics. RESULTS: In 434 hospitals with 570,517 COPD patient visits, overall ICU admission rate was 33.1% (range=0-89%; median (IQR)=24% (8, 54)). The addition of patient, hospital, and quality characteristics decreased the overall variability attributable to individual hospital differences seen within our cohort from 40.9% to 33%. Odds of ICU utilization were increased for larger hospitals and those seeing lower pulmonary case volume. Hospitals with better overall O/E ratios for length-of-stay or mortality had lower ICU utilization. CONCLUSIONS: Hospital characteristics, including quality metrics, are associated with variability in ICU utilization for COPD patients, with higher ICU utilization seen for lower performing hospitals.

To evaluate the trends in risk-group distribution and Pentafecta outcomes in patients treated with nerve-sparing (NS), robot-assisted radical prostatectomy (RARP) in a single low-intermediate volume prostate cancer (PCa) center over a 10-year period. We queried a prospectively maintained database for patients who underwent NS RARP between 2009 and 2018 in a low-intermediate volume PCa center. Risk-groups were defined according to the D’Amico classification. Pentafecta outcomes referred to the postsurgical presence of potency and continence, and the absence of biochemical recurrence (BCR), positive surgical margins (PSM), and perioperative complications. The Kruskall–Wallis test, the t test and the Mann–Whitney tests were used when appropriate. 603 patients underwent NS RARP and 484 patients were evaluated for Pentafecta outcomes. Median postsurgical follow-up was 28 months. Overall, 137 (22.7%), 376 (62.3%), and 90 (15%) patients were diagnosed in the low-, intermediate-, and high-risk groups, respectively. Patients undergoing NS RARP shifted from 33 to 20% in the low-risk group, from 52 to 62% in the intermediate-risk group, and from 10 to 13% in the high-risk group. Patients reaching Pentafecta increased from 38 to 44%. No postoperative potency was the main reason for non-achieving Pentafecta (71%). BCR strongly limited Pentafecta achievement in the high-risk group (61%), but not in intermediate (24%) and low-risk (30%) groups. Low-intermediate volume PCa centers show similar trends to high-volume centers regarding risk group distributions over time in PCa patients undergoing NS RARP. We reported an increase in Pentafecta outcomes achievement over time even for experienced surgeons. Pentafecta outcomes achievement is risk-group dependent.

PURPOSE: Previous studies have demonstrated improved outcomes at high-volume colorectal surgery centers, however the benefit for patients who live far from such centers has not been assessed relative to local, low-volume facilities. METHODS: The 2010–2015 National Cancer Database (NCDB) was queried for patients with stage I-III colon adenocarcinoma undergoing treatment at a single center. A ‘local, low-volume’ cohort was constructed of 12,768 patients in the bottom quartile of travel distance at the bottom quartile of institution surgical volume and a ‘travel, high-volume’ cohort of 11,349 patients in the top quartile of travel distance at the top quartile of institution surgical volume. RESULTS: In unadjusted analysis, patients in the travel cohort had improved rates of positive resection margins (3.7% vs. 5.5%, p

The volume–outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact. A systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded. A total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10–25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing

Background Medical treatment quality has been shown to be better in high volume than in low volume hospitals. However, this relationship has not yet been confirmed in abdominal cancer in Switzerland and is relevant for referral of patients and healthcare planning. Thus, the present study investigates the association between hospital volumes for surgical resections of colon, gastric, rectal, and pancreatic carcinomas and outcomes. Methods This retrospective analysis is based on anonymized claims data of patients with mandatory health insurance at Helsana Group, a leading health insurance in Switzerland. Outcome parameters were length of hospital stay, mortality and cost during the inpatient stay as well as at 1-year follow-up. Hospital volume information was derived from the Quality Indicators dataset provided by the Swiss Federal Office of Public Health. The impact of hospital volume on the different treatment outcomes was statistically tested using generalized estimating equations (GEE) models, taking into account the non-independence of observations from the same hospital. Results The studies included 2′859 resections in patients aged 18 years and older who were hospitalized for abdominal cancer surgery between 2014 and 2018. Colon resections were the most common procedures (n = 1′690), followed by rectal resections (n = 709). For rectal, colon and pancreatic resections, an increase in the mean number of interventions per hospital and a reduction of low volume hospitals could be observed. For the relationship between hospital volume and outcomes, we did not observe a clear dose-response relationship, as no significantly better outcomes were observed in the higher-volume category than in the lower-volume category. Even though a positive “routine effect” cannot be excluded, our results suggest that even hospitals with low volumes are able to achieve comparable treatment outcomes to larger hospitals. Conclusion In summary, this study increases transparency on the relationship between hospital volume and treatment success. It shows that simple measures such as defining a minimum number of procedures only might not lead to the intended effects if other factors such as infrastructure, the operating team or aggregation level of the available data are not taken into account.

Outcomes of acute lower gastrointestinal bleeding have not been compared according to hospital capacity. We aimed to perform a propensity score-matched cohort study with path and mediation analyses for acute hematochezia patients. Hospitals were divided into high- versus low-volume hospitals for emergency medical services. Rebleeding and death within 30 days were compared. Computed tomography, early colonoscopy (colonoscopy performed within 24 h), and endoscopic therapies were included as mediators. A total of 2644 matched pairs were yielded. The rebleeding rate within 30 days was not significant between high- and low-volume hospitals (16% vs. 17%, P = 0.44). The mortality rate within 30 days was significantly higher in the high-volume cohort than in the low-volume cohort (1.7% vs. 0.8%, P = 0.003). Treatment at high-volume hospitals was not a significant factor for rebleeding (odds ratio [OR] = 0.91; 95% confidence interval [CI], 0.79–1.06; P = 0.23), but was significant for death within 30 days (OR = 2.03; 95% CI, 1.17–3.52; P = 0.012) on multivariate logistic regression after adjusting for patients’ characteristics. Mediation effects were not observed, except for rebleeding within 30 days in high-volume hospitals through early colonoscopy. However, the direct effect of high-volume hospitals on rebleeding was not significant. High-volume hospitals did not improve the outcomes of acute hematochezia patients.

Patients with esophageal cancer have poor overall survival, with positive resection margins worsening survival. Margin positivity rates are used as quality measures in other malignancies, but modifiable risk factors are necessary to develop actionable targets for improvement. Our objectives were to (1) evaluate trends in esophageal cancer margin positivity, and (2) identify modifiable patient/hospital factors associated with margin positivity. Patients who underwent esophagectomy from 2004 to 2015 were identified from the National Cancer Database. Trends in margin positivity by time and hospital volume were evaluated using Cochrane–Armitage tests. Associations between patient/hospital factors and margin positivity were assessed by multivariable logistic regression. Among 29,706 patients who underwent esophagectomy for cancer, 9.37% had positive margins. Margin positivity rates decreased over time (10.62% in 2004 to 8.61% in 2015; p

The influence of hospital-related factors on outcomes following colorectal surgery is not well-established. The aim of our study was to evaluate the relationship between hospital factors on outcomes in surgically managed colorectal cancer patients. We performed a 2-year (2014–2015) analysis of the NIS database. Adult (> 18 years) patients who underwent open or laparoscopic colorectal resection were identified using ICD-9 codes. Patients were stratified based on hospital: volume (low vs. high), teaching status, and location (urban vs. rural). Outcome measures were complications and mortality. Multivariate logistic regression was performed. A total of 153,453 patients with CRC were identified of which 35.3% underwent surgical management. Mean age was 69 ± 13 years, 51.6% were female, and 67% were white. Twenty-seven percent of the patients were managed at a high-volume center, 48% at intermediate-volume center while 25% at a low-volume center. Complications and mortality rates were lower in patients who were managed at high-volume centers and urban hospitals, while no difference was noticed based on teaching status. On regression analysis, patients managed at high-volume centers (OR 0.76 [0.56–0.89]) and urban hospitals (OR 0.83 [0.64–0.91]) have lower odds of complications; similarly, high-volume centers (OR 0.79 [0.65–0.90]) and urban facility (OR 0.87 [0.70–0.92]) were associated with lower odds of mortality. However, there was no association between teaching status and outcomes. Hospital factors significantly influence outcomes in patients with CRC managed surgically. High-volume centers and urban facilities have relatively better outcomes. Regionalization of care along with the appropriate availability of resources may improve outcomes in patients with CRC. Level III, Retrospective Observational Study

