1
|
Brooks ES, Finn CB, Wirtalla CJ, Kelz RR. Inefficiencies of care in hub and spoke healthcare systems: A multi-state cohort study. Am J Surg 2024; 229:151-155. [PMID: 38160065 DOI: 10.1016/j.amjsurg.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 12/11/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Complex surgical care is often centralized to one high volume (hub) hospital within a system. The benefit of this centralization in common operations is unknown. METHODS Using the Healthcare Cost and Utilization Project's State Inpatient Databases, adult general surgical patients within hospital systems in 13 states (2016-2018) were identified. Risk-adjusted logistic regression estimated the odds of death or serious morbidity (DSM) and prolonged length of stay (LOS) at hubs relative to other system hospitals (spokes). RESULTS We identified 122,895 patients across 43 hub-and-spoke systems. Hubs completed 83.2 % of complex and 59.6 % of common operations. For complex operations, odds of DSM were significantly lower in hubs (OR: 0.80; 95 % CI [0.65, 0.98]). For common operations, odds of DSM were similar between hubs and spokes, while odds of prolonged LOS were greater at hubs (OR 1.19; 95 % CI [1.16,1.24]). CONCLUSIONS While hub hospitals had lower odds of DSM for complex operation, they had higher odds of prolonged length of stay for common operations. This finding shows an opportunity for improved system efficiency.
Collapse
Affiliation(s)
- Ezra S Brooks
- Brigham and Women's Hospital, General Surgery Residency Program, 75 Francis St, Boston, MA, 02115, USA.
| | - Caitlin B Finn
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, 3400 Spruce St, Philadelphia, PA, 19104, USA; Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
| | - Christopher J Wirtalla
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Rachel R Kelz
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, 3400 Spruce St, Philadelphia, PA, 19104, USA
| |
Collapse
|
2
|
Maxwell CM, Bhat AM, Falls SJ, Bigbee M, Yin Y, Chalikonda S, Bartlett DL, Fernando HC, Allen CJ. Comprehensive value implications of surgeon volume for lung cancer surgery: Use of an analytic framework within a regional health system. JTCVS OPEN 2024; 17:286-294. [PMID: 38420536 PMCID: PMC10897681 DOI: 10.1016/j.xjon.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 11/08/2023] [Accepted: 11/12/2023] [Indexed: 03/02/2024]
Abstract
Objective We used a framework to assess the value implications of thoracic surgeon operative volume within an 8-hospital health system. Methods Surgical cases for non-small cell lung cancer were assessed from March 2015 to March 2021. High-volume (HV) surgeons performed >25 pulmonary resections annually. Metrics include length of stay, infection rates, 30-day readmission, in-hospital mortality, median 30-day charges and direct costs, and 3-year recurrence-free and overall survival. Multivariate regression-based propensity scores matched patients between groups. Metrics were graphed on radar charts to conceptualize total value. Results All 638 lung resections were performed by 12 surgeons across 6 hospitals. Two HV surgeons performed 51% (n = 324) of operations, and 10 low-volume surgeons performed 49% (n = 314). Median follow-up was 28.8 months (14.0-42.3 months). Lobectomy was performed in 71% (n = 450) of cases. HV surgeons performed more segmentectomies (33% [n = 107] vs 3% [n = 8]; P < .001). Patients of HV surgeons had a lower length of stay (3 [2-4] vs 5 [3-7]; P < .001) and infection rates (0.6% [n = 1] vs 4% [n = 7]; P = .03). Low-volume and HV surgeons had similar 30-day readmission rates (14% [n = 23] vs 7% [n = 12]; P = .12), in-hospital mortality (0% [n = 0] vs 0.6% [n = 1]; P = .33), and oncologic outcomes; 3-year recurrence-free survival was 95% versus 91%; P = .44, and 3-year overall survival was 94% versus 90%; P = 0. Charges were reduced by 28%, and direct costs were reduced by 23% (both P < .001) in the HV cohort. Conclusions HV surgeons provide comprehensive value across a health system. This multidomain framework can be used to help drive oncologic care decisions within a health system.
Collapse
Affiliation(s)
- Conor M Maxwell
- Allegheny Health Network Singer Research Institute, Pittsburgh, Pa
| | - Akash M Bhat
- Drexel University College of Medicine, Philadelphia, Pa
| | - Samantha J Falls
- Allegheny Health Network Singer Research Institute, Pittsburgh, Pa
| | - Matthew Bigbee
- Allegheny Health Network Singer Research Institute, Pittsburgh, Pa
| | - Yue Yin
- Allegheny Health Network Singer Research Institute, Pittsburgh, Pa
| | - Sricharan Chalikonda
- Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pa
| | - David L Bartlett
- Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pa
| | - Hiran C Fernando
- Division of Thoracic and Esophageal Surgery, Allegheny Health Network, Pittsburgh, Pa
| | - Casey J Allen
- Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pa
| |
Collapse
|
3
|
Peters X, Sage J, Collins C, Opelka F, Ko C. Programmatic quality measures: a new model to promote surgical quality. HEALTH AFFAIRS SCHOLAR 2024; 2:qxad094. [PMID: 38756396 PMCID: PMC10986278 DOI: 10.1093/haschl/qxad094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/04/2023] [Accepted: 01/04/2024] [Indexed: 05/18/2024]
Abstract
Health care performance metrics are offered predominantly in terms of outcomes, processes, or structural components of health care delivery. However, measurement is limited by variability in data sources, definitions, and workarounds. The American College of Surgeons has recently developed a new type of performance metric known as a "programmatic measure". These metrics align structures, processes, and outcomes to better coordinate quality measurement with support of frontline care teams. In this multifaceted way, these measures differ from current "single" measures such as targeting surgical site infection. The thematic focus of these measures and alignment of structure-resource components to support processes and outcomes also sets these measures apart from contemporary composite measures. Importantly, structural elements of these measures reflect minimum resources required for patient care, addressing staffing and resource barriers felt by local institutions in addressing numerous existing quality metrics. These metrics will streamline quality reporting to improve care navigation for patients. Clinicians will find more appropriately aligned goals and responsibilities, resulting in increased teamwork and communication. These measures are designed to address the current burdens of overabundant metrics, priority misalignment, and low resources in a patient-centric fashion to better align health care quality and measurement.
Collapse
Affiliation(s)
- Xane Peters
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL 60611, United States
- Department of Surgery, Loyola University Medical Center, Maywood, IL 60153, United States
| | - Jill Sage
- Division of Advocacy and Health Policy, American College of Surgeons, Washington, DC 20001, United States
| | - Courtney Collins
- Division of Gastrointestinal and General Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Frank Opelka
- Division of Advocacy and Health Policy, American College of Surgeons, Washington, DC 20001, United States
| | - Clifford Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL 60611, United States
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA 90024, United States
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
| |
Collapse
|
4
|
Chamely EA, Stulberg JJ. Measuring Quality at the Surgeon Level. Clin Colon Rectal Surg 2023; 36:233-239. [PMID: 37223225 PMCID: PMC10202541 DOI: 10.1055/s-0043-1761421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Patients expect high-quality surgical care and increasingly are looking for ways to assess the quality of the surgeon they are seeing, but quality measurement is often more complicated than one might expect. Measurement of individual surgeon quality in a manner that allows for comparison among surgeons is particularly difficult. While the concept of measuring individual surgeon quality has a long history, technology now allows for new and innovative ways to measure and achieve surgical excellence. However, some recent efforts to make surgeon-level quality data publicly available have highlighted the challenges of this work. Through this chapter, the reader will be introduced to a brief history of surgical quality measurement, learn about the current state of quality measurement, and get a glimpse into what the future holds.
Collapse
Affiliation(s)
- Elias A. Chamely
- Department of Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
| | - Jonah J. Stulberg
- Department of Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
| |
Collapse
|
5
|
Blum TG, Morgan RL, Durieux V, Chorostowska-Wynimko J, Baldwin DR, Boyd J, Faivre-Finn C, Galateau-Salle F, Gamarra F, Grigoriu B, Hardavella G, Hauptmann M, Jakobsen E, Jovanovic D, Knaut P, Massard G, McPhelim J, Meert AP, Milroy R, Muhr R, Mutti L, Paesmans M, Powell P, Putora PM, Rawlinson J, Rich AL, Rigau D, de Ruysscher D, Sculier JP, Schepereel A, Subotic D, Van Schil P, Tonia T, Williams C, Berghmans T. European Respiratory Society guideline on various aspects of quality in lung cancer care. Eur Respir J 2023; 61:13993003.03201-2021. [PMID: 36396145 DOI: 10.1183/13993003.03201-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.
Collapse
Affiliation(s)
- Torsten Gerriet Blum
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - David R Baldwin
- Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
| | | | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | | | | | - Bogdan Grigoriu
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Georgia Hardavella
- Department of Respiratory Medicine, King's College Hospital London, London, UK
- Department of Respiratory Medicine and Allergy, King's College London, London, UK
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Neuruppin, Germany
| | - Erik Jakobsen
- Department of Thoracic Surgery, Odense University Hospital, Odense, Denmark
| | | | - Paul Knaut
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Gilbert Massard
- Faculty of Science, Technology and Medicine, University of Luxembourg and Department of Thoracic Surgery, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - John McPhelim
- Lung Cancer Nurse Specialist, Hairmyres Hospital, NHS Lanarkshire, East Kilbride, UK
| | - Anne-Pascale Meert
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Robert Milroy
- Scottish Lung Cancer Forum, Glasgow Royal Infirmary, Glasgow, UK
| | - Riccardo Muhr
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Luciano Mutti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- SHRO/Temple University, Philadelphia, PA, USA
| | - Marianne Paesmans
- Data Centre, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Paul Martin Putora
- Departments of Radiation Oncology, Kantonsspital St Gallen, St Gallen and University of Bern, Bern, Switzerland
| | | | - Anna L Rich
- Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | - Dirk de Ruysscher
- Maastricht University Medical Center, Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
- Erasmus Medical Center, Department of Radiation Oncology, Rotterdam, The Netherlands
| | - Jean-Paul Sculier
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Arnaud Schepereel
- Pulmonary and Thoracic Oncology, Université de Lille, Inserm, CHU Lille, Lille, France
| | - Dragan Subotic
- Clinic for Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Thierry Berghmans
- Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| |
Collapse
|
6
|
Chelazzi C, Villa G, Manno A, Ranfagni V, Gemmi E, Romagnoli S. The new SUMPOT to predict postoperative complications using an Artificial Neural Network. Sci Rep 2021; 11:22692. [PMID: 34811383 PMCID: PMC8608915 DOI: 10.1038/s41598-021-01913-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/28/2021] [Indexed: 12/24/2022] Open
Abstract
An accurate assessment of preoperative risk may improve use of hospital resources and reduce morbidity and mortality in high-risk surgical patients. This study aims at implementing an automated surgical risk calculator based on Artificial Neural Network technology to identify patients at risk for postoperative complications. We developed the new SUMPOT based on risk factors previously used in other scoring systems and tested it in a cohort of 560 surgical patients undergoing elective or emergency procedures and subsequently admitted to intensive care units, high-dependency units or standard wards. The whole dataset was divided into a training set, to train the predictive model, and a testing set, to assess generalization performance. The effectiveness of the Artificial Neural Network is a measure of the accuracy in detecting those patients who will develop postoperative complications. A total of 560 surgical patients entered the analysis. Among them, 77 patients (13.7%) suffered from one or more postoperative complications (PoCs), while 483 patients (86.3%) did not. The trained Artificial Neural Network returned an average classification accuracy of 90% in the testing set. Specifically, classification accuracy was 90.2% in the control group (46 patients out of 51 were correctly classified) and 88.9% in the PoC group (8 patients out of 9 were correctly classified). The Artificial Neural Network showed good performance in predicting presence/absence of postoperative complications, suggesting its potential value for perioperative management of surgical patients. Further clinical studies are required to confirm its applicability in routine clinical practice.
