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Background: Although provider-level volume is frequently associated with outcomes in cancers requiring complex surgeries, whether similar relations exist for cancers treated primarily with systemic therapy is unknown.Methods: Using a population-based cohort analysis of older adults diagnosed with diffuse large B cell lymphoma (DLBCL) during the years 2004-2011, we evaluated the association between oncologist volume and 4 clinical outcomes (receipt of any chemotherapy, receipt of an anthracycline-containing or equivalent regimen, early hospitalization, and overall survival). Our primary explanatory variable was lymphoma treatment volume, defined as the number of patients with newly diagnosed lymphoma for which an oncologist initiated therapy during a 12-month look-back period from each incident DLBCL case.Results: We identified 8247 Medicare beneficiaries who were newly diagnosed with DLBCL. Chemotherapy was administered to 6202 (75.2%) beneficiaries, and 71.4% of cytotoxic regimens contained an anthracycline. Beneficiaries who were treated by higher-volume oncologists had increased odds of receiving chemotherapy (adjusted odds ratio [aOR], 1.45; 95% confidence interval [CI], 1.24-1.70; P <.001) and of receiving an anthracycline-containing regimen (aOR, 1.26; 95% CI, 1.06-1.50; P = .009). Receiving care from a higher-volume provider was also associated with decreased hospitalization (aOR, 0.80; 95% CI, 0.69-0.95; P = .007) and improved survival (adjusted hazard ratio, 0.85; 95% CI, 0.79-0.92; P < .001).Conclusion: In older adults diagnosed with DLBCL, receiving care from a provider with more experience treating lymphoma patients was associated with receipt of guideline-adherent therapy, reduced hospitalizations, and improved survival. Clinical volume may be an important factor in providing high-quality cancer care in the modern era. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of hospital volume (HV) and surgeon volume (SV) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN). Patients and Methods: All consecutive patients who underwent a RAPN from 2009 to 2015, at 11 institutions, were included in a retrospective study. To evaluate the impact of HV, we divided RAPN into four quartiles according to the caseload per year: low HV (<20/year), moderate HV (20-44/year), high HV (45-70/year), and very high HV (>70/year). The SV was also divided into four quartiles: low SV (<7/year), moderate SV (7-14/year), high SV (15-30/year), and very high SV (>30/year). The primary endpoint was the Trifecta defined as the following combination: no complications, warm ischaemia time (WIT) <25 min, and negative surgical margins. Results: In total, 1 222 RAPN were included. The mean (SD) caseload per hospital per year was 44.9 (26.7) RAPNs and the mean (SD) caseload per surgeon per year was 19.2 (14.9) RAPNs. The Trifecta achievement rate increased significantly with SV (69.9% vs 72.8% vs 73% vs 86.1%; P < 0.001) and HV (60.3% vs 72.3% vs 86.2% vs 82.4%; P < 0.001). The positive surgical margins (PSM) rate (P = 0.02), length of hospital stay (LOS; P < 0.001), WIT (P < 0.001), and operative time (P < 0.001), all decreased significantly with increasing SV. The PSM rate (P = 0.02), LOS (P < 0.001), WIT (P < 0.001), operative time (P < 0.001), and major complications rate (P = 0.01), all decreased significantly with increasing HV. In multivariate analysis adjusting for HV and SV (model 3), HV remained the main predictive factor of Trifecta achievement (odds ratio [OR] 3.70 for very high vs low HV; P < 0.001), whereas SV was not associated with Trifecta achievement (OR 1.58 for very high vs low SV; P = 0.34). Conclusion: In this multicentre study HV and SV both greatly influenced RAPN perioperative outcomes, but HV appeared to have a greater impact than SV. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive esophagectomy (MIE) is being increasingly performed; however, it is still associated with high morbidity and mortality. The correlation between surgical team proficiency and patient load lacks clarity. This study evaluates surgical outcomes during the first 3-year period after establishment of a new surgical team.Methods: A new surgical team was established in September 2013 by two expert surgeons having experience of performing more than 100 MIEs. We assessed 237 consecutive patients who underwent MIE for esophageal cancer and evaluated the impact of surgical team proficiency on postoperative outcomes, as well as the team learning curve.Results: In the cumulative sum analysis, a point of downward inflection for operative time and blood loss was observed in case 175. After 175 cases, both operative time and blood loss significantly decreased (P < 0.001 and P < 0.001, respectively), and postoperative incidence of pneumonia significantly decreased from 18.9 to 6.5% (P = 0.024). Median postoperative hospital stay also decreased from 20 to 18 days (P = 0.022). Additionally, serum CRP levels on postoperative day 1 showed a significant, but weak inverse association with the number of cases (P = 0.024).Conclusions: After 175 cases, both operative time and blood loss significantly decreased. In addition, the incidence of pneumonia decreased significantly. Additionally, surgical team proficiency may decrease serum CRP levels immediately after MIE. Surgical team proficiency based on team experience had beneficial effects on patients undergoing MIE. [ABSTRACT FROM AUTHOR]