Retroperitoneal lymph node dissection (RPLND) is a standard treatment in the management of metastatic testicular cancer. Due to modified treatment algorithms, it is becoming less frequent.We analyzed data from the nationwide German hospital billing database covering 2006-2015. Cases with a testicular cancer diagnosis combined with RPLND were included. We assessed the length of hospital stay (LOS), blood transfusion, and in-hospital mortality stratified for surgical approach, hospital characteristics, and annual caseload. Annual hospital caseload categories were defined as low ( 4), medium (4-10), and high ( 10). We supplemented tumor incidence and staging data from the German cancer registry (60% of population).4926 cases were included with decreasing annual caseload numbers from 623 in 2006 to 382 in 2015. The incidence of testicular cancer and higher tumor stages remained stable. High-volume hospitals performed 19.4%, medium-volume hospitals 43.7%, and low-volume hospitals 36.8% RPLNDs. Low- abd medium-volume hospitals declined, while high-volume hospitals (n = 5) maintained their annual caseload. Overall in-hospital mortality was 0.47%. Blood transfusion rates were higher in high-volume centers assumedly due to selection of more complex cases. However, high-volume hospitals showed a shorter LOS with 10.5 vs. 11.2 (medium volume), and 12.7 days (low volume).Total numbers of RPLND have declined from 2006 to 2015, while tumor incidences and stages remained fairly stable. Constant reduction of indication in guidelines contributes to this finding. High-volume hospitals achieve shorter hospital stays in spite of assumedly more complex and extensive cases. There is a modest trend towards unregulated centralization.

Many studies have demonstrated associations between surgical resections at academic centers and improved outcomes, particularly for complex operations. However, few studies have examined this relationship in intrahepatic cholangiocarcinoma (ICC). The hypothesis of this study was that facility type is associated with improved postoperative outcomes and survival for patients with ICC who undergo resection. Patients with stages 1 to 3 ICC who underwent hepatectomy were identified using the National Cancer Database (NCDB) (2004–2014). Facilities were categorized as academic or community centers per Commission on Cancer designations. High-volume hospitals were those that performed 11 or more hepatectomies per year. Multilevel logistic mixed-effects models to identify predictors of outcomes and parametric survival-time models were used to determine overall survival (OS). The study identified 2256 patients. Of these patients, 423 (18.8%) were treated at community centers, and 1833 (81.3%) were treated at academic centers. Nearly all high-volume centers were academic facilities (98.5% academic vs. 1.5% community centers), whereas low-volume centers were mixed (65.5% academic vs. 34.5% community centers) (p

We previously reported a significant volume–outcome relationship in mortality rates after gastrectomies for gastric cancer patients in Texas (1999–2001). We aimed to identify whether changes in the volume distribution of gastrectomies occurred, whether volume–outcome relationships persisted, and potential changes in the factors influencing volume–outcome relationships. We performed a population-based study using the Texas Inpatient Public Use Data File between 2010 and 2015. Hospitals were classified as high-volume centers (HVCs, > 15 cases per year), intermediate-volume centers (IVCs, 3–15 cases per year), and low-volume centers (LVCs

Objective: To determine the influence of delivery hospital on the rate of vaginal birth after cesarean (VBAC). Study Design: This retrospective cohort study used claims data from Blue Cross and Blue Shield of Michigan. Women with a prior cesarean and a singleton livebirth between 2012 and 2016 were included. We calculated the hospital-specific risk-standardized VBAC rates and median odds ratio as a measure of variation. Result: Hospital-level adjusted rates varied nearly 10-fold (3.7%-35.5%). Compared to the lowest volume hospitals (1st quartile), the likelihood of VBAC increased for those in the 2nd (adjusted OR 2.75 [95% CI 1.23-6.17]), 3rd (adjusted OR 3.73 [95% CI 1.59-8.75]), and 4th quartiles (adjusted OR 2.9 [95% CI 1.11-7.72]). The median OR suggested significant variation by hospital after adjustment. Conclusion: The delivery hospital itself explains a large amount of the variation in rates of VBAC after adjustment for patient and hospital characteristics.

PURPOSE: We aimed to obtain information on the number of Nordic centers performing tracheal resections, crico-tracheal resections, and laryngo-tracheal reconstructions, as well as the patient volume and the standard regimens associated with these procedures.METHODS: Consultants at all Departments of Otorhinolaryngology-Head and Neck Surgery (ORL-HNS, n = 22) and Thoracic Surgery (n = 21) in the five Nordic countries were invited (April 2018-January 2019) to participate in an online survey.RESULTS: All 43 departments responded to the survey. Twenty departments declared to perform one or more of the three types of tracheal resections. At five hospitals, departments of ORL-HNS and Thoracic Surgery perform these operations in collaboration. Hence, one or more of the tracheal operations in question are carried out at 15 centers. The median annual number of tracheal operations per center is five (range 1-20). Great variations were found regarding contraindications (relative and absolute) for surgery, the use of guardian sterno-mental sutures (all patients, 33%; selected cases, 40% of centers), prophylactic antibiotic therapy (cefuroxime +/- metronidazole, penicillin +/- metronidazole, clindamycin, imipenem, or none), post-operative follow-up time (range: children: 3-120 months; adults: 0-60 months), and the performance of post-operative bronchoscopy.CONCLUSIONS: Fifteen centers each perform a low number of annual operations with significant variations in the selection of patients and the clinical setup, which raises the question if a higher degree of collaboration and centralization would be warranted. We encourage Nordic transnational collaboration, pursuing alignment on central management issues, and establishment of a common prospective database for future tracheal resection surgery.

Background Medical centers with varying levels of expertise treat gastroenteropancreatic neuroendocrine tumors (GEP-NETs), which are relatively rare tumors. This study assesses the impact of center volume on GEP-NET treatment outcomes. Methods We used the Surveillance, Epidemiology, and End Results (SEER) registry linked to Medicare claims data. The data includes patients diagnosed between 1995 and 2010 who had no health maintenance organization (HMO) coverage, participated in Medicare parts A and B, were older than 65 at diagnosis, had tumor differentiation information, and had no secondary cancer. We identified medical centers at which patients received GEP-NET treatment (surgery, chemotherapy, somatostatin analogues, or radiation therapy) using Medicare claims data. Center volume was divided into 3 tiers – low, medium, and high – based on the number of unique GEP-NET patients treated by a medical center over 2 years. We used Kaplan-Meier curves and Cox regression to assess the association between volume and disease-specific survival. Results We identified 899 GEP-NET patients, of whom 37, 45, and 18% received treatment at low, medium volume, and high-volume centers, respectively. Median disease-specific survival for patients at low and medium tiers were 1.4 years and 5.3 years, respectively, but was not reached for patients at high volume centers. Results showed that patients treated at high volume centers had better survival than those treated in low volume centers (HR: 0.63, 95% CI: 0.4–0.9), but showed no difference in outcomes between medium and high-volume centers. Conclusions Our results suggest that for these increasingly common tumors, referral to a tertiary care center may be indicated. Physicians caring for GEP-NET patients should consider early referral to high volume centers.