Collapse
Affiliation(s)
- Cosimo Chelazzi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Gianluca Villa
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
- Department of Health Sciences, Section of Anesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Andrea Manno
- Center of Excellence Dews, Department of Information Engineering, Computer Science and Mathematics, University of L'Aquila, L'Aquila, Italy.
| | - Viola Ranfagni
- Department of Health Sciences, Section of Anesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Eleonora Gemmi
- Department of Health Sciences, Section of Anesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
- Department of Health Sciences, Section of Anesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| |
Collapse
|
7
|
Ang D, Sugimoto J, Richards W, Liu H, Kinslow K, McKenney M, Ziglar M, Elkbuli A. Hospital Volume of Emergency General Surgery and its Impact on Inpatient Mortality for Geriatric Patients: Analysis From 3994 Hospitals. Am Surg 2021:31348211049251. [PMID: 34761682 DOI: 10.1177/00031348211049251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous investigations have shown a positive association between hospital volume of operations and clinical outcomes. However, it is unclear whether such relationships also apply to emergency surgery. We sought to examine the association between hospital case volume and inpatient mortality for 7 common emergency general surgery (EGS) operations among geriatric patients. METHODS This is a population based retrospective cohort study using the Centers of Medicare and Medicaid Services (CMS) Limited Dataset Files (LDS) from 2011 to 2013. The 7 most common emergency surgeries included (1) partial colectomy, (2) small-bowel resection (SBR), (3) cholecystectomy, (4) appendectomy, (5) lysis of adhesions (LOA), (6) operative management of peptic ulcer disease (PUD), and (7) laparotomy with the primary outcome being inpatient mortality. Risk-adjusted inpatient mortality was plotted against operative volume. Subsequently an operative volume threshold was calculated using a best fit regression method. Based on these estimates, high- and low-volume hospitals were compared to examine significance of outcomes. Significance was defined as P-value < .05. RESULTS The final cohort comprised of 414 779 patients from 3994 hospitals. The standardized mortality ratio (SMR) for high-volume centers were lower in 6 out of 8 surgeries examined. Small-bowel resection and partial colectomy operations had a significant decrease in mortality based on a volume threshold. CONCLUSION We observed decreased mortality with higher surgical volume for small-bowel resection and partial colectomy operations. Such differences may be related to practice patterns during the perioperative period, as complications related to the perioperative care were significantly lower for high-volume centers.
Collapse
Affiliation(s)
- Darwin Ang
- Department of Surgery, 23703Ocala Regional Medical Center, Ocala, FL, USA.,7286Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,University of South Florida, Tampa, FL, USA.,University of Central Florida, Orlando, FL, USA
| | | | - Winston Richards
- Department of Surgery, 23703Ocala Regional Medical Center, Ocala, FL, USA.,7286Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,University of South Florida, Tampa, FL, USA.,University of Central Florida, Orlando, FL, USA
| | - Huazhi Liu
- Department of Surgery, 23703Ocala Regional Medical Center, Ocala, FL, USA.,2757Hospital Corporation of America, Nashville, TN, USA
| | - Kyle Kinslow
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- University of South Florida, Tampa, FL, USA.,Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | | | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| |
Collapse
|
8
|
Matsuzaki S, Klar M, Chang EJ, Matsuzaki S, Maeda M, Zhang RH, Roman LD, Matsuo K. Minimally Invasive Surgery and Surgical Volume-Specific Survival and Perioperative Outcome: Unmet Need for Evidence in Gynecologic Malignancy. J Clin Med 2021; 10:jcm10204787. [PMID: 34682910 PMCID: PMC8537091 DOI: 10.3390/jcm10204787] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/18/2021] [Indexed: 01/21/2023] Open
Abstract
This study examined the effect of hospital surgical volume on oncologic outcomes in minimally invasive surgery (MIS) for gynecologic malignancies. The objectives were to assess survival outcomes related to hospital surgical volume and to evaluate perioperative outcomes and examine non-gynecologic malignancies. Literature available from the PubMed, Scopus, and the Cochrane Library databases were systematically reviewed. All surgical procedures including gynecologic surgery with hospital surgical volume information were eligible for analysis. Twenty-three studies met the inclusion criteria, and nine gastro-intestinal studies, seven genitourinary studies, four gynecological studies, two hepatobiliary studies, and one thoracic study were reviewed. Of those, 11 showed a positive volume–outcome association for perioperative outcomes. A study on MIS for ovarian cancer reported lower surgical morbidity in high-volume centers. Two studies were on endometrial cancer, of which one showed lower treatment costs in high-volume centers and the other showed no association with perioperative morbidity. Another study examined robotic-assisted radical hysterectomy for cervical cancer and found no volume–outcome association for surgical morbidity. There were no gynecologic studies examining the association between hospital surgical volume and oncologic outcomes in MIS. The volume–outcome association for oncologic outcome in gynecologic MIS is understudied. This lack of evidence calls for further studies to address this knowledge gap.
Collapse
Affiliation(s)
- Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan;
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90033, USA; (E.J.C.); (L.D.R.); (K.M.)
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
- Correspondence: ; Tel.: +81-6-6879-3355; Fax: +81-6-6879-3359
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg, 79085 Freiburg, Germany;
| | - Erica J. Chang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90033, USA; (E.J.C.); (L.D.R.); (K.M.)
| | - Satoko Matsuzaki
- Department of Obstetrics and Gynecology, Osaka General Medical Center, Osaka 558-8558, Japan;
| | - Michihide Maeda
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan;
| | - Renee H. Zhang
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA;
| | - Lynda D. Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90033, USA; (E.J.C.); (L.D.R.); (K.M.)
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA 90033, USA; (E.J.C.); (L.D.R.); (K.M.)
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA
| |
Collapse
|
9
|
Rohe S, Brodt S, Windisch C, Matziolis G, Böhle S. [Patient safety during endoprosthetic training : Does the training of surgeons in primary hip arthroplasty at certified endoprosthesis centres lead to increased complications?]. DER ORTHOPADE 2021; 51:52-60. [PMID: 33929552 PMCID: PMC8766393 DOI: 10.1007/s00132-021-04110-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 11/30/2022]
Abstract
Hintergrund Ziel der Studie war die Untersuchung, ob sich das perioperative Outcome und operationsspezifische Prozessgrößen bei Patienten mit Hüftgelenksersatz signifikant verschlechtern, wenn die Operation durch einen unerfahrenen Operateur, assistiert durch einen erfahrenen Operateur, im Kontext eines zertifizierten Endoprothesenzentrums durchgeführt wird. Material und Methoden Es wurden 1480 Patienten eingeschlossen, die zwischen 2013 und 2016 bei primärer Koxarthrose mit einer primären zementfreien Hüfttotalendoprothese (HTEP) versorgt wurden. Die relevanten Daten wurden retrospektiv aus dem Krankenhausinformationssystem, dem Entlassungsbrief und aus dem EndoCert-Bogen dokumentiert. Die Operateure wurden nach ihrer Qualifikation in erfahrene (Senior, > 50 HTEP pro Jahr) und unerfahrene Operateure (Junior, < 50 HTEP pro Jahr) unterteilt. Anschließend erfolgte der Vergleich der erhobenen Daten anhand dieser Unterteilung. Resultate Es zeigte sich bei unerfahrenen Operateuren eine signifikante Verlängerung der Operationsdauer um 20,7 min (Senior 62,6 ± 20,4 min; Junior 83,3 ± 19,5 min; p ≤ 0,001), der Krankenhausverweildauer um 0,25 Tage (Senior 8,8 ± 0,9 d; Junior 9,0 ± 0,9 d; p ≤ 0,001) und eine Erhöhung der Transfusionshäufigkeit von Erythrozytenkonzentraten (Senior 0,6 ± 1,1 Stk.; Junior 0,9 ± 1,4 Stk.; p ≤ 0,001). Dagegen zeigte sich kein Unterschied bei perioperativen Komplikationen (p = 0,682) und beim perioperativen Blutverlust (Senior 1,3 ± 0,5 l; Junior 1,3 ± 0,5 l; p = 0,097). Zwischen Operationsdauer und Blutverlust bestand allerdings eine positive Korrelation (Senior r = 0,183; Junior r = 0,214; jeweils p ≤ 0,01). Schlussfolgerung Die Ausbildung von unerfahrenen Operateuren an einem zertifizierten Endoprothesenzentrum führt bei Assistenz durch erfahrene Operateure nicht zur Reduktion der Patientensicherheit mit vermehrten Komplikationen. Aufgrund der Operationszeitverlängerung kommt es allerdings zu einer Mehrbelastung der Kliniken im Wettbewerb mit nichtausbildenden Kliniken, die nicht im DRG-System abgebildet ist.