Background: Data evaluating the financial implications of volume-based referral are lacking. This study sought to compare in-hospital costs for pancreatic surgery by annual hospital volume.Methods: Eleven thousand and eighty-one patients aged ≥18 years undergoing an elective pancreatic resection for cancer were identified using the Nationwide Inpatient Sample 2002-2011. Multivariable regression analysis was performed to compare length-of-stay (LOS), postoperative morbidity and mortality, failure-to-rescue (FTR), and inpatient costs by annual hospital volume group.Results: Patients undergoing surgery at high-volume hospitals (HVH) demonstrated 23% lower odds (odds ratio [OR] = 0.77, 95% confidence interval [95%CI] 0.63-0.95) of developing a postoperative complication, 59% lower odds of experiencing an LOS > 14 days (OR = 0.41, 95%CI 0.34-0.50), 51% lower odds of postoperative mortality (OR = 0.49, 95%CI 0.34-0.71), and 47% lower odds of FTR (OR = 0.53, 95%CI 0.37-0.76; all p<0.05). The overall mean in-hospital cost was $39,012 (SD = $15,214) with minimal differences observed across hospital volume groups. Rather, postoperative complications (no complication vs. complication $26,686 [SD = $5762] vs. $44,633 [SD = $11,637]) and FTR (rescue vs. FTR $42,413 [SD = $8481] vs. $69,546 [SD = $13,131]) were determinant of higher in-hospital costs. While this pattern was observed at all hospital volume groups, costs varied minimally between hospital volume groups after this stratification.Conclusions: Annual hospital surgical volume was not associated with in-hospital costs among patients undergoing pancreatic surgery. [ABSTRACT FROM AUTHOR]

Background: Routine data from hospitals in the public healthcare system allow the analysis of large patient datasets without generating additional documentation efforts for hospitals. This study reports the frequencies of postoperative complications after thyroid surgery based on routine nationwide data. Moreover, volume-outcome relationships were investigated. Material and methods: Nationwide routine data from insured patients of the Local Health Insurance Fund (AOK) who underwent thyroid surgery between 2008 and 2010 were analyzed. Complications were determined based on indicators for permanent vocal cord palsy, re-bleeding with re-operations and wound infections with specific treatment. The effect of hospital volumes (volume quintiles) on the indicators was determined by multivariate logistic regression. Results: A total of 66,902 thyroid gland operations were identified. The overall frequency of permanent vocal cord palsy was 1.5 %, re-bleeding 1.8 % and wound infections 0.4 %. In the four lowest case volume categories the risk of permanent vocal cord palsy was significantly higher compared to the highest case volume hospitals (odds ratio 1.5, 1.7, 1.7 and 2.2, respectively). Conclusion: This study represents the reality of healthcare for thyroid surgery in Germany. Additionally, it was determined that the risk for permanent vocal cord palsy after thyroid gland operations decreased with increasing case volumes of hospitals. [ABSTRACT FROM AUTHOR]

Background Though the volume-outcome relationship has been well-established in adults, low mortality rates and small sample sizes have precluded definitive demonstration in children. This study compares treatment-specific factors for children with nephroblastoma at high (HVC) versus low volume centers (LVC). Methods We performed a retrospective cohort study comparing patients ≤ 18 years with unilateral nephroblastoma treated at HVCs and LVCs using the National Cancer Data Base (1998–2012). Definitions of HVCs included performing above the median, the upper two quartiles, and the highest decile of nephroblastoma resections. Outcomes included nodal sampling, margin status, time to chemotherapy and radiation, and survival. Statistical analyses included χ 2 , t-tests, generalized linear, and Cox regression models (p < 0.05). Results Of 2911 patients from 210 centers, 1443 (49.6%) were treated at HVCs. There was no difference in frequency of preoperative biopsy or days to radiation (p > 0.05). High volume centers were more likely to perform nodal sampling (RR 1.04, 95%CI 1.01–1.08) and had fewer days to chemotherapy (RR 0.80, 95%CI 0.69–0.93). Five-year survival was similar (HVC: 0.93, 95%CI 0.92–0.94; LVC: 0.93, 95%CI 0.91–0.94). Conclusions HVCs were more likely to perform nodal sampling and had fewer days to chemotherapy. There was no difference in days to radiation or survival between centers. Level of evidence Level II (retrospective prognosis study). [ABSTRACT FROM AUTHOR]