Background Hospital volume is known to be associated with outcomes of patients requiring complicated medical care. However, the relationship between hospital volume and prognosis of hospitalized patients with heart failure (HF) remains not fully understood. We aimed to clarify the impact of hospital volume on clinical outcomes of hospitalized HF patients using a nationwide inpatient database. Methods and results We studied 447,818 hospitalized HF patients who were admitted from January 2010 and discharged until March 2018 included in the Japanese Diagnosis Procedure Combination database. According to the number of patients, patients were categorized into three groups; those treated in low-, medium-, and high-volume centers. The median age was 81 years and 238,192 patients (53%) were men. Patients who had New York Heart Association class IV symptom and requiring inotropic agent within two days were more common in high volume centers than in low volume centers. Respiratory support, hemodialysis, and intra-aortic balloon pumping were more frequently performed in high volume centers. As a result, length of hospital stay was shorter, and in-hospital mortality was lower in high volume centers. Lower in-hospital mortality was associated with higher hospital volume. Multivariable logistic regression analysis fitted with generalized estimating equation indicated that medium-volume group (Odds ratio 0.91, p = 0.035) and high-volume group (Odds ratio 0.86, p = 0.004) had lower in-hospital mortality compared to the low-volume group. Subgroup analysis showed that this association between hospital volume and in-hospital mortality among overall population was seen in all subgroups according to age, presence of chronic renal failure, and New York Heart Association class. Conclusion Hospital volume was independently associated with ameliorated clinical outcomes of hospitalized patients with HF.

Background Gastroschisis is a congenital anomaly that needs surgical management for repositioning intestines into the abdominal cavity and for abdominal closure. Higher hospital or surgeon volume has previously been found to be associated with better clinical outcomes for different especially high-risk, low volume procedures. Therefore, we aim to examine the relationship between hospital or surgeon volume and outcomes for gastroschisis. Methods We will perform a systematic literature search from inception onwards in Medline, Embase, CENTRAL, CINAHL, and Biosis Previews without applying any limitations. In addition, we will search trial registries and relevant conference proceedings. We will include (cluster-) randomized controlled trials (RCTs) and prospective or retrospective cohort studies analyzing the relationship between hospital or surgeon volume and clinical outcomes. The primary outcomes will be survival and mortality. Secondary outcomes will be different measures of morbidity (e.g., severe gastrointestinal complications, gastrointestinal dysfunctions, and sepsis), quality of life, and length of stay. We will systematically assess risk of bias of included studies using RoB 2 for individually or cluster-randomized trials and ROBINS-I for cohort studies, and extract data on the study design, patient characteristics, case-mix adjustments, statistical methods, hospital and surgeon volume, and outcomes into standardized tables. Title and abstract screening, full text screening, critical appraisal, and data extraction of results will be conducted by two reviewers independently. Other data will be extracted by one reviewer and checked for accuracy by a second one. Any disagreements will be resolved by discussion. We will not pool results statistically as we expect included studies to be clinically and methodologically very diverse. We will conduct a systematic synthesis without meta-analysis and use GRADE for assessing the certainty of the evidence. Discussion Given the lack of a comprehensive summary of findings on the relationship between hospital or surgeon volume and outcomes for gastroschisis, this systematic review will put things right. Results can be used to inform decision makers or clinicians and to adapt medical care. Systematic review registration Open Science Framework (DOI: 10.17605/OSF.IO/EX34M; 10.17605/OSF.IO/HGPZ2)

To investigate whether minimally invasive mitral valve repair (MIMVR) can be transferred from a high-volume center into a very small volume center and to clarify how many cases are necessary for maintenance of this program, early outcomes of MIMVR in Asahikawa Medical University were compared with those results in patients operated by a single surgeon in Duesseldorf University Hospital. Sixty-five patients who underwent MIMVR in Asahikawa Medical University (group A) between May 2014 and July 2018 and 134 patients who underwent MIMVR in Duesseldorf University Hospital (group D) between September 2009 and January 2014 by a surgeon who started MIMVS later in Asahikawa were retrospectively analyzed. In group D, there were more patients with ischemic mitral valve regurgitation and with annular calcification than in group A. Survival rate at 6 months and 1 year was 98.5% and 98.5% in group A and 92.9% and 91.3% in group D, respectively. EuroSCORE II was significantly higher in patients dead within 30 days and within the first year. The present study demonstrated that MIMVR programs can be transferred with acceptable early results into very low volume centers, if the team is developed by surgeons who are well trained and experienced in MIMVR. Moreover, the present study suggested that case number for maintenance of acceptable results may be obviously less than the previous recognition that this kind of specialized surgery could be maintained with at least 50 cases annually. However, meticulous preparations for surgery are essential for satisfactory surgical outcomes.

High-volume hospitals are associated with improved outcomes in glioblastoma (GBM). However, the impact of travel burden to high-volume centers is poorly understood. We examined post-operative outcomes between GBM patients that underwent treatment at local, low-volume hospitals with those that traveled long distances to high-volume hospitals. The National Cancer Database was queried for GBM patients that underwent surgery (2010–2014). We established two cohorts: patients in the lowest quartile of travel distance and volume (Short-travel/Low-Volume: STLV) and patients in the highest quartile of travel and volume (Long-travel/High-Volume: LTHV). Outcomes analyzed were 30-day, 90-day mortality, overall survival, 30-day readmission, and hospital length of stay. Of 35,529 cases, STLV patients (n = 3414) traveled a median of 3 miles (Interquartile range [IQR] 1.8–4.2) to low-volume centers (5 [3–7] annual cases) and LTHV patients (n = 3808) traveled a median of 62 miles [44.1–111.3] to high-volume centers (48 [42–71]). LTHV patients were younger, had lower Charlson scores, largely received care at academic centers (84.4% vs 11.9%), were less likely to be minorities (8.1% vs 17.1%) or underinsured (6.9% vs 12.1), and were more likely to receive trimodality therapy (75.6% vs 69.2%; all p

© 2018, Society of Surgical Oncology. Background: Outcomes for pancreatic resection have been studied extensively due to the high morbidity and mortality rates, with high-volume centers achieving superior outcomes. Ongoing investigations include healthcare costs, given the national focus on reducing expenditures. Therefore, we sought to evaluate the relationships between pancreatic surgery costs with perioperative outcomes and volume status. Methods: We performed a retrospective analysis of 27,653 patients who underwent elective pancreatic resections from October 2013 to June 2017 using the Vizient database. Costs were calculated from charges using cost–charge ratios and adjusted for geographic variation. Generalized linear modeling adjusting for demographic, clinical, and operation characteristics was performed to assess the relationships between cost and length of stay, complications, in-hospital mortality, readmissions, and hospital volume. High-volume centers were defined as hospitals performing ≥ 19 operations annually. Results: The unadjusted mean cost for pancreatic resection and corresponding hospitalization was $20,352. There were no differences in mean costs for pancreatectomies performed at high- and low-volume centers [− $1175, 95% confidence interval (CI) − $3254 to $904, p = 0.27]. In subgroup analysis comparing adjusted mean costs at high- and low-volume centers, there was no difference among patients without an adverse outcome (− $99, 95% CI − $1612 to 1414, p = 0.90), one or more adverse outcomes (− $1586, 95% CI − $4771 to 1599, p = 0.33), or one or more complications (− $2835, 95% CI − $7588 to 1919, p = 0.24). Conclusions: While high-volume hospitals have fewer adverse outcomes, there is no relationship between surgical volume and costs, which suggests that, in itself, surgical volume is not an indicator of improved healthcare efficiency reflected by lower costs. Patient referral to high-volume centers may not reduce overall healthcare expenditures for pancreatic operations.