Collapse
Affiliation(s)
- S Rohe
- Waldklinken Eisenberg, Campus für Orthopädie, Medizinische Fakultät, Friedrich-Schiller-Universität Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Deutschland.
| | - S Brodt
- Waldklinken Eisenberg, Campus für Orthopädie, Medizinische Fakultät, Friedrich-Schiller-Universität Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Deutschland
| | - C Windisch
- Abteilung für Orthopädie und Unfallchirurgie, Helios Klinikum Blankenhain, Wirthstr. 5, 99444, Blankenhain, Deutschland
| | - G Matziolis
- Waldklinken Eisenberg, Campus für Orthopädie, Medizinische Fakultät, Friedrich-Schiller-Universität Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Deutschland
| | - S Böhle
- Waldklinken Eisenberg, Campus für Orthopädie, Medizinische Fakultät, Friedrich-Schiller-Universität Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Deutschland
| |
Collapse
|
10
|
Mull HJ, Rosen AK, Charns MP, Itani KM, Rivard PE. Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Veterans Health Administration Staff Perceptions. J Patient Saf 2021; 17:e177-e185. [PMID: 29112029 PMCID: PMC8445239 DOI: 10.1097/pts.0000000000000311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Little is known about patient safety risks in outpatient surgery. Inpatient surgical adverse events (AEs) risk factors include patient- (e.g., advanced age), process- (e.g., inadequate preoperative assessment), or structure-related characteristics (e.g., low surgical volume); however, these factors may differ from outpatient care where surgeries are often elective and in younger/healthier patients. We undertook an exploratory qualitative research project to identify risk factors for AEs in outpatient surgery. METHODS We developed a conceptual framework of patient, process, and structure factors associated with surgical AEs on the basis of a literature review. This framework informed our semistructured interview guide with (1) open-ended questions about a specific outpatient AE that the participant experienced and (2) outpatient surgical patient safety risk factors in general. We interviewed nationwide Veterans Health Administration surgical staff. Results were coded on the basis of categories in the conceptual framework, and additional themes were identified using content analysis. RESULTS Fourteen providers representing diverse surgical roles participated. Ten reported witnessing an AE, and everyone provided input on risk factors in our conceptual framework. We did not find evidence that patient race/age, surgical technique, or surgical volume affected patient safety. Emerging factors included patient compliance, postoperative patient assessments/instruction, operating room equipment needs, and safety culture. CONCLUSIONS Surgical staff are familiar with AEs and patient safety problems in outpatient surgery. Our results show that processes of care undertaken by surgical providers, as opposed to immutable patient characteristics, may affect the occurrence of AEs. The factors we identified may facilitate more targeted research on outpatient surgical AEs.
Collapse
Affiliation(s)
- Hillary J. Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Martin P. Charns
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
| | - Kamal M.F. Itani
- Department of Surgery, Boston University School of Medicine, Boston, MA
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA
- Harvard Medical School, Boston, MA
| | - Peter E. Rivard
- Healthcare Administration, Sawyer Business School Suffolk University, Boston, MA
| |
Collapse
|
11
|
Farjah F, Grau-Sepulveda MV, Gaissert H, Block M, Grogan E, Brown LM, Kosinski AS, Kozower BD. Volume Pledge is Not Associated with Better Short-Term Outcomes After Lung Cancer Resection. J Clin Oncol 2020; 38:3518-3527. [PMID: 32762615 DOI: 10.1200/jco.20.00329] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE We examined the relationship between short-term outcomes and hospitals and surgeons who met minimum volume thresholds for lung cancer resection based on definitions provided by the Volume Pledge. A secondary aim was to evaluate the volume-outcome relationship to determine alternative thresholds in the event the Volume Pledge was not associated with outcomes. PATIENTS AND METHODS We conducted a retrospective study (2015-2017) using the Society of Thoracic Surgeons General Thoracic Surgery Database. We used generalized estimating equations that accounted for confounding and clustering to compare outcomes across hospitals and surgeons who did and did not meet the Volume Pledge criteria: ≥ 40 patients per year for hospitals and ≥ 20 patients per year for surgeons. Our secondary aim was to model volume by using restricted cubic splines to determine the association between volume and short-term outcomes. RESULTS Among 32,183 patients, 465 surgeons, and 209 hospitals, 16,630 patients (52%) received care from both a hospital and surgeon meeting the Volume Pledge criteria. After adjustment, there was no relationship with operative mortality, complications, major morbidity, a major morbidity-mortality composite end point, or failure to rescue. The Volume Pledge group had a 0.5 day (95% CI, 0.2 to 0.7 day) shorter length of stay. Our secondary aim revealed a nonlinear relationship between hospital volume and complications in which intermediate-volume hospitals had the highest risk of complications. Surgeon volume was associated with major morbidity, a major morbidity-mortality composite end point, and length of stay in an inverse linear fashion. Only 8% of surgeons had volumes associated with better outcomes. CONCLUSION The Volume Pledge was not associated with better outcomes except for a marginally shorter length of stay. A re-examination of volume-outcome relationships for hospitals and surgeons yielded mixed results that did not reveal a practical alternative for volume-based quality improvement efforts.
Collapse
Affiliation(s)
- Farhood Farjah
- Department of Surgery, University of Washington, Seattle, WA
| | | | - Henning Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mark Block
- Division of Thoracic Surgery, Memorial Healthcare System, Hollywood, FL
| | - Eric Grogan
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Lisa M Brown
- Section of General Thoracic Surgery, Department of Surgery, University of California Davis Health, Sacramento, CA
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Durham, NC.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Benjamin D Kozower
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
12
|
Swan RZ, Niemeyer DJ, Seshadri RM, Thompson KJ, Walters A, Martinie JB, Sindram D, Iannitti DA. The Impact of Regionalization of Pancreaticoduodenectomy for Pancreatic Cancer in North Carolina since 2004. Am Surg 2020. [DOI: 10.1177/000313481408000619] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreaticoduodenectomy (PD) carries a significant risk. High-volume centers (HVCs) provide improved outcomes and regionalization is advocated. Rapid regionalization could, however, have detrimental effects. North Carolina has multiple HVCs, including an additional HVC added in late 2006. We investigated regionalization of PD and its effects before, and after, the establishment of this fourth HVC. The North Carolina Hospital Discharge Database was queried for all PDs performed during 2004 to 2006 and 2007 to 2009. Hospitals were categorized by PD volume as: low (one to nine/year), medium (10 to 19/year), and high (20/year or more). Mortality and major morbidity was assessed by comparing volume groups across time periods. Number of PDs for cancer increased 91 per cent (129 to 246 cases) at HVCs, whereas decreasing at low-volume (62 to 58 cases) and medium-volume (80 to 46 cases) centers. Percentage of PD for cancer performed at HVCs increased significantly (47.6 to 70.3%) while decreasing for low- and medium-volume centers ( P < 0.001). Mortality was significantly less at HVCs (2.8%) compared with low-volume centers (10.3%) for 2007 to 2009. Odds ratio for mortality was significantly lower at HVCs during 2004 to 2006 (0.31) and 2007 to 2009 (0.34). Mortality for PD performed for cancer decreased from 6.6 to 4.6 per cent ( P = 0.31). Major morbidity was not significantly different between groups within either time period; however, there was a significant increase in major morbidity at low-volume centers ( P = 0.018). Regionalization of PD for cancer is occurring in North Carolina. Mortality was significantly lower at HVCs, and rapid regionalization has not detracted from the superior outcomes at HVCs.
Collapse
Affiliation(s)
- Ryan Z. Swan
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David J. Niemeyer
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Ramanathan M. Seshadri
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kyle J. Thompson
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Amanda Walters
- Division of GI and Minimally-Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John B. Martinie
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David Sindram
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David A. Iannitti
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| |
Collapse
|
13
|
Raphael MJ, Siemens DR, Booth CM. Would Regionalization of Systemic Cancer Therapy Improve the Quality of Cancer Care? J Oncol Pract 2019; 15:349-356. [PMID: 31112481 DOI: 10.1200/jop.18.00671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Michael J Raphael
- 1 Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,2 Queen's University, Kingston, Ontario, Canada
| | - D Robert Siemens
- 1 Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,2 Queen's University, Kingston, Ontario, Canada
| | - Christopher M Booth
- 1 Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,2 Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
14
|
Prophylactic Pancreatectomies Carry Prohibitive Mortality at Low-Volume Centers: A California Cancer Registry Study. World J Surg 2019; 43:2290-2299. [PMID: 31062057 DOI: 10.1007/s00268-019-05019-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Pancreatectomy for malignancy is associated with improved outcomes when performed at high-volume centers. The goal of this study was to assess pancreatectomy outcomes for premalignant cystic lesions as a function of hospital volume. METHODS The Healthcare Cost and Utilization Project (HCUP) was queried for all pancreatectomies performed in California from 2003 to 2011. Cases were stratified, separating benign versus malignant disease. Hospitals were categorized as low-volume (≤25 pancreatectomies/year; LV) or high-volume (>25; HV) centers. Perioperative morbidity, mortality, and length of stay were compared in HV vs. LV centers. RESULTS There were 7554 pancreatectomies performed in 201 hospitals during the study period, where 5652 (75%) procedures were performed for malignancy, 338 (4%) for chronic pancreatitis, and 1564 (21%) for benign/premalignant cysts. The majority of pancreatectomies for cystic disease were performed at LV centers (65%). There were no significant differences in length of stay (7 vs. 8 days; p = 0.6) or 90-day readmission rates (12.8% vs. 12.9%; p = 1.0) in HV versus LV centers. However, there were higher surgical (46.2% LV vs. 41.1% HV, p = 0.05) and medical (13.3% LV vs. 9.2% HV; p = 0.017) complications at LV centers. Most importantly, there was a fourfold higher in-hospital mortality at LV centers (2.36% vs. 0.55%; p = 0.007). CONCLUSION Pancreatic resection for benign lesions at HV hospitals is associated with significantly lower morbidity and mortality, suggesting that when feasible, patients should seek care at high-volume centers for these semi-elective surgeries.
Collapse
|
15
|
Kallmayer MA, Salvermoser M, Knappich C, Trenner M, Karlas A, Wein F, Eckstein HH, Kuehnl A. Quality appraisal of systematic reviews, and meta-analysis of the hospital/surgeon-linked volume-outcome relationship of carotid revascularization procedures. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:354-363. [DOI: 10.23736/s0021-9509.19.10943-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
16
|
Optimizing the Volume-Value Relationship in Laminectomy: An Evidence-Based Analysis of Outcomes and Economies of Scale. Spine (Phila Pa 1976) 2019; 44:659-669. [PMID: 30363014 DOI: 10.1097/brs.0000000000002910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective of the present study was to establish evidence-based volume thresholds for surgeons and hospitals predictive of enhanced value in the setting of laminectomy. SUMMARY OF BACKGROUND DATA Previous studies have attempted to characterize the relationship between volume and value; however, none to the authors' knowledge has employed an evidence-based approach to identify thresholds yielding enhanced value. METHODS In total, 67,758 patients from the New York Statewide Planning and Research Cooperative System database undergoing laminectomy in the period 2009 to 2015 were included. We used stratum-specific likelihood ratio analysis of receiver operating characteristic curves to establish volume thresholds predictive of increased length of stay (LOS) and cost for surgeons and hospitals. RESULTS Analysis of LOS by surgeon volume produced strata at: <17 (low), 17 to 40 (medium), 41 to 71 (high), and >71 (very high). Analysis of cost by surgeon volume produced strata at: <17 (low), 17 to 33 (medium), 34 to 86 (high), and >86 (very high). Analysis of LOS by hospital volume produced strata at: <43 (very low), 43 to 96 (low), 97 to 147 (medium), 148 to 172 (high), and >172 (very high). Analysis of cost by hospital volume produced strata at: <43 (very low), 43 to 82 (low), 83 to 115 (medium), 116 to 169 (high), and >169 (very high). LOS and cost decreased significantly (P < 0.05) in progressively higher volume categories for both surgeons and hospitals. For LOS, medium-volume surgeons handle the largest proportion of laminectomies (36%), whereas very high-volume hospitals handle the largest proportion (48%). CONCLUSION This study supports a direct volume-value relationship for surgeons and hospitals in the setting of laminectomy. These findings provide target-estimated thresholds for which hospitals and surgeons may receive meaningful return on investment in our increasingly value-based system. Further value-based optimization is possible in the finding that while the highest volume hospitals handle the largest proportion of laminectomies, the highest volume surgeons do not. LEVEL OF EVIDENCE 3.