Background: The surgeon volume-outcome relationship has been discussed for many years and its existence or nonexistence is of importance for various reasons. A lot of empirical work has been published on it. We aimed to summarize systematic reviews in order to present current evidence. Methods: Medline, Embase, Cochrane database of systematic reviews (CDSR), and health technology assessment websites were searched up to October 2015 for systematic reviews on the surgeon volume-outcome relationship. Reviews were critically appraised, and results were extracted and synthesized by type of surgical procedure/ condition. Results: Thirty-two reviews reporting on 15 surgical procedures/conditions were included. Methodological quality of included systematic reviews assessed with the assessment of multiple systematic reviews (AMSTAR) was generally moderate to high albeit included literature partly neglected considering methodological issues specific to volumeoutcome relationship. Most reviews tend to support the presence of a surgeon volume-outcome relationship. This is most clear-cut in colorectal cancer, bariatric surgery, and breast cancer where reviews of high quality show large effects. Conclusions: When taking into account its limitations, this overview can serve as an informational basis for decision makers. Our results seem to support a positive volume-outcome relationship for most procedures/ conditions. However, forthcoming reviews should pay more attention to methodology specific to volume-outcome relationship. Due to the lack of information, any numerical recommendations for minimum volume thresholds are not possible. Further research is needed for this issue. [ABSTRACT FROM AUTHOR]

Aims: To examine the association of patient volume with quality of diabetes care in the primary care setting.Methods: We analyzed population-based data from Hospital Authority administrative database using a Hong Kong representative sample of 187,031 diabetic patients managed in 74 primary care general outpatient clinics between 04/2011 and 03/2012. We assessed the associations between annual clinic-based patient volume and quality of care in terms of adherence to care criteria of process (HbA1c test, renal function test, full lipid profile, urine protein analysis, diabetic retinopathy screening, and appropriate drug prescription) and clinical outcomes (HbA1c⩽7%, BP⩽130/80mmHg, LDL-C⩽2.6mmol/L) of care criteria, with and without adjustment for patient and clinic characteristics.Results: Patient volume was associated with three of seven process of care criteria; however, when compared to clinics in higher volume quartiles, those in lowest-volume quartile had more odds of HbA1c test (odds ratios (OR): 0.781, 0.655 and 0.646 for quartile from 2 to 4, respectively), renal function test (OR: 0.357, 0.367 and 0.590 for quartile from 2 to 4, respectively), and full lipid profile test (OR: 0.508, 0.612 and 0.793 for quartile from 2 to 4, respectively). There was no significant association between patient volume and the standards of achieving of HbA1c, BP and LDL-C outcome targets.Conclusions: Disparities in volume and quality of diabetes care were observed in public primary care setting. Lower patient volumes at clinic level were associated with greater adherence to three process criteria but a volume-outcome association was not present. [ABSTRACT FROM AUTHOR]

Background: Compliance with minimum volume standards for specific procedures serves as a criterion for high-quality patient care. International experiences report a centralization of the respective procedures. In Germany, minimum volume standards for hospitals were introduced in 2004 for 5 procedures (complex esophageal and pancreatic interventions; liver, kidney and stem cell transplantations), in 2006 total knee replacement was added. This study explores whether any centralization is discernible for these procedures in Germany. Methods: A retrospective longitudinal analysis of secondary data serves to determine a possible centralization of procedures from the system perspective. Centralization means that over time, fewer hospitals perform the respective procedure, the case volume in high-volume hospitals increases together with their percentage of the annual total case volume, and the case volume in low-volume hospitals decreases together with their percentage of the annual total case volume. Using data from the mandatory hospital quality reports for the years 2006, 2008 and 2010 we performed Kruskal Wallis and chi-square tests to evaluate potential centralization effects. Results: No centralization was found for any of the six types of interventions over the period from 2006 to 2010. The annual case volume and the number of hospitals performing interventions rose at differing rates over the 5-year period depending on the type of intervention. Seven percent of esophagectomies and 14 % of pancreatectomies are still performed in hospitals with less than 10 interventions per year. Conclusions: For the purpose of further centralization of interventions it will be necessary to first analyze and then appropriately address the reasons for non-compliance from the hospital and patient perspective. [ABSTRACT FROM AUTHOR]