The objectives of this study are to evaluate the associations between ventral hernia repair procedure volume and patient outcomes, including both clinical and economic outcomes. The 2014 National Inpatient Sample was queried for patients who underwent elective, open ventral (incisional) hernia repair with or without mesh. Outcomes included occurrence of major or wound-based in-hospital complications, extended length of stay (> 4 days), and increased costs (> $12,816). High-volume hospitals were defined as the 90th percentile of case volume or higher (> 60 cases/year). Multivariate regression was performed to access the outcomes associated with high-volume hospitals. 54,075 patients at 2049 hospitals were retrieved. 41.4 percent of patients were treated at high-volume hospitals. Patients treated at high-volume hospitals were less likely to experience a major complication (OR 0.88; 95% CI 0.82–0.96; p = 0.002) or wound-based complication (OR 0.84; 95% CI 0.76–0.92; p

To review the United States National Cancer Database (NCDB) from 2004 to 2015 and analyze survival outcomes of invasive non-urachal adenocarcinoma based on treatment modality. The NCDB 2004–2015 bladder dataset was queried for adenocarcinoma histology, excluding urachal variant, and limited to patients with clinical stage T2–T4 disease. Treatment modality was categorized as no treatment, cystectomy (partial or radical), external beam radiation therapy (EBRT), or EBRT plus cystectomy. Our primary outcome was overall survival. Cox regression (CR) and Kaplan–Meier (KM) analysis were performed. 851 patients were identified with invasive (cT2–T4) adenocarcinoma of the bladder. Treatment modalities included 398 (47.8%) no treatment, 298 (35.8%) cystectomy, 124 (14.9%) EBRT, and 31 (3.7%) EBRT plus cystectomy. On KM analysis excluding those with metastatic disease, the 5-year survival was significantly better (p

To estimate the cost of rescue and cost of failure and determine cost-effectiveness of rescue from major complications at high-volume (HV) and low-volume (LV) centers METHODS: Ninety-six thousand one hundred seven patients undergoing liver resection were identified from the Nationwide Inpatient Sample (NIS) between 2002 and 2011. The incremental cost of rescue and cost of FTR were calculated. Using propensity-matched cohorts, a cost-effectiveness analysis was performed to determine the incremental cost-effectiveness ratio (ICER) between HV and LV hospitals.Ninety-six thousand one hundred seven patients were identified in NIS. The overall mortality was 2.3% and was lowest in HV centers (HV 1.4% vs. MV 2.1% vs. LV 2.6%; p 0.001). Major complications occurred in 14.9% of hepatectomies and were comparable regardless of volume (HV 14.2% vs. MV 14.3% vs. LV 15.4%; p 0.001). The FTR rate was substantially lower among HV centers (HV 7.7%, MV 11%, LV 12%; p 0.001). At a willingness to pay benchmark of $50,000 per year of life saved, both HV (ICER = $3296) and MV (ICER = $4182) centers were cost-effective at rescuing patients from a major complication compared to LV hospitals.Not only was FTR less common at HV hospitals, but the management of most major complications was cost-effective at higher volume centers.

Improvement in mortality has been shown for esophagectomies performed at high-volume centers.This study aimed to determine if centralization of esophageal cancer surgery occurred in the US, and to establish its impact on postoperative mortality. In addition, we aimed to analyze the relationship between regionalization of cancer care and health disparities.A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000-2014. Adult patients (≥ 18 years of age) diagnosed with esophageal cancer and who underwent esophagectomy were included. Yearly hospital volume was categorized as low ( 5 procedures), intermediate (5-20 procedures), and high ( 20 procedures). Multivariable analyses on the potential effect of hospital volume on patient outcomes were performed, and the yearly rate of esophagectomies was estimated using Poisson regression.A total of 5235 patients were included. Esophagectomy at low- [odds ratio (OR) 2.17] and intermediate-volume (OR 1.62) hospitals, compared with high-volume hospitals, was associated with a significant increase in mortality. The percentage of esophagectomies performed at high-volume centers significantly increased during the study period (29.2-68.5%; p 0.0001). The trend towards high-volume hospitals was different among the different US regions: South (7.7-54.3%), West (15.0-67.6%), Midwest (37.3-67.7%), and Northeast (55.8-86.8%) [p 0.0001]. Overall, the mortality rate of esophagectomy dropped from 10.0 to 3.5% (p = 0.006), with non-White race, public insurance, and low household income patients also showing a significant reduction in mortality.A spontaneous centralization for esophageal cancer surgery occurred in the US. This process was associated with a decrease in the mortality rate, without contributing to health disparities.

We sought to determine if hospital delivery volume was associated with a patient’s risk for cesarean delivery in low-risk women. This study retrospectively examines a cohort of 1 657 495 deliveries identified in the 2013 Nationwide Readmissions Database. Hospitals were stratified by delivery volume quartiles. Low-risk patients were identified using the Society for Maternal–Fetal Medicine definition (n=845 056). A multivariable logistic regression accounting for hospital-level clustering was constructed to assess the factors affecting a patient’s odds for cesarean delivery. The range of cesarean delivery rates was 2.4–51.2% among low-risk patients, and the median was 16.5% (IQR 12.8–20.5%). The cesarean delivery rate was higher in the top two-volume-quartile hospitals (17.4 and 18.2%) compared to the bottom quartiles (16.4 and 16.3%) (P

Paroxysmal supraventricular tachycardia (PSVT) ablation can result in injury to the atrioventricular (AV) node causing complete heart block requiring permanent pacemaker (PPM) implantation. Few studies have examined the impact of hospital PSVT ablation volume and PPM implantation rates post ablation.We included adult patients from the Nationwide Inpatient Sample (NIS) database, from 1998 to 2011, using ICD-9 diagnoses codes 427.0 and 427.89 for PSVT and ICD-9 procedure code 37.34 for ablation. Patients with concomitant arrhythmias, prior pacemaker/defibrillator implants, or pre-existing sinus node dysfunction were excluded. Multivariate logistic regression analysis was performed to identify predictors of PPM implantation.There were 119,938 PSVT ablations from 1998 to 2011 with a mean age of 54.6 ± 17.5 years and 64.1% females. The overall PPM implantation rate was 3.2%. PPM implantation rates in the first (1-14 ablations/year), second (15-32 ablations/year), and third ( 32/ablations/year) tertiles of annual PSVT ablation volume were respectively 4.4, 3.3, and 1.9% (p 0.001). Increasing age, female gender, bifascicular, or trifascicular block and teaching hospital status were independent predictors of PPM implantation. The adjusted odds ratio for PPM implantation in hospitals performing 32 PSVT ablations/year compared to hospitals performing ≤ 14 PSVT ablations/year was 0.54 (95% confidence interval 0.3-0.9, p = 0.026).PPM implantation rates are significantly lower in hospitals performing 32 PSVT ablations/year, indicating that hospital experience is an important determinant of outcomes after PSVT ablation.

Patient and tumor factors have been associated with rates for pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) for breast cancer, but variation in pCR rates across facilities has not been studied. This study used the National Cancer Data Base to identify women with clinical stages 1–3a breast cancer undergoing NAC from 2010 to 2013. Generalized estimation equation models were used to examine the relationship between facility characteristics and pCR rates, with adjustment for patient and tumor factors, while accounting for patient clustering at facilities. Analyses were stratified by tumor molecular subtype. Overall, 16,885 women underwent NAC, of whom 3130 (18.5%) were hormone receptor-positive (HR+) and human epidermal growth factor 2-positive (HER2+), 7045 (41.7%) were HR+HER2−, 1847 (10.9%) were HR−HER2+, and 4863 (28.8%) were HR−HER2−. Overall, 4002 of the patients (23.7%) achieved a pCR. The pCR rates were 29.5% for HR+HER2+, 10.8% for HR+HER2−, 45.3% for HR−HER2+, and 30.5% for HR−HER2− tumors. Multivariable analysis showed that pCR rates were significantly higher at high-volume facilities (>75th vs.