Collapse
|
17
|
Karaca O, Bauer M, Taube C, Auhuber T, Schuster M. [Does hospital volume correlate with surgical process time? : Retrospective analysis of the five most common procedures for visceral surgery, trauma and orthopedic surgery and gynecology/obstetrics from the benchmarking program of the Berufsverband Deutscher Anästhesisten (BDA), Berufsverband Deutscher Chirurgen (BDC) and Verband für OP-Management (VOPM)]. Anaesthesist 2019; 68:218-227. [PMID: 30895350 DOI: 10.1007/s00101-019-0559-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/01/2019] [Accepted: 02/05/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Minimum volume thresholds for specific surgical procedures in German hospitals were established in 2004 but remain controversial. For the first time, this study investigated the relationship between hospital performance volume and surgical procedure duration in a multicenter approach. The question here was whether a concentration on frequently performed procedures leads to a reduction in surgical process times. METHODS In a retrospective analysis, the 5 most common procedures from visceral, trauma/orthopedic and gynecological/obstetrics surgery were examined in hospitals participating in a benchmarking program. For each procedure performed between 2013 and 2015, hospitals were divided into 4 groups depending on the hospital volume provided. The average surgical duration of incision to suture time was calculated between the group with "very low" hospital volume and the other three groups ("low", "high" and "very high"). RESULTS OR cases from 75 hospitals were analyzed. The number of included cases per procedure ranged from 31,940 to 2705. The average number of operations performed in a specific procedure was 3-4 times higher in high-volume hospitals compared to very low-volume hospitals. A linear relationship between hospital volume and surgical process time only appeared to be clearly seen in laparoscopic cholecystectomy, appendectomy and arthroscopic meniscus surgery: a higher case load led to a reduction in incision to suture time. For the other procedures, the surgical process times were inconsistent between the hospital groups. CONCLUSION The case volume only appeared to have a direct but limited influence on incision to suture times in laparoscopic and arthroscopic procedures. Overall, the hospital performance volume appeared to be of subordinate importance in terms of OR-economics.
Collapse
Affiliation(s)
- O Karaca
- digmed Datenmanagement im Gesundheitswesen GmbH, Hamburg, Deutschland
| | - M Bauer
- Klinik für Anästhesiologie und operative Intensivmedizin, KRH Klinikum Nordstadt und Siloah, Hannover, Deutschland.,Forum für Qualitätsmanagement und Ökonomie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin und des Berufsverbandes Deutscher Anästhesisten, Nürnberg, Deutschland.,Verband für OP-Management e. V., Hannover, Deutschland
| | - C Taube
- Verband für OP-Management e. V., Hannover, Deutschland
| | - T Auhuber
- Medizinmanagement, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Deutschland.,Berufsverband Deutscher Chirurgen, Berlin, Deutschland.,Hochschule der Deutschen Gesetzlichen Unfallversicherung, Bad Hersfeld, Deutschland
| | - M Schuster
- Forum für Qualitätsmanagement und Ökonomie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin und des Berufsverbandes Deutscher Anästhesisten, Nürnberg, Deutschland. .,Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Kliniken Landkreis Karlsruhe, Fürst-Stirum-Klinik Bruchsal und Rechbergklinik Bretten, Akademische Lehrkrankenhäuser der Universität Heidelberg, Gutleutstr. 1-14, 76646, Bruchsal, Deutschland.
| |
Collapse
|
18
|
Russo MJ, McCabe JM, Thourani VH, Guerrero M, Genereux P, Nguyen T, Hong KN, Kodali S, Leon MB. Case Volume and Outcomes After TAVR With Balloon-Expandable Prostheses. J Am Coll Cardiol 2019; 73:427-440. [DOI: 10.1016/j.jacc.2018.11.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/02/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
|
19
|
Yoon S, Jang EJ, Kim GH, Kim DH, Lim TY, Lee H, Ryu HG. Adult lung transplantation case-volume and in-hospital and long-term mortality in Korea. J Cardiothorac Surg 2019; 14:19. [PMID: 30674327 PMCID: PMC6343357 DOI: 10.1186/s13019-019-0849-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/17/2019] [Indexed: 11/17/2022] Open
Abstract
Background The inverse relationship between case-volume and surgical mortality has been reported in complex surgical procedures. The aim of this study was to evaluate the effect of case-volume on mortality after lung transplantation in Korea. Methods The National Health Insurance Service data was used to analyse all adult lung transplantations in Korea between 2007 and 2016. Institutions were categorized into low-volume (< 5 lung transplantations/year) centers or high-volume (≥ 5 lung transplantations/year) centers. Risk-adjusted in-hospital mortality and long-term survival according to case-volume was evaluated. Results A total of 315 adult recipients underwent lung transplantation at 7 centers. The odds ratio for in-hospital mortality in low-volume centers was similar to high-volume centers (OR, 1.496; 95% CI, 0.81–2.76; p = 0.197). Log-rank analysis of Kaplan-Meier curves according to case-volume also did not show a difference in long-term survival between high- and low-volume centers (p = 0.052). Conclusions There was no association between case-volume and in-hospital mortality after lung transplantation in Korea, although there was a tendency towards better long-term survival associated with high-volume centers.
Collapse
Affiliation(s)
- Susie Yoon
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, 1375 Gyeongdong-ro, Andong-si, Gyeongsangbuk-do, 36729, South Korea
| | - Ga Hee Kim
- Department of Statistics, Kyungpook National University, 80 Daehak-ro, Buk-gu, Daegu, 41566, South Korea
| | - Dal Ho Kim
- Department of Statistics, Kyungpook National University, 80 Daehak-ro, Buk-gu, Daegu, 41566, South Korea
| | - Tae-Yoon Lim
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Hannah Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Ho Geol Ryu
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
| |
Collapse
|
20
|
White MD, Zollman J, McDowell MM, Agarwal N, Abel TJ, Hamilton DK. Neurosurgical Resident Exposure to Pediatric Neurosurgery: An Analysis of Resident Case Logs. Pediatr Neurosurg 2019; 54:181-187. [PMID: 31112956 DOI: 10.1159/000500299] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/11/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The purpose of this study is to identify the national trends of exposure to pediatric procedures during neurosurgical residency and to subsequently evaluate how neurosurgery residents' experiences correlate with the minimum requirements set forth by the American College of Graduate Medical Education (ACGME). METHODS ACGME resident case logs from residents graduating between 2013 and 2017 were retrospectively reviewed. These reports were analyzed to determine trends in resident operative experience in pediatric procedures. The number of cases performed by residents was compared to the required minimums set by the ACGME within each pediatric surgical category. A linear regression analysis and t tests were utilized to analyze the change in cases performed over the study period. RESULTS A mean of 98.8 procedures were performed for each of the 877 residents graduating between 2013 and 2017. The total number of pediatric procedures declined at a rate of 1.7 cases/year (r2 = 0.77, p = 0.05). Spine and cerebrospinal fluid diversion procedures showed decreasing trends at rates of 1.9 (r2 = 0.70, p = 0.08) and 1.2 (r2 = 0.70, p = 0.08) cases/year, respectively. The number of trauma and brain tumor cases were shown to have increasing rates at 1.0 (r2 = 0.86, p = 0.02) and 0.3 (r2 = 0.69, p = 0.08) cases/year, respectively, with trauma cases showing significant increases. There was also a trend of increasing cases logged as the lead resident surgeon by 12.9 cases/year (r2 = 0.99, p < 0.001). The number of cases performed by the average graduating resident was also significantly higher than the minimums required by the ACGME; residents, on average, performed 3 times the required minimum number of pediatric cases. CONCLUSION Neurosurgical residents graduating from 2013 to 2017 reported significantly higher volumes of pediatric neurosurgery cases than the standards set for by the ACGME. During this time, there was also a significant trend of increasing cases logged as the lead resident surgeon, suggesting more involvement in the critical portions of pediatric cases. There was also a significant, but not clinically impactful, decrease in pediatric case volumes during this time. However, the overall data indicate that residents are continuing to gain valuable pediatric experience during residency training.
Collapse
Affiliation(s)
- Michael D White
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joshua Zollman
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA,
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David K Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
21
|
Navarro SM, Ramkumar PN, Egger AC, Goodwin RC. Evidence-Based Thresholds for the Volume-Value Relationship in Adolescent Idiopathic Scoliosis: Outcomes and Economies of Scale. Spine Deform 2018; 6:156-163. [PMID: 29413738 DOI: 10.1016/j.jspd.2017.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/17/2017] [Accepted: 08/01/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Increased surgeon and hospital volume has been associated with improved patient outcomes and cost effectiveness for adolescent idiopathic scoliosis (AIS). However, no evidence-based thresholds that clarify the volume at which these strata occur exist. The objective of this study was to establish statistically meaningful thresholds that define high-volume surgeons and hospitals performing spinal fusion for AIS from those that are low volume with respect to length of stay (LOS) and cost. METHODS Using 3,224 patients undergoing spinal fusion for AIS from an administrative database, we created and applied four models using stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve. We generated four sets of thresholds predictive of adverse outcomes, namely, increased cost and LOS, for both surgeon and hospital volume. RESULTS For both LOS and cost, surgeon volume produced the same strata with low volume identified as 0-5 annual surgeries and high as greater than 5. LOS and cost decreased significantly (p < .05) between volume strata. For hospital volume in terms of LOS, low volume was identified as 0-10 annual surgeries and high as greater than 10; in terms of cost, low volume was identified as 0-15 annual surgeries and high as greater than 15. LOS decreased significantly (p < .05) and cost was $1,500 less but not statistically significant between volume strata for hospital volume. CONCLUSIONS Our study of risk-based volume stratification established a direct volume-value relationship for surgeons and hospitals performing fusion for AIS. A meaningful threshold for low- and high-volume surgeons was established at 5 annual surgeries, but no consensus or clinically meaningful conclusion was reached for hospitals, although the threshold approached 10-15 annual surgeries. This analysis should aid patients, surgeons, and administration reach value-based decisions in the optimal delivery of pediatric spinal fusion for AIS.