For decades, there is an ongoing discussion about the quality of hospital care leading i.a. to the introduction of minimum volume standards in various countries. In this paper, we analyze the volume-outcome relationship for patients with intact abdominal aortic aneurysm and hip fracture. We define hypothetical minimum volume standards in both conditions and assess consequences for access to hospital services in Germany. The results show clearly that patients treated in hospitals with a higher case volume have on average a significant lower probability of death in both conditions. Furthermore, we show that the hypothetical minimum volume standards do not compromise overall access measured with changes in travel times. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective To examine the association of hospital volume and 90-day mortality after cystectomy, conditional on survival for 30 days. Patients and Methods The National Cancer Data Base was used to evaluate 30- and 90-day mortality for 35 055 patients who underwent cystectomy for bladder cancer at one of 1118 hospitals. Patient data were aggregated into hospital volume categories based on the mean annual number of procedures (low-volume hospital: <10 procedures; intermediate-volume hospital: 10-19 procedures; high-volume hospital: ≥20 procedures). Associations between mortality and clinical, demographic and hospital characteristics were analysed using hierarchical logistic regression models. To assess the association between hospital volume and 90-day mortality independently of shorter-term mortality, 90-day mortality conditional on 30-day survival was assessed in the multivariate modelling. Results Unadjusted 30- and 90-day mortality rates were 2.7 and 7.2% overall, 1.9 and 5.7% among high-volume hospitals, and 3.2 and 8.0% among low-volume hospitals, respectively. Compared with high-volume hospitals, the adjusted risks among low-volume hospitals (odds ratio [95% CI]) of 30- and 90-day mortality, conditional on having survived for 30 days, from the hierarchical models were 1.5 (1.3-1.9), and 1.2 (1.0-1.4), respectively. Conclusions A low hospital volume was associated with greater 30- and 90-day mortality. These data support the need for further research to better understand the relatively high mortality rates seen between 30 and 90 days, which are high and less variable across hospital volume strata. The stronger association between volume and 30-day mortality suggests that quality-reporting efforts should focus on shorter-term outcomes. [ABSTRACT FROM AUTHOR]

Background: In the treatment of oral cavity squamous cell carcinoma (OCSCC), surgical quality measures which are expected to affect outcomes, including the achievement of a clear margin, are surgeon-dependent but might not be invariably associated with hospital volume. Our objective was to explore surgical margin variations and survival differences of OCSCC between two highest-volume hospitals in Taiwan., Materials and Methods: A total of 2009 and 1019 patients with OCSCC who were treated at the two highest-volume Taiwanese hospitals (termed Hospital 1 and Hospital 2, respectively) were included. We examined how a pathological margin <5 mm impacted patient outcomes before and after propensity score (PS) matching., Results: The prevalence of margins <5 mm was markedly lower in Hospital 1 than in Hospital 2 (34.5%/65.2%, p <0.0001). Compared with Hospital 2, tumor severity was higher in Hospital 1. On univariable analysis, being treated in Hospital 2 (versus Hospital 1; hazard ratio [HR] for 5-year disease-specific survival [DSS] = 1.34, p =0.0002; HR for 5-year overall survival [OS] = 1.17, p =0.0271) and margins <5 mm (versus ≥5 mm; HR for 5-year DSS = 1.63, p <0.0001; HR for 5-year OS = 1.48, p <0.0001) were identified as adverse factors. The associations of treatment in Hospital 2 and margins <5 mm with less favorable outcomes remained significant after adjustment for potential confounders in multivariable analyses, as well as in the PS-matched cohort. The 5-year survival differences between patients operated in Hospital 1 and Hospital 2 were even more pronounced in the PS-matched cohort (before PS matching: DSS, 79%/74%, p =0.0002; OS, 71%/68%, p =0.0269; after PS matching: DSS, 84%/72%, p <0.0001; OS, 75%/66%, p <0.0001). In the entire cohort, the rate of adjuvant therapy was found to be lower in patients with margins ≥5 mm than in those with margins <5 mm (42.7% / 57.0%, p <0.0001)., Conclusions: Within the two highest-volume hospitals in Taiwan, patients with OCSCC with a clear margin status (≥5 mm) achieved more favorable outcomes. These results have clinical implications and show how initiatives aimed at improving the margin quality can translate in better outcomes. A clear margin status can reduce the need for adjuvant therapy, ultimately improving quality of life., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Liao, Lee, Lee, Ng, Liu, Chien, Lin, Wang, Terng, Hua, Chen, Chen, Tsai, Kang, Tsai, Chu, Lin, Fan, Wang, Hsieh, Yeh, Lin, Tsao, Yen, Cheng, Fang, Huang, Lee, Fang, Wang, Lin, Hsin and Wen.)