BackgroundA shift in the healthcare system towards the centralization of common yet costly surgeries, such as total hip arthroplasty (THA), to high-volume centers of excellence, is an attempt to control the economic burden while simultaneously enhancing patient outcomes. The “volume-outcome” relationship suggests that hospitals performing more treatment of a given type exhibit better outcomes than hospitals performing fewer. This theory has surfaced as an important factor in determining patient outcomes following THA. We performed a systematic review with meta-analyses to review the available evidence on the impact of hospital volume on outcomes of THA.Materials and methodsWe conducted a review of PubMed (MEDLINE), OVID MEDLINE, Google Scholar, and Cochrane library of studies reporting the impact of hospital volume on THA. The studies were evaluated as per the inclusion and exclusion criteria. A total of 44 studies were included in the review. We accessed pooled data using random-effect meta-analysis.ResultsResults of the meta-analyses show that low-volume hospitals were associated with a higher rate of surgical site infections (1.25 [1.01, 1.55]), longer length of stay (RR, 0.83[0.48–1.18]), increased cost of surgery (3.44, [2.57, 4.30]), 90-day complications (RR, 1.80[1.50–2.17]) and 30-day (RR, 2.33[1.27–4.28]), 90-day (RR, 1.26[1.05–1.51]), and 1-year mortality rates (RR, 2.26[1.32–3.88]) when compared to high-volume hospitals following THA. Except for two prospective studies, all were retrospective observational studies.ConclusionsThese findings demonstrate superior outcomes following THA in high-volume hospitals. Together with the reduced cost of the surgical procedure, fewer complications may contribute to saving considerable opportunity costs annually. However, a need to define objective volume-thresholds with stronger evidence would be required.Trial registrationPROSPEROCRD42019123776.

Background The use of inappropriate elective Percutaneous Coronary Intervention (PCI) has decreased over time, but hospital-level variation in the use of inappropriate PCI persists. Understanding the barriers and facilitators to the implementation of Appropriate Use Criteria (AUC) guidelines may inform efforts to improve elective PCI appropriateness. Methods All hospitals performing PCI in Washington State were categorized by their use of inappropriate elective PCI in 2010 to 2013. Semi-structured, qualitative telephone interviews were then conducted with 17 individual interviews at 13 sites in Washington State to identify barriers and facilitators to the implementation of the AUC guidelines. An inductive and deductive, team-based analytical approach, drawing primarily on Matrix analysis was performed to identify factors affecting implementation of the AUC. Results Specific facilitators were identified that supported successful implementation of the AUC. These included collaborative catheterization laboratory environments that allow all staff to participate with questions and opinions; ongoing AUC education with catheterization laboratory teams and referring providers; internal AUC peer review processes; interventional cardiologist be directly involved with the pre-procedural review process; checklist-based algorithms for pre-procedural documentation; systems redesign to include insurance companies; and AUC educational information with patients. Barriers to implementation of the AUC included external pressures, such as competition for patients, and the lack of shared medical records with sites that referred patients for coronary angiography. Conclusions The identified facilitators enabled sites to successfully implement the AUC. Catheterization laboratories struggling to successfully implement the AUC may consider utilizing these strategies to improve their processes to improve patient selection for elective PCI.

Although proposed as a means for quality improvement, little is known regarding the economic consequences of volume-based referral. The objective of the current study was to investigate the relationship between inpatient costs and hospital volume. Patients undergoing elective liver surgery were identified using the Nationwide Inpatient Sample from 2001 to 2012. Multivariable hierarchical regression analyses were performed to calculate and compare risk-adjusted costs and postoperative outcomes across hospital volume terciles. A total of 27,813 patients underwent surgery at 2207 hospitals. Although costs were comparable across the three volume groups (all p > 0.05), patients who developed a postoperative complication incurred a higher overall cost (complication vs. no complication; median costs $17,974 [IQR 13,865–25,623] vs. $41,731 [IQR 27,008–64,266], p

The purpose of this article was to broadly review the most up-to-date information pertaining to the centralization of ovarian cancer care in the United States (US) and worldwide. Much of the present literature pertaining to disparities in, and centralization of, ovarian cancer care in the US and internationally was reviewed, and specifically included original research and review articles. Data show improved optimal debulking rates, National Comprehensive Cancer Network (NCCN) guideline adherence, and overall survival rates in higher-volume, more specialized hospitals, and amongst higher-volume providers. Patients with invasive epithelial ovarian cancer, especially those with higher stages (III and IV), are better served by centralized care in high-volume hospitals and by high-volume physicians, who adhere to NCCN guidelines wherever possible. More research is needed to determine the policy changes that can increase NCCN guideline adherence in low-volume hospitals and low-provider caseload scenarios. Policy and future research should be aimed at increasing patient access, either directly or indirectly, to high-volume hospital and high-volume providers, especially amongst Medicare, lower socioeconomic status, and minority patients.

Data on the importance of margin status after total thyroidectomy for papillary thyroid cancer (PTC) remain limited. This study sought to identify factors associated with positive margins and to determine the impact of positive margins on survival for patients with PTC.The National Cancer Data Base (1998-2006) was queried for patients with PTC who had undergone total thyroidectomy. The patients were divided into three groups based on margin status (negative, microscopically positive, and macroscopically positive). Patient demographic, clinical, and pathologic features were evaluated. A binary logistic regression model was developed to identify factors associated with positive margins. A Cox proportional hazards model was developed to identify factors associated with survival.Of the 31,129 patients enrolled in the study, 91.3 % had negative margins, 8.1 % had microscopically positive margins, and 0.6 % had macroscopically positive margins. The patients with negative margins were younger and more likely to be female, white, covered by private insurance, and treated at an academic or high-volume center (p0.05). They had smaller tumors and were less likely to have advanced-stage disease. After multivariable adjustment, increasing patient age [odds ratio (OR) = 1.02; p0.01], government insurance (OR = 1.20; p0.01), and no insurance (OR = 1.34; p = 0.01) were associated with positive margins. Reception of surgery at a high-volume facility (OR = 0.72; p0.01) was protective. After multivariable adjustment, both microscopically [hazard ratio (HR), 1.49; p0.01] and macroscopically positive margins (HR = 2.38; p0.01) were associated with compromised survival.Several vulnerable patient populations have a higher risk of incomplete resection after thyroidectomy for PTC. High-risk thyroid cancer patients should be referred to high-volume centers to optimize outcomes.

To determine the safety and outcome of outpatient thyroid surgery in a small low-surgical volume hospital. To evaluate clinical and social factors that may prohibit outpatient thyroid surgery.Retrospective analysis of all thyroid surgery performed at a low-surgical volume hospital from August 2006 to July 2014. One-hundred and sixty patients underwent thyroid surgery during the study period. Electronic medical records were reviewed for all patients. Data collection included demographic information, extent of thyroid surgery, length of hospital stay, laboratory/pathology results, co-morbidities, and complications.Of the 160 patients who underwent thyroid surgery, 109 (68.1%) were discharged on the day of surgery. Forty-three patients (26.9%) were admitted for 23-h observation and eight patients (5%) required full admission (longer than 24 h). Sixty-one patients (38.1%) underwent a total thyroidectomy, while 99 patients (61.9%) underwent a hemithyroidectomy. Complications included four temporary recurrent laryngeal nerve (RLN) injuries (2.5% patients/1.8% of total RLN at risk), one permanent RLN injury (0.63% patients/0.45% of total RLN as risk), one temporary bilateral RLN injury (0.63%), two delayed hematomas (1.3%), and eight cases of transient hypocalcemia (5%).Outpatient thyroid surgery can be performed safely in a low-surgical volume center. Reasons for a longer stay include clinical as well as social factors.