Collapse
Affiliation(s)
- Sergio M Navarro
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Prem N Ramkumar
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.
| | - Anthony C Egger
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Ryan C Goodwin
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| |
Collapse
|
22
|
Osseis M, Esposito F, Lim C, Doussot A, Lahat E, Fuentes L, Moussallem T, Salloum C, Azoulay D. Impact of postoperative complications on long-term survival following surgery for T4 colorectal cancer. BMC Surg 2018; 18:87. [PMID: 30332994 PMCID: PMC6192193 DOI: 10.1186/s12893-018-0419-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 10/01/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Postoperative complications (POCs) after the resection of locally advanced colorectal cancer (CRC) may influence adjuvant treatment timing, outcomes, and survival. This study aimed to evaluate the impact of POCs on long-term outcomes in patients surgically treated for T4 CRC. METHODS All consecutive patients who underwent the resection of T4 CRC at a single centre from 2004 to 2013 were retrospectively analysed from a prospectively maintained database. POCs were assessed using the Clavien-Dindo classification. Patients who developed POCs were compared with those who did not in terms of recurrence-free survival (RFS) and overall survival (OS). RESULTS The study population comprised 106 patients, including 79 (74.5%) with synchronous distant metastases. Overall, 46 patients (43%) developed at least one POC during the hospital stay, and of those patients, 9 (20%) had severe complications (Clavien-Dindo ≥ grade III). POCs were not associated with OS (65% with POCs vs. 69% without POCs; p = 0.72) or RFS (58% with POCs vs. 70% without POCs; p = 0.37). Similarly, POCs did not affect OS or RFS in patients who had synchronous metastases at diagnosis compared with those who did not. CONCLUSIONS POCs do not affect the oncological course of patients subjected to the resection of T4 CRC, even in cases of synchronous metastases.
Collapse
Affiliation(s)
- Michael Osseis
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, UPEC, 51 avenue de Lattre de Tassigny, 94010, Créteil, France
| | - Francesco Esposito
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, UPEC, 51 avenue de Lattre de Tassigny, 94010, Créteil, France
| | - Chetana Lim
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, UPEC, 51 avenue de Lattre de Tassigny, 94010, Créteil, France
| | - Alexandre Doussot
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, UPEC, 51 avenue de Lattre de Tassigny, 94010, Créteil, France
| | - Eylon Lahat
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, UPEC, 51 avenue de Lattre de Tassigny, 94010, Créteil, France
| | - Liliana Fuentes
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, UPEC, 51 avenue de Lattre de Tassigny, 94010, Créteil, France
| | - Toufic Moussallem
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, UPEC, 51 avenue de Lattre de Tassigny, 94010, Créteil, France
| | - Chady Salloum
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, UPEC, 51 avenue de Lattre de Tassigny, 94010, Créteil, France
| | - Daniel Azoulay
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, APHP, UPEC, 51 avenue de Lattre de Tassigny, 94010, Créteil, France.
- INSERM, U955, Créteil, France.
| |
Collapse
|
23
|
Navarro SM, Frankel WC, Haeberle HS, Ramkumar PN. Fixed and Variable Relationship Models to Define the Volume-Value Relationship in Spinal Fusion Surgery: A Macroeconomic Analysis Using Evidence-Based Thresholds. Neurospine 2018; 15:249-260. [PMID: 30184616 PMCID: PMC6226132 DOI: 10.14245/ns.1836088.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/23/2018] [Indexed: 11/19/2022] Open
Abstract
Objective Increased surgical volume has been associated with improved patient outcomes at the surgeon and hospital level. To date, clinically meaningful stratified volume benchmarks have yet to be defined for surgeons or hospitals in the context of spinal fusion surgery. The objective of this study was to establish evidence-based thresholds using outcomes and cost to stratify surgeons and hospitals performing spinal fusion surgery by volume.
Methods Using 155,788 patients undergoing spinal fusion surgery, we created and applied 4 models using stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve. This statistical approach was used to generate 4 sets of volume thresholds predictive of increased length of stay (LOS) and increased cost for surgeons and hospitals.
Results SSLR analysis of the 2 ROC curves by annual surgical volume produced 3 or 4 distinct volume categories. Analysis of LOS by annual surgeon spinal fusion volume produced 4 strata: low, medium, high, and very high. Analysis of LOS by annual hospital spinal fusion volume produced 3 strata: low, medium, and high. No relationship between volume and cost could be clearly defined based on the generation of ROC curves for surgeons or hospitals offering spinal fusion.
Conclusion This study used evidence-based thresholds to identify a direct, variable relationship model between volume and outcomes of spinal fusion surgery, using LOS as a surrogate, for both surgeons and hospitals. A fixed relationship model was identified between surgeon and hospital volume and cost, as no statistically meaningful relationship could be established.
Collapse
Affiliation(s)
- Sergio M Navarro
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Heather S Haeberle
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | | |
Collapse
|
24
|
Harrison S, Tangel V, Wu X, Christos P, Gaber-Baylis L, Turnbull Z, Port J, Altorki N, Stiles B. Are minimum volume standards appropriate for lung and esophageal surgery? J Thorac Cardiovasc Surg 2018; 155:2683-2694.e1. [DOI: 10.1016/j.jtcvs.2017.11.073] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 11/10/2017] [Accepted: 11/16/2017] [Indexed: 12/22/2022]
|
25
|
Murray AC, Markar S, Mackenzie H, Baser O, Wiggins T, Askari A, Hanna G, Faiz O, Mayer E, Bicknell C, Darzi A, Kiran RP. An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK. Surg Endosc 2018; 32:3055-3063. [PMID: 29313126 DOI: 10.1007/s00464-017-6016-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/19/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood. METHODS In this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998-2012) and USA (National Inpatient Sample 1998-2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England. RESULTS Patients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; p < 0.001). Pre-treatment (1 vs. 2 days; p < 0.001) and total ( 4 vs. 7 days; p < 0.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; p < 0.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission. CONCLUSION This study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.
Collapse
Affiliation(s)
- A C Murray
- Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor: 8, New York, NY, 10032, USA.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - S Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - H Mackenzie
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - O Baser
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - T Wiggins
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Askari
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - G Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - O Faiz
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - E Mayer
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - C Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - R P Kiran
- Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor: 8, New York, NY, 10032, USA. .,Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA.
| |
Collapse
|
26
|
Ramkumar PN, Navarro SM, Haeberle HS, Ricchetti ET, Iannotti JP. Evidence-based thresholds for the volume-value relationship in shoulder arthroplasty: outcomes and economies of scale. J Shoulder Elbow Surg 2017; 26:1399-1406. [PMID: 28734539 DOI: 10.1016/j.jse.2017.05.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/09/2017] [Accepted: 05/12/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Whereas several studies suggest that high-volume surgeons and hospitals deliver superior patient outcomes with greater cost efficiency, no evidence-based thresholds separating high-volume surgeons and hospitals from those that are low or medium volume exist in shoulder arthroplasty. The objective of this study was to establish meaningful thresholds that take outcomes and cost into consideration for surgeons and hospitals performing shoulder arthroplasty. METHODS Using 9546 patients undergoing primary shoulder arthroplasty for osteoarthritis from an administrative database, we created and applied 4 models using stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve. We generated 4 sets of thresholds predictive of adverse outcomes, namely, increased length of stay (LOS) and increased cost for both surgeon and hospital volume. RESULTS SSLR analysis of the 4 ROC curves by surgeon volume produced 3 volume categories. LOS and cost by annual shoulder arthroplasty surgeon volume produced the same strata: 0-4 (low), 5-14 (medium), and 15 or more (high). LOS and cost by annual shoulder arthroplasty hospital volume produced the same strata: 0-3 (low), 4-14 (medium), and 15 or more (high). LOS and cost decreased significantly (P < .05) in progressively higher volume categories. CONCLUSIONS Our study validates economies of scale in shoulder arthroplasty by demonstrating a direct relationship between volume and value through SSLR analysis of ROC curves for risk-based volume stratification using meaningful volume definitions for low-, medium-, and high-volume surgeons and hospitals. The described volume-value relationship offers patients, surgeons, hospitals, and other stakeholders meaningful thresholds for the optimal delivery of shoulder arthroplasty.
Collapse
Affiliation(s)
- Prem N Ramkumar
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA.
| | - Sergio M Navarro
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Heather S Haeberle
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric T Ricchetti
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph P Iannotti
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
27
|
|
28
|
Huo YR, Phan K, Morris DL, Liauw W. Systematic review and a meta-analysis of hospital and surgeon volume/outcome relationships in colorectal cancer surgery. J Gastrointest Oncol 2017; 8:534-546. [PMID: 28736640 DOI: 10.21037/jgo.2017.01.25] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Numerous hospitals worldwide are considering setting minimum volume standards for colorectal surgery. This study aims to examine the association between hospital and surgeon volume on outcomes for colorectal surgery. METHODS Two investigators independently reviewed six databases from inception to May 2016 for articles that reported outcomes according to hospital and/or surgeon volume. Eligible studies included those in which assessed the association hospital or surgeon volume with outcomes for the surgical treatment of colon and/or rectal cancer. Random effects models were used to pool the hazard ratios (HRs) for the association between hospital/surgeon volume with outcomes. RESULTS There were 47 articles pooled (1,122,303 patients, 9,877 hospitals and 9,649 surgeons). The meta-analysis demonstrated that there is a volume-outcome relationship that favours high volume facilities and high volume surgeons. Higher hospital and surgeon volume resulted in reduced 30-day mortality (HR: 0.83; 95% CI: 0.78-0.87, P<0.001 & HR: 0.84; 95% CI: 0.80-0.89, P<0.001 respectively) and intra-operative mortality (HR: 0.82; 95% CI: 0.76-0.86, P<0.001 & HR: 0.50; 95% CI: 0.40-0.62, P<0.001 respectively). Post-operative complication rates depended on hospital volume (HR: 0.89; 95% CI: 0.81-0.98, P<0.05), but not surgeon volume except with respect to anastomotic leak (HR: 0.59; 95% CI: 0.37-0.94, P<0.01). High volume surgeons are associated with greater 5-year survival and greater lymph node retrieval, whilst reducing recurrence rates, operative time, length of stay and cost. The best outcomes occur in high volume hospitals with high volume surgeons, followed by low volume hospitals with high volume surgeons. CONCLUSIONS High volume by surgeon and high volume by hospital are associated with better outcomes for colorectal cancer surgery. However, this relationship is non-linear with no clear threshold of effect being identified and an apparent ceiling of effect.