The empirical association between high hospital procedure volume and lower mortality rates has led to recommendations for the centralization of complex surgical procedures. Yet redirecting patients to a select number of high-volume hospitals creates potential negative consequences for market competition. We use patient-level data to estimate the association between hospital procedure volume and patient mortality and costs. We also estimate the association between hospital market concentration and mortality, cost, and prices. We use our estimates to simulate the change in social welfare resulting from redirecting patients at low-volume hospitals to high-volume facilities. We find that a higher procedure volume leads to significant reductions in mortality for patients undergoing surgery for pancreatic cancer, but not colon cancer. Procedure volume also influences costs for both surgeries, but in a nonlinear fashion. Increased market concentration is associated with higher costs and prices for colon cancer, but not pancreatic cancer patients. Simulations indicated that centralizing pancreatic cancer surgery is unambiguously welfare enhancing. In contrast, there is less evidence to suggest that centralizing colon cancer surgery would be welfare improving. [ABSTRACT FROM AUTHOR]

Abstract: Background: Bariatric surgery is technically demanding surgery performed on high-risk patients. Previous studies using administrative databases have shown a relationship between surgeon volume and patient outcome after Roux-en-Y gastric bypass (RYGB). We examined the relationship between surgeons'' annual RYGB volumes and 30-day patient outcomes at 10 centers within the United States. Methods: The Longitudinal Assessment of Bariatric Surgery (LABS)-1 is a prospective study examining the 30-day adverse outcomes after bariatric surgery. The outcomes after RYGB were adjusted by procedure type (open versus laparoscopic), functional status, body mass index, history of deep vein thrombosis, pulmonary embolism, and obstructive sleep apnea. The data were examined to determine the nature and strength of the association between surgeon volume and patients'' short-term (30-day) adverse outcomes after RYGB. Results: The analysis included 3410 initial RYGB operations performed by 31 surgeons, 15 of whom averaged <50 cases annually. The crude composite adverse outcome (i.e., death, deep vein thrombosis, pulmonary embolism, reintervention or nondischarge at day 30) incidence was 5.2%. After risk adjustment, a greater surgeon RYGB volume was associated with lower composite event rates, with a continuous relationship (i.e., varying cutpoints differentiated the composite event rates), such that for each 10-case/yr increase in volume, the risk of a composite event decreased by 10%. Conclusion: In the LABS, the patient''s risk of an adverse outcome after RYGB decreased significantly with the increase in surgeon RYGB volume (cases performed annually). [Copyright &y& Elsevier]

Objectives. To examine the strength of the volume–outcome relationship among paramedics, a group of providers that has not been previously studied in this context. By identifying the effects of individual learning on performance, we also assess the value of paramedics' retention. The prehospital emergency medical services (EMS) setting allows us to interpret any volume–outcome relationship as learning by doing, uncontaminated by reputation-based referrals because ambulance units are dispatched based on proximity. Data Sources. Incident-level EMS data spanning 1991 to 2005 from the Mississippi Emergency Medical Services Information System collected by the Mississippi Department of Health. Research Design. Using linear and quantile methods with and without provider fixed effects, we estimate the relationship between experience accumulation and performance using the universe of trauma incidents involving injured patients (including motor vehicle crashes, falls, stabbings, and shootings). Principal Findings. We find that greater individual volume is robustly related to improved performance. In addition, we find that the benefit of learning operates through both recent and past experiences, accrues differentially across tenure groups, and operates on both mean performance and the upper quantiles of the performance distribution. Conclusions. Persistent past and current volume effects suggest that policy and managerial implications in EMS should be directed at retention efforts to take advantage of individual learning by paramedics. [ABSTRACT FROM AUTHOR]

Background: No study has explored the volume-outcome relationship for peptic ulcer treatment.Objective: To investigate the association between peptic ulcer case volume per hospital, on the one hand, and in-hospital mortality and 14-day readmission rates, on the other, using a nationwide population-based dataset.Design: A retrospective cross-sectional study, set in Taiwan.Participants: There were 48,250 peptic ulcer patients included. Each patient was assigned to one of three hospital volume groups: low-volume (< or = 189 case), medium volume (190-410 cases), and high volume (> or = 411 cases).Measurements: Logistic regression analysis employing generalized estimating equations was used to examine the adjusted relationship of hospital volume with in-hospital mortality and 14-day readmission.Main Results: After adjusting for other factors, results showed that the likelihood of in-hospital mortality for peptic ulcer patients treated by low-volume hospitals (mortality rate = 0.68%) was 1.6 times (p < 0.05) that of those treated in high-volume hospitals (mortality rate = 0.72%) and 1.4 times (p < 0.05) that of those treated in medium-volume hospitals (mortality rate = 0.73%). The adjusted odds ratio of 14-day readmission likewise declined with increasing hospital volume, with the odds of 14-day readmission for those patients treated by low-volume hospitals being 1.5 times (p < 0.001) greater than for high-volume hospitals and 1.3 times (p < 0.01) greater than for medium-volume hospitals.Conclusions: We found that, after adjusting for other factors, peptic ulcer patients treated in the low-volume hospitals had inferior clinical outcomes compared to those treated in medium-volume or high-volume ones. [ABSTRACT FROM AUTHOR]