A strong relationship between hospital caseload and adverse outcomes has been demonstrated for pancreatic resections. Participation in regional surgical collaboratives may mitigate this phenomenon. This study sought to investigate changes over time in adverse outcomes after pancreatectomy across hospitals with different caseloads in a statewide surgical collaborative. The study investigated patients undergoing pancreatic resection from January 2008 to August 2013 at Michigan Surgical Quality Collaborative (MSQC) hospitals (1007 patients in 19 academic and community hospitals). Risk-adjusted rates of major complications, mortality, and failure to rescue were compared between hospitals based on caseloads (low, medium, and high) in early (2008–2010) and later (2011–2013) periods. Finally, the degree to which different complications explained changes in hospital outcome variation was assessed. Adjusted rates of major complications and mortality decreased over time, driven largely by improvements at low-caseload hospitals. In 2008–2010, risk-adjusted major complication rates were higher for low-caseload than for high-caseload hospitals (27.8 vs. 17.8 %; p = 0.02). However, these differences were attenuated in 2011–2013 (22.2 vs. 20.0 %; p = 0.74). Similarly, adjusted mortality rates were higher in low-caseload hospitals in 2008–2010 (6.2 vs. 0.8 %; p = 0.02), but these differences were attenuated in 2011–2013 (3.3 vs. 1.1 %; p = 0.18). Variation in major complications decreased, largely due to decreased variation in “medical” complication rates, with less change in surgical-site complications. Participation in regional quality collaboratives by lower-volume hospitals can attenuate the volume–outcome relationship for pancreatic surgery. Continued work in collaboratives with an emphasis on technical and intraoperative aspects of care may improve overall quality of care.

This retrospective study was designed to assess the feasibility of laparoscopic total gastrectomy (LTG) in clinical stage I gastric cancer patients, and validate the appropriateness of the widespread adoption of LTG for experienced open surgeons. Eighty-eight patients with clinical stage I gastric cancer underwent LTG in our hospitals (n = 55) and affiliated hospitals (n = 33). Esophagojejunostomy was performed intracoporeally using a circular stapler with an incision in the left upper abdomen. We investigated the patients’ clinicopathologic factor, and evaluated the effect of hospital volume on short-term outcomes. Fixed insertion of the anvil head was successfully achieved in all patients (lift-up method in 58 patients and transoral method in 28 patients), although 2 patients were converted to open surgery. The approach using a circular stapler through a small incision from the upper left quadrant of the abdomen facilitated a good laparoscopic visual field for the plane of the esophagojejunostomy. Fourteen patients developed Clavien–Dindo classification grade II or more postoperative complications, and the overall operative morbidity rate was 15.9 %. No anastomotic leakage was encountered in this series. No significant difference was observed in clinical outcomes between patients in the high- and low-volume hospital groups. Laparoscopic total gastrectomy can be performed safely on clinical stage I gastric cancer patients by surgeons with sufficient experience in open gastrectomy and therefore represents a feasible procedure that is not clinically impacted by hospital volume.

High center procedural volume has been shown to reduce postoperative mortality (POM); however, the cause of POM has been poorly studied previously. The aim of this study was to define the pattern of POM and major morbidity in relation to center procedural volume. Data from 2,944 consecutive adult patients undergoing esophagectomy for esophageal cancer in 30 centers between 2000 and 2010 were retrospectively collected. Data between patients who suffered 30-day POM were compared with those who did not. Factors associated with POM were identified using binary logistic regression, with propensity matching to compare low- (LV) and high-volume (HV) centers. The 30-day and in-hospital POM rates were 5.0 and 7.3 %, respectively. Pulmonary complications were the most common, affecting 38.1 % of patients, followed by surgical site infection (15.5 %), cardiovascular complications (11.2 %), and anastomotic leak (10.2 %). Factors that were independently associated with 30-day POM included American Society of Anesthesiologists grade IV, LV center, anastomotic leak, pulmonary, cardiovascular and neurological complications, and R2 resection margin status. Surgical complications preceded POM in approximately 30 % of patients compared to medically-related causes in 68 %. Propensity-matched analysis demonstrated LV centers were significantly associated with increased 30-day POM, and POM secondary to anastomotic leak, and pulmonary- and cardiac-related causes. The results of this large, multicenter study provide further evidence to support the centralization of esophagectomy to HV centers, with a lower rate of morbidity and better infrastructure to deal with complications following major surgery preventing further mortality.

This study investigated the effect of hospital volume on outcomes of laparoscopic appendectomy for acute appendicitis.In total, 30,525 patients who underwent laparoscopic appendectomy for acute appendicitis were referred to 825 hospitals in Japan from 2010 to 2012. We compared appendectomy-related complications, length of stay (LOS), and medical costs in relation to hospital volume. For this study period, hospitals were categorized as low-volume hospitals (LVHs,50 cases), medium-volume hospitals (MVHs, 50-100 cases), or high-volume hospitals (HVHs,100 cases).Significant differences in appendectomy-related complications were observed among the LVHs, MVHs, and HVHs (6.9, 7.2, and 6.0 %, respectively; p = 0.001). Multiple logistic regression revealed that HVHs were associated with a lower relative risk of appendectomy-related complications than were LVHs and MVHs (odds ratio [OR], 0.84; 95 % confidence interval [CI], 0.74-0.95; p = 0.006). Multiple linear regression showed that HVHs were associated with shorter LOS and lower medical costs than were LVHs and MVHs. The unstandardized coefficient for LOS was -0.92 days (95 % CI, -1.07 to -0.78; p 0.001), whereas that for medical costs was - $167.4 (95 % CI, -256.2 to -78.6; p 0.001).Hospital volume was significantly associated with laparoscopic appendectomy outcomes.

Operative mortality traditionally has been defined as the rate within 30 days or during the initial hospitalization, and studies that established the volume–outcome relationship for pancreatectomy used similar definitions. Pancreatectomies reported to the National Cancer Data Base (NCDB) during 2007–2010 were examined for 30- and 90-day mortality. Unadjusted mortality rates were compared by type of resection, stage, comorbidities, and average annual hospital volume. Hierarchical logistic regression models generated risk-adjusted odds ratios for 30- and 90-day mortality. After 21,482 pancreatectomies, the unadjusted 30-day mortality rate was 3.7 % (95 % confidence interval [CI] 3.4–3.9 %), which doubled at 90 days to 7.4 % (95 % CI 7.0–7.8). The unadjusted and risk-adjusted mortality rates were higher at 30 days with increasing age, increasing stage, male gender, lower income, low hospital volume, resections other than distal pancreatectomy, Medicare or Medicaid insurance coverage, residence in a Southern census division, history of prior cancer, and multiple comorbidities. The lowest-volume hospitals (

BackgroundAdrenocortical carcinoma (ACC) is a rare, aggressive disease with no apparent change in treatment or survival in the United States over the past two decades. Our objective was to determine whether treatment patterns or clinical outcomes vary by hospital case volume.MethodsPatients with ACC were identified from the National Cancer Database (1998-2011). High-volume centers (HVCs) were defined by a case load of ≥4 cases of primary adrenal malignancy annually, which corresponded to the 90th percentile. All other facilities were considered low-volume centers (LVCs).ResultsA total of 2,765 ACC patients were treated across 1,046 facilities. Compared to patients treated at LVCs, patients treated at HVCs were younger (50 vs. 54years), with larger tumors (11.2 vs. 10.5cm), and underwent higher rates of surgery (78.8 vs. 73.4%), radical resection (17.3 vs. 13.9%), regional lymph node evaluation (23.2 vs. 18.8%), and chemotherapy including mitotane (43.8 vs. 31.0%, all p&nbsp

Hospital and surgeon volume are potential factors influencing postoperative mortality and morbidity after pancreatic resection. Data on perioperative outcome of individual surgeons in different institutions, however, are scarce. We evaluated the perioperative outcome after pancreatic head resections (PHR) performed by a high-volume pancreatic surgeon in a high-volume university department and (later) in a community hospital with low prior experience in major pancreatic surgery. We compared the results after PHR were performed by a single experienced surgeon between 2001 and October 2006 in a specialized unit of a German university hospital (n = 83; group A) with the results after PHR were performed in a community hospital between November 2006 and 2011 (n = 145; group B). Before the study period (−2001), the surgeon already had a personal caseload of >200 PHR. In addition to the 228 PHR analyzed here, the surgeon also had taught further >150 PHR to residents and consulting surgeons. Comparable surgical and perioperative techniques were applied in both series (e.g., types of resection and reconstruction, abdominal drains, early enteral feeding). The data of both series were prospectively recorded in SPSS databases. The median age of the patients was lower in group A (58 vs. 66 years in B; p