Collapse
Affiliation(s)
- Ya Ruth Huo
- Hepatobiliary and Surgical Oncology Unit, UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia.,Faculty of Medicine, St George Clinical School, UNSW Australia, Kensington, NSW, Australia
| | - Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - David L Morris
- Hepatobiliary and Surgical Oncology Unit, UNSW Department of Surgery, St George Hospital, Kogarah, NSW, Australia.,Faculty of Medicine, St George Clinical School, UNSW Australia, Kensington, NSW, Australia
| | - Winston Liauw
- Faculty of Medicine, St George Clinical School, UNSW Australia, Kensington, NSW, Australia.,Cancer Care Centre, St George Hospital, Kogarah, NSW, Australia
| |
Collapse
|
29
|
Austvoll-Dahlgren A, Underland V, Straumann GH, Forsetlund L. [Patient volume and quality in surgery for abdominal aortic aneurysm]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:529-537. [PMID: 28383226 DOI: 10.4045/tidsskr.16.0718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Patient volume is assumed to affect quality, whereby complex procedures are best performed by those who perform them frequently. We have conducted a systematic review of the research on the association between patient volume and quality of vascular surgery. In this article we describe the outcomes for abdominal aortic aneurysm surgery.MATERIAL AND METHOD We undertook systematic searches in relevant databases. We searched for systematic reviews, and randomised and observational studies. The search was concluded in December 2015. We have summarised the results descriptively and assessed the overall quality of the evidence.RESULTS Forty-six observational studies fulfilled our inclusion criteria. We found a possible association for both hospital and surgeon volume. Higher patient volume may possibly be associated with lower 30-day mortality and lower hospital mortality for both open and endovascular surgery. Although the association appears to apply to both elective and acute hospitalisations, there is greater uncertainty with regard to the most ill patients. For hospital volume there may also be fewer complications for open and endovascular surgery, as well as for all surgery assessed as a whole. We considered the evidence base to be medium to very low quality.INTERPRETATION We found a possible correlation between patient volume and quality indicators such as mortality and complications. It may be advantageous to allocate planned procedures to institutions and surgeons with high volume, while this is less certain with regard to acute hospitalisations.
Collapse
|
30
|
Noureldin M, Habermann EB, Ubl DS, Kakar S. Unplanned Readmissions Following Outpatient Hand and Elbow Surgery. J Bone Joint Surg Am 2017; 99:541-549. [PMID: 28375886 DOI: 10.2106/jbjs.15.01423] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Unplanned readmission following surgery is a quality metric that helps surgeons assess initiatives targeted at improving patient care. We utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine the rates, causes, and predictors of unplanned 30-day readmissions after outpatient elective hand and elbow surgery. METHODS The ACS-NSQIP database was queried using hand-and-elbow-specific Current Procedural Terminology (CPT) codes to retrospectively identify patients who had undergone outpatient hand or elbow surgery in 2012 and 2013. Patients who required an unplanned readmission to the hospital within 30 days were compared with those who were not readmitted. Preoperative patient characteristics, intraoperative variables, complications, and mortality were compared between the cohorts. Cox proportional hazard models were used to determine independent associations with 30-day unplanned readmission. RESULTS A total of 14,106 outpatient hand or elbow surgery procedures were identified between 2012 and 2013, and 169 (1.2%) of them were followed by an unplanned readmission. The leading causes of readmission included postoperative infections (19.5%), pain (4.7%), thromboembolic events (4.1%), and pulmonary complications (3.0%). The causes of approximately 1/3 of the readmissions were missing from the database, and these readmissions were likely unrelated to the principal procedure. Independent predictors of readmission included an age of 70 to 84 years (hazard ratio [HR] = 2.83, 95% confidence interval [CI] = 1.67 to 4.78), smoking (HR = 2.23, 95% CI = 1.57 to 3.18), a lower hematocrit (HR = 2.19, 95% CI = 1.38 to 3.46), renal dialysis (HR = 3.32, 95% CI = 1.60 to 6.91), and an elbow procedure (with or without a hand procedure) (HR = 2.19, 95% CI = 1.57 to 3.04). CONCLUSIONS The prevalence of unplanned readmission following outpatient hand and elbow surgery is low. Several modifiable factors, including preoperative smoking and anemia, are associated with unplanned readmission. These data may be helpful in developing quality-control initiatives to target unplanned readmissions following hand and elbow procedures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Mohamed Noureldin
- 1Department of Orthopedic Surgery, University of Toledo College of Medicine, Toledo, Ohio 2Departments of Health Sciences Research (E.B.H. and D.S.U.) and Orthopedic Surgery (S.K.), Mayo Clinic, Rochester, Minnesota
| | | | | | | |
Collapse
|
31
|
Hussaini SMQ, Murphy KR, Han JL, Elsamadicy AA, Yang S, Premji A, Parente B, Xie J, Pagadala P, Lad SP. Specialty-Based Variations in Spinal Cord Stimulation Success Rates for Treatment of Chronic Pain. Neuromodulation 2017; 20:340-347. [PMID: 28370989 DOI: 10.1111/ner.12582] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 11/21/2016] [Accepted: 12/07/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) has emerged as an appropriate modality of treatment for intractable chronic pain. The present study examines variations in SCS trial-to-permanent conversion rates based on provider types performing the procedure. MATERIALS AND METHODS We designed a large, retrospective analysis using the Truven MarketScan data base analyzing adult SCS patients with provider information available, with or without IPG implantation from the years 2007-2012. Patients were categorized based on provider type performing the implantation including anesthesiologists, neurosurgeons, orthopedic surgeons, and physical medicine and rehabilitation (PM&R). Univariate and multivariate models identified factors associated with successful conversion. RESULTS A total of 7667 unique instances of SCS implants were identified across five providers. Overall, 4842 (63.2%) of those receiving trials underwent permanent SCS system implantation. Anesthesiology performed the majority of implants (62.8%), followed by neurosurgery (22.0%), orthopedic surgery (10.2%), and PM&R (5.3%). Compared to anesthesiologists, both neurosurgeons (OR 10.99, 95% CI [9.11, 13.25]; p < 0.001) and orthopedic surgeons (OR 4.64, 95% CI [3.81, 5.65]; p < 0.001) had significantly higher conversion rates, while PM&R (OR 0.71, 95% CI [0.58, 0.87]; p = 0.001) had significantly lower. Percutaneous implants comprised 5473 (71.4%) of all implants. Neurosurgeons and orthopedic surgeons performed a significantly greater number of paddle implants among the different providers (p < 0.0001). Explant rates were similar across all cohorts analyzed (average 11.6%; p = 0.546). CONCLUSIONS In this nationwide analysis, our results suggest that over a recent five-year period, conversion rates are highest when SCS trials are performed by neurosurgeons and orthopedic surgeons. The study has important implications for establishing uniform guidelines for training, patient selection, and education of physicians across multiple disciplines.
Collapse
Affiliation(s)
| | - Kelly Ryan Murphy
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jing L Han
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | | | - Siyun Yang
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Alykhan Premji
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Beth Parente
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jichun Xie
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Promila Pagadala
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
32
|
Case mix-adjusted cost of colectomy at low-, middle-, and high-volume academic centers. Surgery 2016; 161:1405-1413. [PMID: 27919447 DOI: 10.1016/j.surg.2016.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 09/20/2016] [Accepted: 10/07/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Efforts to regionalize surgery based on thresholds in procedure volume may have consequences on the cost of health care delivery. This study aims to delineate the relationship between hospital volume, case mix, and variability in the cost of operative intervention using colectomy as the model. METHODS All patients undergoing colectomy (n = 90,583) at 183 academic hospitals from 2009-2012 in The University HealthSystems Consortium Database were studied. Patient and procedure details were used to generate a case mix-adjusted predictive model of total direct costs. Observed to expected costs for each center were evaluated between centers based on overall procedure volume. RESULTS Patient and procedure characteristics were significantly different between volume tertiles. Observed costs at high-volume centers were less than at middle- and low-volume centers. According to our predictive model, high-volume centers cared for a less expensive case mix than middle- and low-volume centers ($12,786 vs $13,236 and $14,497, P < .01). Our predictive model accounted for 44% of the variation in costs. Overall efficiency (standardized observed to expected costs) was greatest at high-volume centers compared to middle- and low-volume tertiles (z score -0.16 vs 0.02 and -0.07, P < .01). CONCLUSION Hospital costs and cost efficiency after an elective colectomy varies significantly between centers and may be attributed partially to the patient differences at those centers. These data demonstrate that a significant proportion of the cost variation is due to a distinct case mix at low-volume centers, which may lead to perceived poor performance at these centers.
Collapse
|
33
|
Abelson JS, Spiegel JD, Afaneh C, Mao J, Sedrakyan A, Yeo HL. Evaluating cumulative and annual surgeon volume in laparoscopic cholecystectomy. Surgery 2016; 161:611-617. [PMID: 27771160 DOI: 10.1016/j.surg.2016.08.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 08/09/2016] [Accepted: 08/18/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although there is a large body of published data demonstrating improved outcomes for complex operations when performed by high-volume surgeons at high-volume hospitals, the literature is mixed regarding whether this same relationship applies in less complex and more common surgeries such as laparoscopic cholecystectomy. METHODS This study utilized the New York State Department of Health Statewide Planning and Research Cooperative System database to identify patients undergoing laparoscopic cholecystectomy for acute and chronic biliary pathology. Rates of perioperative outcomes were compared among 4 distinct categories of surgeons based on surgeon annual and cumulative volume: low cumulative/low annual, low cumulative/high annual, high cumulative/low annual, and high cumulative/high annual. RESULTS A total of 150,938 patients undergoing operation by 3,306 surgeons at 250 hospitals across New York state were included for analysis from 2000-2014. There was no difference in adjusted 30-day in-hospital mortality, major events, procedural complications, bile duct injury, or reintervention rates between the 4 groups of surgeons. However, patients undergoing operation by high cumulative/high annual volume surgeons were less likely to experience 30-day readmission, prolonged duration of stay, and high charges when compared with low cumulative/low annual volume surgeons. CONCLUSION In New York state, increased surgeon annual and cumulative volume predicts lower rates of 30-day readmission, prolonged duration of stay, and high charges in laparoscopic cholecystectomy, but has no effect on in-hospital mortality, major events, bile duct injury, procedural complications, or reintervention. There is no evidence to support regionalization of this procedure as operative outcomes are comparable even in less experienced hands.