Increasing physician case volumes are documented to reduce costs and improve outcomes for many surgical procedures but not for medical conditions such as pneumonia that consume significant health care resources. This study explored the association between physicians’ inpatient pneumonia case volume and cost per discharge. The design was a retrospective, population-based, cross-sectional study, using National Health Insurance administrative claims data. The setting was Taiwan. The participants were a universal sample of 270,002 adult, acute pneumonia hospitalizations, during 2002–2004, excluding transferred cases and readmissions. Hierarchical linear regression modeling was used to examine the association of physician’s volume (three volume groups, designed to classify patients into approximately equal sized groups) with cost, adjusting for hospital random effects, case severity, physician demographics and specialty, hospital characteristics, and geographic location. Mean cost was NT$2,255 (US$1 = NT$33 in 2004) for low-volume physicians (≤100 cases) and NT$1,707 for high-volume physicians (≥316 cases). The adjusted patient costs for low-volume physicians were higher (US$264 and US$235 than high- and medium-volume physicians, respectively; both P < .001), with no difference between high- and medium-volume physicians. High-volume physicians had lower in-hospital mortality and 14-day readmission rates than low-volume physicians. Data support an inverse volume–cost relationship for pneumonia care. Decision processes and clinical care of high-volume physicians versus low-volume physicians should be studied to develop effective care algorithms to improve pneumonia outcomes and reduce costs. [ABSTRACT FROM AUTHOR]

Abstract: Aim: We used nationwide, population-based data to examine associations between hospital and surgeon volumes of gastric cancer resections and their patients’ short-term and long-term survival likelihood. Methods: The study uses 1997–1999 inpatient claims data from Taiwan''s National Health Insurance linked to “cause of death” data for 1997–2004. The total cohort of 6909 gastric cancer resection patients were categorized by their surgeon''s/hospital''s procedure volume, and examined for differences in 6-month mortality and 5-year mortality (post 6months), by procedure volume, using Cox proportional hazard regressions, adjusting for surgeon, hospital and patient characteristics. We hypothesized that surgeons’ case volume and age but not hospital volume will predict short-term and long-term survival. Results: Adjusted estimates show that increasing surgeon volume predicts better 6-month survival (adjusted mortality hazard ratio=1.3 for low-volume surgeons relative to very high-volume surgeons; p <0.01) and 5-year survival (adjusted mortality hazard ratios=1.3; p <0.001 for low-volume; 1.2 with p <0.01 for medium volume) and increasing surgeon''s age (adjusted hazards ratio=1.4 for age<41years relative to 41–50years; p ≤0.001; 0.8 for ≥51years relative to 41–50years; p <0.05). In hospital volume regressions, surgeon''s age is a consistent and significant predictor, not hospital volume. Findings suggest a key role of experience in surgical skill and sensitivity for early stage diagnosis in gastric cancer survival. Conclusions: Although a key study limitation is the lack of cancer stage data, the pattern of findings suggests that experienced surgeons have relatively better survival outcomes among gastric cancer patients. [Copyright &y& Elsevier]

Although much prior research has found a consistently positive volume-outcome relationship, there is scanty documentation on this issue in mental healthcare. This study examines the association between a hospitals’ psychiatric inpatient volume and 30-day readmission rates. Using administrative data from Taiwan’s National Health Insurance Research Database for 2003, the likelihood of 30-day readmission is examined relative to the hospital’s volume of voluntary psychiatric admissions and total bed-days. As hospital volume increases, so too does the 30-day readmission rates for patients with schizophrenia, bipolar disorder and major depressive disorders. The positive volume-outcome relationship in patients suffering from psychiatric disorders suggests a different scenario from the ‘practice makes perfect’ phenomenon that may underlie the inverse volume-outcome relationship found among most physical disorders, both surgical and medical. [ABSTRACT FROM AUTHOR]