Although hemorrhagic complications are major complications of percutaneous renal biopsy (PRB), the relationship between procedure volume and morbidity remains unclear for PRB. The present study investigated the impact of hospital volume on the occurrence of hemorrhagic complications after PRB. Using large claims-based data in the diagnosis procedure combination database in Japan, we identified inpatients with renal disorders who underwent PRB within 4 days after admission during July to December 2007 to 2010. We assessed patient age, sex, clinical syndromes, hemorrhagic complications and diagnoses, and annual hospital volume of PRB divided into quintiles. Multivariate logistic regression analyses fitted with a generalized estimation equation were performed accounting for within-hospital clustering. A total of 15,191 patients were identified from 942 hospitals. The overall proportion of hemorrhagic complications was 2.1 %, including diagnoses of hemorrhagic events (1.6 %), red blood cell transfusion (0.5 %), and requiring angiography or endovascular procedure (0.1 %). In-hospital deaths attributable to the complications occurred in 0.06 % of the patients. Patients with rapidly progressive nephritic syndrome (odds ratio 3.41, 95 % confidence interval 2.22–5.25) had significantly higher incidence than those with chronic nephritic syndrome. No significant association was observed between hospital volume and hemorrhagic complications, with odds ratios for the low-intermediate, intermediate, intermediate-high, and high-volume groups relative to the low-volume group of 0.74 (0.43–1.26), 1.19 (0.74–1.92), 1.16 (0.67–2.00), and 1.35 (0.78–2.34), respectively. No significant relationship was observed between hemorrhagic complication incidence and hospital volume regarding PRB.

Surgeon experience has been demonstrated to result in better outcomes after a variety of advanced operations. Less information is available regarding adrenal surgery. We compared the outcomes after adrenalectomy for a variety of indications and determined the effect of surgeon's case volume.Cross-sectional analysis was performed using ICD-9 procedure codes included in the Nationwide Inpatient Sample from 2003 to 2009 to identify all adult patients who underwent unilateral or bilateral adrenalectomy for benign or malignant conditions. Logistic regression was used to test for interaction between surgeon case volume (low = 1, intermediate = 2-5, and high =5 adrenalectomies per year), diagnosis, type of operation performed, and risk of complications.A total of 7,829 adrenalectomies were included. Risk of complications after bilateral adrenalectomy was 23.4 % compared to 15.0 % for unilateral adrenalectomy (odds ratio 2.165, 95 % confidence interval 1.335, 3.512). Malignancy was associated with higher risk of complication (23.1 %) than benign disease (13.2 %) (odds ratio 1.685, 95 % confidence interval 1.371, 2.072). Complication rates for low- and intermediate-volume surgeons were 18.8 and 14.6 %, respectively, and both were significantly higher than complications by high-volume surgeons (11.6 %, p0.05). Length of stay and charges were both significantly less for high-volume surgeons compared to lower-volume groups (p0.05).Low surgeon case volumes and adrenal surgery for malignant or bilateral disease are associated with increased risk of postoperative complications. Length of stay and charges were significantly less when high-volume surgeons perform adrenal surgery.

There is an inverse relationship between hospital and surgeon volume and mortality in many types of complex surgery. The aim of this paper is to investigate the volume effect on outcomes of liver surgery. A systematic review and meta-analysis was performed. A literature search was conducted using Medline and EMBASE from 1995 to 2012. A random effects model was used. Seventeen studies were selected for detailed analysis. Definition of a high-volume institution varied from 2 to more than 33 procedures per year. The pooled odds ratio of mortality rate in low- vs high-volume centres was 2.0 [95 % confidence interval (CI), 1.6–2.4; P

The purpose of the present study was to examine the effects of surgeon elective abdominal aortic aneurysm repair volume on outcomes after ruptured abdominal aortic aneurysm (rAAA) repair. A nationwide claims database was used to identify patients who underwent rAAA repair from 1998 to 2009. Surgeon elective open abdominal aortic aneurysm repair (EAR) volume was classified as low, medium, or high. Associations between surgeon EAR volume and in-hospital mortality, overall survival, and complications after open rAAA repair (RAR) were compared with multivariate analysis. Associations between surgeon elective endovascular abdominal aortic aneurysm repair (EER) volume and outcomes after endovascular rAAA repair (RER) were also analyzed. A total of 537 patients who underwent rAAA repair were identified, including 498 who underwent RAR and 39 who underwent RER. In-hospital mortality rates after RAR were 49, 38, and 24 % in the low, medium, and high EAR volume groups, respectively (p

Analysis of mastectomy rates in breast cancer patients diagnosed between 2006 and 2010 in Germany with focus on impact of breast magnetic resonance imaging (MRI), immediate breast reconstruction (IBR) rates, and hospital volume as possible influencing factors of mastectomy rates. Data of a voluntary monitored benchmarking project were used to evaluate mastectomy trends across time in an unselected cohort of breast cancer patients. We used univariate and multivariate logistic regression analysis to identify predictive factors of mastectomy. A total of 142.863 cases were included into the analysis. There was an overall decrease of 5.9 % (95 % confidence interval 5.1–6.7) in mastectomy trend from 36.5 % in 2006 to 30.6 % in 2010 (P

Avoiding mortality is the ultimate goal when managing patients with suspected appendicitis. Previous studies have shown high mortality after negative appendectomy. This national cohort study analyzes short- and long-term mortality after appendectomy in relation to appendectomy diagnosis, age, co-morbidity, surgical method, hospital volume, and time period.A total of 223,543 appendectomy patients treated from 1987 to 2006 were identified from the Swedish National Patient Register and followed up via the Swedish Cause of Death Register. Analysis of mortality was conducted as Standardized Mortality Ratio (SMR) and by Cox multivariate regression.Negative appendectomy was followed by a higher mortality in the short term (30-day Standardized Mortality Ratio (SMR30d) 8.95, confidence interval (CI) 6.68-12.61) than after perforated appendicitis (SMR30d 6.39, CI 5.44-7.48), and remained increased for up to 5 years (SMR5yr 1.31, CI 1.16-1.47). Non-perforated appendicitis had a lower than expected long-term mortality (SMR5yr 0.72, CI 0.68-0.76). These differences remained after adjustment for covariates. Laparoscopic appendectomy had similar short-term mortality as open appendectomy but lower than expected long-term morality (SMR5yr 0.70, CI 0.62-0.78). Mortality was decreasing during the study period. Hospital volume had no influence on mortality.Negative appendectomy is associated with excess short- and long-term mortality that remains after adjustment for known confounders, suggesting an association with underlying undetected morbidity. This motivates an improved preoperative diagnosis to avoid the additional trauma from unnecessary surgical interventions, but further studies are needed to investigate the cause of the increased long-term mortality and if this can be prevented by an improved follow-up of patients with negative appendectomy. Laparoscopic and open appendectomy have similar short-term mortality. The lower long-term mortality after non-perforated appendicitis and laparoscopic appendectomy suggest selection of healthier patients for these interventions. This possibility should be taken into account when comparing mortality after open and laparoscopic appendectomy.