Collapse
Affiliation(s)
- Jonathan S Abelson
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY
| | - Joshua D Spiegel
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY
| | - Cheguevara Afaneh
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY
| | - Jialin Mao
- Department of Public Health, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY
| | - Art Sedrakyan
- Department of Public Health, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY
| | - Heather L Yeo
- Department of Surgery, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY; Department of Public Health, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY.
| |
Collapse
|
34
|
The impact of acute perioperative myocardial infarction on clinical outcomes after total joint replacement. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
35
|
Numan RC, Berge MT, Burgers JA, Klomp HM, van Sandick JW, Baas P, Wouters MW. Peri- and postoperative management of stage I-III Non Small Cell Lung Cancer: Which quality of care indicators are evidence-based? Lung Cancer 2016; 101:129-136. [PMID: 27794401 DOI: 10.1016/j.lungcan.2016.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 05/30/2016] [Accepted: 06/11/2016] [Indexed: 10/21/2022]
Abstract
Quality of care (QoC) has a central role in our health care system. The aim of this review is to present a set of evidence-based quality indicators for the surgical treatment and postoperative management of lung cancer. A search was performed through PubMed, Embase and the Cochrane library database, including English literature, published between 1980 and 2012. Search terms regarding 'lung neoplasms', 'surgical treatment' and 'quality of care' were used. Potential QoC indicators were divided into structure, process or outcome measures and a final selection was made based upon the level of evidence. High hospital volume and surgery performed by a thoracic surgeon, were identified as important structure indicators. Sleeve resection instead of pneumonectomy and the importance of treatment within a clinical care path setting were identified as evidence-based process indicators. A symptom-based follow-up regime was identified as a new QoC indicator. These indicators can be used for registration, benchmarking and ultimately quality improvement in lung cancer surgery.
Collapse
Affiliation(s)
- Rachel C Numan
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands.
| | - Martijn Ten Berge
- Department of Surgical Oncology, Leids Universitair Medisch Centrum, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jacobus A Burgers
- Department of Thoracic Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Houke M Klomp
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Paul Baas
- Department of Thoracic Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Michel W Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| |
Collapse
|
36
|
Rajeev R, Klooster B, Turaga KK. Impact of surgical volume of centers on post-operative outcomes from cytoreductive surgery and hyperthermic intra-peritoneal chemoperfusion. J Gastrointest Oncol 2016; 7:122-8. [PMID: 26941990 PMCID: PMC4754306 DOI: 10.3978/j.issn.2078-6891.2015.099] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/17/2015] [Indexed: 12/21/2022] Open
Abstract
Complex surgical operations performed at centers of high volume have improved outcomes due to improved surgical proficiency, and betters systems of care including avoidance of errors. Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemoperfusion (HIPEC), which has been shown to be an oncologically effective strategy for peritoneal carcinomatosis (PC), is one such procedure with significant morbidity and mortality. The learning curve to reach technical proficiency in CRS + HIPEC is about 140-220 cases for a center. Focus on improving surgical proficiency through training, improving systems of care through partnerships and reporting mechanisms for quality could reduce the time to proficiency.
Collapse
Affiliation(s)
- Rahul Rajeev
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Brittany Klooster
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kiran K Turaga
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
37
|
Hayanga JA, Lira A, Vlahu T, D'Cunha J, Hayanga HK, Girgis R, Aboagye J, Khaghani A. Procedural volume and survival after lung transplantation in the United States: the need to look beyond volume in the establishment of quality metrics. Am J Surg 2016; 211:671-6. [PMID: 26830718 DOI: 10.1016/j.amjsurg.2015.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND We sought to evaluate the effect of center volume on patient survival. METHODS We performed a retrospective analysis on nationwide data from the Scientific Registry of Transplant Recipients provided by United Network for Organ Sharing pertaining to lung transplantation (LT) recipients transplanted between 2005 and 2013. Centers were categorized into 4 groups based on their annual volume as follows: less than 20, 20 to 29, 30 to 39, and greater than or equal to 40 LTs. Baseline characteristics were compared and Kaplan-Meier analysis was used to estimate survival. RESULTS A total of 13,506 adult recipients underwent LT during the study period. Of these, 2,491 (18.4%) patients were transplanted in centers with volume less than 20, 2,562 (19.0%) in centers with volume 20 to 29, 2,998 (22.2%) in centers with volume 30 to 39, and 5,455(40.4%) in centers with volume greater than or equal to 40. Survival was poorest in the lowest volume centers (1-year 81.4% vs 85.5% and 5-year 49.7% vs 56.5%, respectively). CONCLUSIONS Post-LT survival in low volume centers is significantly lower than in high volume centers but the explanatory power of volume as a predictor of survival is low.
Collapse
Affiliation(s)
- Jeremiah A Hayanga
- Department of Cardiothoracic Surgery, DeVos Heart & Lung Transplantation Program, Spectrum Health-Michigan State University, 330 Barclay Avenue NE, Suite 200, Grand Rapids, MI 49503, USA.
| | - Alena Lira
- Department of Pulmonary-Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Tedi Vlahu
- Department of Cardiothoracic Surgery, DeVos Heart & Lung Transplantation Program, Spectrum Health-Michigan State University, 330 Barclay Avenue NE, Suite 200, Grand Rapids, MI 49503, USA
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Heather K Hayanga
- Department of Anesthesia, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Reda Girgis
- Department of Cardiothoracic Surgery, DeVos Heart & Lung Transplantation Program, Spectrum Health-Michigan State University, 330 Barclay Avenue NE, Suite 200, Grand Rapids, MI 49503, USA
| | - Jonathan Aboagye
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Asghar Khaghani
- Department of Cardiothoracic Surgery, DeVos Heart & Lung Transplantation Program, Spectrum Health-Michigan State University, 330 Barclay Avenue NE, Suite 200, Grand Rapids, MI 49503, USA
| |
Collapse
|
38
|
Abstract
It is a fundamental value of the surgical profession to improve care for its patients. In the last 100 years, the principles of prospective quality improvement have started to work their way into the traditional method of retrospective case review in morbidity and mortality conference. This article summarizes the history of "improvement science" and its intersection with the field of surgery. It attempts to clarify the principles and jargon that may be new or confusing to surgeons with a different vocabulary and experience. This is done to bring the significant power and resources of improvement science to the traditional efforts to improve surgical care.
Collapse
Affiliation(s)
| | - Saleem Islam
- Department of Surgery, University of Florida, 1600 SW Archer Rd, PO Box 100119, Gainesville, FL 32610.
| |
Collapse
|
39
|
Alsfasser G, Leicht H, Günster C, Rau BM, Schillinger G, Klar E. Volume-outcome relationship in pancreatic surgery. Br J Surg 2015; 103:136-43. [PMID: 26505976 DOI: 10.1002/bjs.9958] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 06/12/2015] [Accepted: 09/03/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Volume-outcome relationships related to major surgery may be of limited value if observation ends at the point of discharge without taking transfers and later events into consideration. METHODS The volume-outcome relationship in patients who underwent pancreatic surgery between 2008 and 2010 was assessed using claims data for all inpatient episodes from Germany's largest provider of statutory health insurance covering about 30 per cent of the population. Multiple logistic regression models with random effects were used to analyse the effect of hospital volume (using volume quintiles) on 1-year mortality, adjusting for age, sex, primary disease, type of surgery and co-morbidities. Additional outcomes were in-hospital (including transfer to other hospitals until final discharge) and 90-day mortality. RESULTS Of 9566 patients identified, risk-adjusted 1-year mortality was significantly higher in the three lowest-volume quintiles compared with the highest-volume quintile (odds ratio 1·73, 1·53 and 1·37 respectively). A similar, but less pronounced, effect was demonstrated for in-hospital and 90-day mortality. The effect of hospital volume on 1-year mortality was comparable to the effect of co-morbid conditions such as renal failure. CONCLUSION Although mortality related to pancreatic surgery is influenced by many factors, this study demonstrated lower mortality at 1 year in high-volume centres in Germany.
Collapse
Affiliation(s)
- G Alsfasser
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - H Leicht
- Research Institute of the Local Health Care Funds (AOK), Berlin, Germany
| | - C Günster
- Research Institute of the Local Health Care Funds (AOK), Berlin, Germany
| | - B M Rau
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | | | - E Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| |
Collapse
|
40
|
Altieri MS, Yang J, Telem DA, Chen H, Talamini M, Pryor A. Robotic-assisted outcomes are not tied to surgeon volume and experience. Surg Endosc 2015; 30:2825-33. [DOI: 10.1007/s00464-015-4562-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 09/10/2015] [Indexed: 11/29/2022]
|
41
|
Temporal Changes in the Influence of Hospitals and Regional Healthcare Networks on Severe Sepsis Mortality. Crit Care Med 2015; 43:1368-74. [PMID: 25803652 DOI: 10.1097/ccm.0000000000000970] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES There is systematic variation between hospitals in their care of severe sepsis, but little information on whether this variation impacts sepsis-related mortality, or how hospitals' and health-systems' impacts have changed over time. We examined whether hospital and regional organization of severe sepsis care is associated with meaningful differences in 30-day mortality in a large integrated health care system, and the extent to which those effects are stable over time. DESIGN In this retrospective cohort study, we used risk- and reliability-adjusted hierarchical logistic regression to estimate hospital- and region-level random effects after controlling for severity of illness using a rich mix of administrative and clinical laboratory data. SETTING One hundred fourteen U.S. Department of Veterans Affairs hospitals in 21 geographic regions. PATIENTS Forty-three thousand seven hundred thirty-three patients with severe sepsis in 2012, compared to 33,095 such patients in 2008. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The median hospital in the worst quintile of performers had a risk-adjusted 30-day mortality of 16.7% (95% CI, 13.5%, 20.5%) in 2012 compared with the best quintile, which had a risk-adjusted mortality of 12.8% (95% CI, 10.7%, 15.3%). Hospitals and regions explained a statistically and clinically significant proportion of the variation in patient outcomes. Thirty-day mortality after severe sepsis declined from 18.3% in 2008 to 14.7% in 2012 despite very similar severity of illness between years. The proportion of the variance in sepsis-related mortality explained by hospitals and regions was stable between 2008 and 2012. CONCLUSIONS In this large integrated healthcare system, there is clinically significant variation in sepsis-related mortality associated with hospitals and regions. The proportion of variance explained by hospitals and regions has been stable over time, although sepsis-related mortality has declined.
Collapse
|
42
|
Kalakoti P, Missios S, Menger R, Kukreja S, Konar S, Nanda A. Association of risk factors with unfavorable outcomes after resection of adult benign intradural spine tumors and the effect of hospital volume on outcomes: an analysis of 18, 297 patients across 774 US hospitals using the National Inpatient Sample (2002−2011). Neurosurg Focus 2015; 39:E4. [DOI: 10.3171/2015.5.focus15157] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECT
Because of the limited data available regarding the associations between risk factors and the effect of hospital case volume on outcomes after resection of intradural spine tumors, the authors attempted to identify these associations by using a large population-based database.