Background: The Leapfrog Group is a consortium of Fortune 500 corporations and healthcare purchasers whose intent is to harness their purchasing power to improve the quality of care by regionalizing high complexity operations at high volume hospitals (HVH). The Whipple resection has been designated a “Leapfrog” procedure and the recommendation issued that it be performed at HVH. However, alternatives to the Leapfrog Initiative are likely necessary because regionalization has been difficult to implement, as the number of Leapfrog sites is low in rural areas, and the initiative’s relevance to facilities that care for the uninsured is unclear. We hypothesized that defining exportable elements of the Whipple resection could allow a low volume hospital (LVH) to improve upon its processes of care to safely attempt these procedures. Study design: We describe the surgical experience of the University of California, San Francisco at the San Mateo Medical Center (SMMC) from 2002 to 2004. A quality improvement program was introduced at this LVH, focusing on enhancing structure and processes of care. High-volume UCSF pancreas surgeons were polled to define exportable elements of Whipple resection. A senior pancreas consultant assisted in the perioperative preparation of SMMC. Results: Of the nine patients who underwent exploratory surgery for an intended Whipple resection, four had a successful resection, and five were unresectable. Morbidity was minimal and 30-d mortality was zero. Conclusions: Whipple resections can be safely performed at a LVH after exporting surgical excellence. The structure and process changes allowed the LVH to improve its quality of care. Alternatives to the Leapfrog Initiative are feasible and can extend its original intent. [Copyright &y& Elsevier]

Subspecialization has changed the way that general surgery is practiced. Hepatobiliary and pancreatic surgery (HPB) is maturing as a subspecialty. The objective of this study was to identify the current levels of practice, self-assessments of adequacy of training, referral patterns, and perceptions regarding regionalization of HPB care to high-volume centers. A total of 240 nonstratified general surgeons from across Canada were randomly selected to receive a survey developed by an expert work group. A reference group of 10 HPB specialists were also polled for a total of 250 respondents. The overall response rate was 73% (182 responders). Subspecialty training had been completed by 65% of respondents. This included surgical oncology (15%), HPB (15%), HPB and transplant (8%), laparoscopy (7%), liver transplantation (5%), and other (50%). This training was obtained in Canada (51%), the United States (35%), Europe (11%), and Australia (3%). Ninety-five percent of responders believed that some HPB services should be regionalized. Similarly, most responders thought that they were not adequately trained to perform these procedures. The following were especially considered subspecialty procedures: major hepatectomy (93%), pancreaticoduodenectomy (90%), and biliary reconstruction (79%). The majority of non-HPB surgeons do not consider themselves adequately trained to perform complex HPB procedures. Furthermore, most surgeons think that major hepatectomy, pancreaticoduodenectomy, and biliary reconstruction should be referred to HPB specialists at high-volume centers. [ABSTRACT FROM AUTHOR]