Compared to the open approach, randomized trials have shown that laparoscopic colectomy is associated with a shorter hospitalization without increases in morbidity or mortality rates. With broader adoption of laparoscopic colectomy for cancer in the USA, it is unclear if laparoscopic colectomy continues to be associated with shorter hospitalization and comparable morbidity.The purpose of this study is to determine if hospitals where a greater proportion of colon resections for cancer are approached laparoscopically (laparoscopy rate) achieve improved short-term outcomes compared to hospitals with lower laparoscopy rates.From the 2008-2009 Nationwide Inpatient Sample, we identified hospitals where ≤ 12 colon resections for cancer were reported with ≥ 1 approached laparoscopically. We assessed the correlation between a hospital's laparoscopy rate and risk-standardized outcomes (intra- and postoperative morbidity, in-hospital mortality rates, and average length of stay).Overall, 6,806 colon resections were performed at 276 hospitals. Variation was noted in hospital laparoscopy rates (median = 52.0 %, range = 3.8-100 %) and risk-standardized intra- (2.7 %, 1.8-8.6 %) and postoperative morbidity (27.8 %, 16.4-53.4 %), in-hospital mortality (0.7 %, 0.3-42.0 %), and average length of stay (7.0 days, 4.9-10.3 days). While no association was noted with in-hospital mortality, higher laparoscopy rates were correlated with lower postoperative morbidity [correlation coefficient (r) = -0.12, p = 0.04) and shorter hospital stays (r = -0.23, p 0.001), but higher intraoperative morbidity (r = 0.19, p 0.001) rates. This was not observed among hospitals with high procedure volumes.Higher laparoscopy rates were associated with only slightly lower postoperative morbidity rates and modestly shorter hospitalizations.

Pancreatic resection is a complex surgical procedure. Although its associated mortality has decreased significantly over time, morbidity remains high. A strong volume–outcome relation has been demonstrated for pancreatic resection, with decreases in the mortality, hospital length of stay, and cost when performed in high-volume hospitals. Despite these compelling data, complete regionalization of pancreatectomy to high-volume centers has not been achieved, with 20–40 % of pancreatic resections still being performed at low-volume centers. There is evidence that failure of regionalization is driven, in part, by patient preferences and physician referral patterns. In Texas, 19 % of patients traveled a distance farther than the distance to the nearest high-volume hospital to have their operation performed at a low-volume hospital. Finlayson and colleagues found that only 55 % of patients were willing to travel to a high-volume center even if told that their mortality risk was double at their local facility. Also, only 82 % were willing to travel if told that their mortality risk was sixfold higher at their local facility. Even across high-volume centers, there is significant variability in outcomes. Given the wide variability in outcomes and the challenges and reality of regionalization, it is critical to explore alternative approaches to improving overall outcomes as well as closing the ‘‘quality gap’’ observed between highand low-volume providers. Healy et al. provide data to suggest that participation in a regional quality improvement collaborative may provide an alternative model to improving outcomes for patients undergoing pancreatic resection. Leveraging data from an already existing statewide surgical quality collaborative, the authors demonstrate improvement in risk-adjusted morbidity, mortality, and failure to rescue rates for pancreatectomy between two time periods, 2008–2010 and 2011–2013. Importantly, the majority of the observed improvement in outcomes was due to attenuation of the variation in outcomes across lowand high-volume hospitals. Adjusted mortality rates (from 6.2 to 3.3 %) and major complication rates (from 27.8 to 22.2 %) improved over time in low-volume hospitals. However, there was a slight increase in the mortality rate (from 0.8 to 1.1 %) and morbidity rate (from 17.8 to 20.0 %) at high-volume hospitals, although this increase is likely not statistically or clinically significant. When evaluating these outcomes, the reader should understand that this collaborative effort was not procedure-specific. It did not assess pancreatectomyspecific outcomes across institutions, nor was it a true collaboration between centers to learn from each other and drive further improvement. Regardless of these drawbacks, the data suggest that a collaborative approach to quality improvement could provide another important piece of the puzzle. Pancreatectomyspecific improvement occurred even when it was not the primary goal of the collaborative design. Therefore, it is reasonable to extrapolate that a procedure-specific collaborative could help hospitals and physicians improve outcomes for complex procedures. Ideally, collaboratives would provide benefit beyond the outcomes reporting by learning from one another and implementing strategic interventions, ultimately improving global outcomes. These results, in turn, could lead to a reduction in the variation between lowand high-volume providers as well as improved outcomes at all centers. For example, instead of improving overall pancreatic fistula rates by bringing the low-volume centers to the current level of the high-volume Society of Surgical Oncology 2015

Background A number of factors have been identified as influencing total knee arthroplasty outcomes, including patient factors such as gender and medical comorbidity, technical factors such as alignment of the prosthesis, and provider factors such as hospital and surgeon procedure volumes. Recently, strategies aimed at optimizing provider factors have been proposed, including regionalization of total joint arthroplasty to higher volume centers, and adoption of volume standards. To contribute to the discussions concerning the optimization of provider factors and proposals to regionalize total knee arthroplasty practices, we undertook a systematic review to investigate the association between surgeon volume and primary total knee arthroplasty outcomes. Methods We performed a systematic review examining the association between surgeon volume and primary knee arthroplasty outcomes. To be included in the review, the study population had to include patients undergoing primary total knee arthroplasty. Studies had to report on the association between surgeon volume and primary total knee arthroplasty outcomes, including perioperative mortality and morbidity, patient-reported outcomes, or total knee arthroplasty implant survivorship. There were no restrictions placed on study design or language. Results Studies were variable in defining surgeon volume (‘low’: 5 to >70 total knee arthroplasty per year). Mortality rate, survivorship and thromboembolic events were not found to be associated with surgeon volume. We found a significant association between low surgeon volume and higher rate of infection (0.26% - 2.8% higher), procedure time (165 min versus 135 min), longer length of stay (0.4 - 2.13 days longer), transfusion rate (13% versus 4%), and worse patient reported outcomes. Conclusions Findings suggest a trend towards better outcomes for higher volume surgeons, but results must be interpreted with caution.

It was with great interest that we read the editorial by Dr. Julie Ann Sosa, ‘‘What’s Old is New Again,’’ which reviews our recent publication ‘Total thyroidectomy is associated with increased risk of complications for lowand high-volume surgeons,’’ in the current issue of Annals of Surgical Oncology. Dr. Sosa has been a pioneer in the field of endocrine surgery and has paved the way for studies examining the relationships between volume and outcomes such as ours. We agree with Dr. Sosa that the relationship between provider volume and improved patient outcomes is not a novel discovery and has been demonstrated for a number of operations. With regard to thyroid surgery, these relationships have been demonstrated in both pediatric and geriatric thyroid patients. Our study confirms previous findings as Dr. Sosa suggests, and it is currently the largest study of its kind. The fact that it confirms previous findings suggests that such findings are reproducible, and this should not be felt to be an insignificant point. Additionally, using a nationwide database with weighted data points allows us to attempt to scale the data to most accurately reflect information at the national level. By doing so, we confirmed that, nationally, high-volume surgeons performed the smallest percentage of thyroidectomies and not a disproportionately large number, as previously suggested by Sosa et al. However, for the first time using a national database, we show that the type of thyroid operation does have significant influence on morbidity. We demonstrate, by controlling for surgeon volume, and hence, surgeon skills and experience, that these factors are not the sole determinant of complication rates. There is an inherent risk to total thyroidectomy even among high-volume surgeons. This risk, however, is mitigated when high-volume surgeons perform these operations compared with low-volume surgeons, as previously demonstrated. As Dr. Sosa points out, debate currently surrounds the appropriate management for lowand medium-risk differentiated thyroid cancers\4 cm in size, and whether thyroid lobectomy or total thyroidectomy should be performed. Additionally, The American Thyroid Association released guidelines in 2009 recommending that thyroid lobectomy alone may be sufficient treatment for isolated indeterminate solitary nodules in those who prefer a more limited surgical procedure and for those with small (\1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastases. These recommendations have been based on data demonstrating similar survival between lobectomy and total thyroidectomy. Despite these recommendations, there has been an increasing trend toward performing total thyroidectomy, especially for the management of benign disease, in America over the last 15 years, and total thyroidectomy continues to be offered for cases of microcarcinoma and low-grade thyroid malignancies. Society of Surgical Oncology 2014