Aims: Valve surgery is indicated and can be life-saving in patients with infective endocarditis (IE). We evaluated the impact of hospital valvular surgery volume on utilization and outcomes of surgery for IE., Methods and Results: National Inpatient Sample (NIS) database was used for IE hospitalizations from 2008 to 2015. Hospitals were divided into quartiles based on valve surgery volume with quartile 1 (Q1) indicating lowest volume and quartile 4 (Q4) highest volume. Primary outcome was utilization of valve surgery in patients hospitalized with IE and secondary outcomes were in-hospital mortality and length of stay for IE patients undergoing valve surgery. Volume-outcome relationship was analysed both as categorical (quartiles) and continuous variable (restricted cubic splines). A total of 36 471 hospitalizations for IE were identified using the NIS database from 2008 to 2015 of which 17.33% underwent any valve surgery. Utilization rates of valve surgery for IE were significantly higher in Q4 hospitals (Q1: 6.73%; Q2: 10.39%; Q3: 14.91%; Q4: 2321%). Amongst the admissions for IE endocarditis undergoing valve surgery, there was no significant difference in in-hospital mortality when analysed as a categorical variable (as quartiles). However, when analysed as a continuous variable we note significant variation in outcomes across the Q4 hospitals, with highest volume centres having reduced mortality rates and length of stay., Conclusion: Hospital valvular surgery volume has direct impact on utilization and outcomes of surgery for IE. Given rising rates of IE and ongoing intravenous drug pandemic, there is need for regionalization of care for IE patients and development of 'endocarditis centres of excellence' for improved patient outcomes., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Adoption of implantable left ventricular assist devices has dramatically improved survival and quality of life in suitable patients with end-stage heart failure. In the era of value-based healthcare delivery, assessment of clinical outcomes and resource use associated with left ventricular assist devices is warranted. Adult patients undergoing left ventricular assist device implantation from 2008 to 2016 were identified using the National Inpatient Sample. Hospitals were designated as low-volume, medium-volume, or high-volume institutions based on annual institutional left ventricular assist device case volume. Multivariable logistic regression was used to evaluate adjusted odds of mortality across left ventricular assist device volume tertiles. Over the study period, an estimated 23,972 patients underwent left ventricular assist device implantation with an approximately 3-fold increase in the number of annual left ventricular assist device implantations performed (P for trend <.001). In-hospital mortality in patients with left ventricular assist devices decreased from 19.6% in 2008 to 8.1% in 2016 (P for trend <.001) and was higher at low-volume institutions compared with high-volume institutions (12.0% vs 9.2%, P <.001). Although the overall adjusted mortality was higher at low-volume compared with high-volume institutions (adjusted odds ratio, 1.66; 95% confidence interval, 1.28-2.15), this discrepancy was only significant for 2008 and 2009 (low-volume 2008 adjusted odds ratio, 5.5; 95% confidence interval, 1.9-15.8; low-volume 2009 adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.8). Left ventricular assist device use has rapidly increased in the United States with a concomitant reduction in mortality and morbidity. With maturation of left ventricular assist device technology and increasing experience, volume-related variation in mortality and resource use has diminished. Whether the apparent uniformity in outcomes is related to patient selection or hospital quality deserves further investigation. Trends in LVAD implantation and mortality by hospital implantation volume. LVAD implantation has increased by 3-fold from 2008 to 2016. Although low-volume hospitals were found to have worse mortality in the early era, this discrepancy in outcomes has diminished. LVAD , Left ventricular assist device; AOR , adjusted odds ratio; CI , confidence interval; LVH , low-volume LVAD institution; MVH , medium-volume LVAD institution; HVH , high-volume LVAD institution. [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose Hospital volume–outcome association has been examined for many high-risk surgical procedures. Little is known about this association for thumb replantation, a complex but essential surgical procedure to restore hand function. We aimed to determine patient and hospital characteristics that are associated with increased probability of replanted thumb survival and to examine volume–outcome association among hospitals that performed thumb replantation. Methods We used data from 2008 to 2012 from the National Trauma Data Bank. Our sample included 773 patients who underwent thumb replantation procedures in 1 of 180 hospitals during the study period. We used patient-level logistic models to examine the association between a hospital’s annual thumb replantation volume and the probability of survival for the replanted thumb. Results Patients with drug/alcohol abuse record, and higher numbers of comorbid conditions had lower odds of replant success. Treatment in teaching hospitals and hospitals with a higher volume of thumb replantation increased the odds of replant survival. The risk-adjusted replantation success rate in high-volume hospitals was 12% higher than in low-volume hospitals. Conclusions Regionalization of digit replantation procedures to high-volume centers can achieve the highest rate of successful revascularization. Type of study/level of evidence Economic/Decision Analysis II. [ABSTRACT FROM AUTHOR]

Objectives: Determine national outcomes for pyloromyotomy; how these are affected by: (i) surgical approach (open/laparoscopic), or (ii) centre type/volume and establish potential benchmarks of quality., Methods: Hospital Episode Statistics data were analysed for admissions 2002-2011. Data presented as median (IQR)., Results: 9686 infants underwent pyloromyotomy (83% male). Surgery was performed in 22 specialist (SpCen) and 39 nonspecialist centres (NonSpCen). The proportion treated in SpCen increased linearly by 0.4%/year (r=0.76, p=0.01). Annual case volume in SpCen vs. NonSpCen was 40 (24-53) vs. 1 (0-3). Time to surgery was shorter in SpCen (1day [1, 2] vs. 2 [1-3]), but total stay equal (4days [3-6]). 137 (1.4%) had complications requiring reoperation (wound problem 0.6%; repeat pyloromyotomy 0.5% and perforation, bleeding or obstruction 0.2%): pooled rates were similar between SpCen and NonSpCen (1.4% vs. 1.6%, p=0.52). Three NonSpCen had >5% reoperations (within 99.8% C.I. as small denominators). There was no relationship between reoperation and centre volume. Laparoscopic pyloromyotomy had increased risk of repeat pyloromyotomy (OR 2.28 [1.14-4.57], p=0.029)., Conclusions: Pyloric stenosis surgery shifted from centres local to patients, but outcomes were unaffected by centre type/volume. Modest reported benefits of laparoscopy appear offset by increased reoperations. Quality benchmarks could be set for reoperation <4%., Type of Study: Treatment Study., Level of Evidence: Level III., (Copyright © 2017 Elsevier Inc. All rights reserved.)