METHODS
Using the National Inpatient Sample database, the authors performed a retrospective cohort study that involved patients who underwent surgery for an intradural spinal tumor between 2002 and 2011. Using national estimates, they identified associations of patient demographics, medical comorbidities, and hospital characteristics with inpatient postoperative outcomes. In addition, the effect of hospital volume on unfavorable outcomes was investigated. Hospitals that performed fewer than 14 resections in adult patients with an intradural spine tumor between 2002 and 2011 were labeled as low-volume centers, whereas those that performed 14 or more operations in that period were classified as high-volume centers (HVCs). These cutoffs were based on the median number of resections performed by hospitals registered in the National Inpatient Sample during the study period.
RESULTS
Overall, 18,297 patients across 774 hospitals in the United States underwent surgery for an intradural spine tumor. The mean age of the cohort was 56.53 ± 16.28 years, and 63% were female. The inpatient postoperative risks included mortality (0.3%), discharge to rehabilitation (28.8%), prolonged length of stay (> 75th percentile) (20.0%), high-end hospital charges (> 75th percentile) (24.9%), wound complications (1.2%), cardiac complications (0.6%), deep vein thrombosis (1.4%), pulmonary embolism (2.1%), and neurological complications, including durai tears (2.4%). Undergoing surgery at an HVC was significantly associated with a decreased chance of inpatient mortality (OR 0.39; 95% CI 0.16−0.98), unfavorable discharge (OR 0.86; 95% CI 0.76−0.98), prolonged length of stay (OR 0.69; 95% CI 0.62−0.77), high-end hospital charges (OR 0.67; 95% CI 0.60−0.74), neurological complications (OR 0.34; 95% CI 0.26−0.44), deep vein thrombosis (OR 0.65; 95% CI 0.45−0.94), wound complications (OR 0.59; 95% CI 0.41−0.86), and gastrointestinal complications (OR 0.65; 95% CI 0.46−0.92).
CONCLUSIONS
The results of this study provide individualized estimates of the risks of postoperative complications based on patient demographics and comorbidities and hospital characteristics and shows a decreased risk for most unfavorable outcomes for those who underwent surgery at an HVC. These findings could be used as a tool for risk stratification, directing presurgical evaluation, assisting with surgical decision making, and strengthening referral systems for complex cases.
Collapse
|
43
|
Fukuda H, Okuma K, Imanaka Y. Can experience improve hospital management? PLoS One 2014; 9:e106884. [PMID: 25250813 PMCID: PMC4175069 DOI: 10.1371/journal.pone.0106884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/09/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Experience curve effects were first observed in the industrial arena as demonstrations of the relationship between experience and efficiency. These relationships were largely determined by improvements in management efficiency and quality of care. In the health care industry, volume-outcome relationships have been established with respect to quality of care improvement, but little is known about the effects of experience on management efficiency. Here, we examine the relationship between experience and hospital management in Japanese hospitals. METHODS The study sample comprised individuals who had undergone surgery for unruptured abdominal aortic aneurysms and had been discharged from participant hospitals between April 1, 2006 and December 31, 2008. We analyzed the association between case volume (both at the hospital and surgeon level) and postoperative complications using multilevel logistic regression analysis. Multilevel log-linear regression analyses were performed to investigate the associations between case volume and length of stay (LOS) before and after surgery. RESULTS We analyzed 909 patients and 849 patients using the hospital-level and surgeon-level analytical models, respectively. The odds ratio of postoperative complication occurrence for an increase of one surgery annually was 0.981 (P < 0.001) at the hospital level and 0.982 (P < 0.001) at the surgeon level. The log-linear regression analyses showed that shorter postoperative LOS was significantly associated with high hospital-level case volume (coefficient for an increase of one surgery: -0.006, P = 0.009) and surgeon-level case volume (coefficient for an increase of one surgery: -0.011, P = 0.022). Although an increase of one surgery annually at the hospital level was statistically associated with a reduction of preoperative LOS by 1.1% (P = 0.006), there was no significant association detected between surgeon-level case volume and preoperative LOS (P = 0.504). CONCLUSION Experience at the hospital level may contribute to the improvement of hospital management efficiency.
Collapse
Affiliation(s)
- Haruhisa Fukuda
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Kazuhide Okuma
- Department of Healthcare Economics and Quality Management, School of Public Health, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, School of Public Health, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, Japan
- * E-mail:
| |
Collapse
|
44
|
Murzi M, Miceli A, Di Stefano G, Cerillo AG, Kallushi E, Farneti P, Solinas M, Glauber M. Enhancing quality control and performance monitoring in thoracic aortic surgery: a 10-year single institutional experience. Eur J Cardiothorac Surg 2014; 47:608-15. [PMID: 24948415 DOI: 10.1093/ejcts/ezu249] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of the present study was to monitor performance and learning effects for thoracic aortic surgery. In addition, we evaluated the volume-outcome relationship of patients undergoing surgery of the thoracic aorta, comparing the results of two higher-volume surgeons (HVSs) with six lower volume surgeons. METHODS A total of 867 thoracic aortic procedures (elective cases n = 753 and Type A acute dissection n = 114) were performed from 2003 to 2013 by eight surgeons (range 28-238 procedures) at our institution. Departmental and individual performance was monitored using control charts, with a predetermined acceptable failure rate of 10%. Perioperative death or one or more of four adverse events constituted failure. Moreover, results of two higher-volume operators (n = 460; 53%) were compared with those of six lower-volume operators (n = 407; 47%). RESULTS The incidence rate of in-hospital mortality for elective cases was 2% and for Type A dissection repair 9.6%. Institutional control charts revealed that the surgical process was under control for all the study periods apart from small periods of worse than expected performance which were congruent with new surgeons joining the programme. The predominant surgical failure was reoperation for bleeding. There were differences between surgeons with regard to the learning curves and performance. No significant differences were observed between high- and low-volume surgeons in terms of mortality and morbidity for elective cases. However, high-volume surgeons presented a trend suggesting a higher mortality rate in Type A aortic dissection repair (17.1 vs 6.3%; P = 0.09). CONCLUSIONS Thoracic aortic surgery can be performed with similar results by high- and low-volume surgeon. Control charts can facilitate learning effects and performance monitoring. Implementation of continuous departmental and individual performance monitoring is practicable.
Collapse
Affiliation(s)
- Michele Murzi
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Antonio Miceli
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Gioia Di Stefano
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Alfredo G Cerillo
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Enkel Kallushi
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Pierandrea Farneti
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Marco Solinas
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| | - Mattia Glauber
- Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy
| |
Collapse
|
45
|
Wilson MZ, Soybel DI, Hollenbeak CS. Operative volume in colon surgery: a matched cohort analysis. Am J Med Qual 2014; 30:271-82. [PMID: 24671097 DOI: 10.1177/1062860614526970] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although previous studies have suggested that higher volumes of colectomies performed by surgeons and hospitals are associated with lower mortality, less is known about the relationship between volume and resource utilization. The research team tested the association between volume, costs, complications, length of stay, and mortality using data from the National Inpatient Sample. Results suggest higher volumes for both surgeons and hospitals were associated with lower costs, fewer complications, shorter length of stay, and lower mortality. Propensity score matching showed no significant difference in mortality by surgeon volume (7.38% vs 7.46%, P=.0.842), but significantly fewer complications (45.06% vs 49.10%, P=.008), shorter length of stay (11.8 vs 13.1 days, P<.0001), and lower costs ($33,142 vs $29,578, P<.0001) for high-volume surgeons. Although the major driver of complications and mortality is burden of disease and comorbid conditions, individual surgeon volume is an important determinant of length of stay and costs.
Collapse
Affiliation(s)
| | - David I Soybel
- Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Christopher S Hollenbeak
- Penn State Milton S. Hershey Medical Center, Hershey, PA Penn State College of Medicine, Hershey, PA
| |
Collapse
|
46
|
Abstract
Health care quality measurement has become increasingly emphasized, as providers and administrators respond to public and government demands for improved patient care. This article will review the evolution of surgical quality measurement and improvement from its infancy in the 1850s to the vast efforts being undertaken today.
Collapse
Affiliation(s)
- Jonathan Chun
- Section of Colon and Rectal Surgery, Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, Maryland
| | - Andrea Chao Bafford
- Section of Colon and Rectal Surgery, Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, Maryland
| |
Collapse
|
47
|
Abstract
Health care quality measurement has become increasingly emphasized, as providers and administrators respond to public and government demands for improved patient care. This article will review the evolution of surgical quality measurement and improvement from its infancy in the 1850s to the vast efforts being undertaken today.
Collapse
Affiliation(s)
- Jonathan Chun
- Section of Colon and Rectal Surgery, Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, Maryland
| | - Andrea Chao Bafford
- Section of Colon and Rectal Surgery, Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, Maryland
| |
Collapse
|
48
|
Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e278S-e313S. [PMID: 23649443 DOI: 10.1378/chest.12-2359] [Citation(s) in RCA: 875] [Impact Index Per Article: 79.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined. METHODS The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. RESULTS Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.
Collapse
Affiliation(s)
- John A Howington
- NorthShore HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, IL.
| | - Matthew G Blum
- Penrose Cardiothoracic Surgery, Memorial Hospital, University of Colorado Health, Colorado Springs, CO
| | | | - Alex A Balekian
- Division of Pulmonary, Critical Care, and Sleep Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
49
|
Andrews S. Does concentration of surgical expertise improve outcomes for laparoscopic cholecystectomy? 9 year audit cycle. Surgeon 2013; 11:309-12. [PMID: 23916664 DOI: 10.1016/j.surge.2013.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 06/18/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Evidence from surgery shows that high volume is often associated with better outcomes. The aim of this study was to investigate this principle related to elective laparoscopic cholecystectomy practice. METHODS A retrospective analysis of all conversions and complications for patients undergoing elective laparoscopic cholecystectomy was performed. Data was collected and then repeated after restrictions were implemented to concentrate practice. Hospital databases and patient notes were used to collect data. RESULTS Between January 1999 and March 2004, 1605 laparoscopic cholecystectomies were performed by 8 surgeons. Case load varied from an average of <1 to 104 procedures per annum. Only 1 surgeon was an upper gastrointestinal specialist. Overall rates for conversion to open surgery were 4.9%, common bile duct injury was 0.31%, bile leak 0.75%, bowel injury 0.25%, haemorrhage 0.44% and death 0.06%, which met guidelines. Significant correlation between conversion and procedure number was identified (p=0.033) Between April 2006 and March 2010, 1820 laparoscopic cholecystectomies were performed by 4 surgeons. Case load varied from 23 to 268 procedures per annum, 2 surgeons were upper gastrointestinal specialists. Overall rates for conversion to open surgery were 3.5%, common bile duct injury 0.1%, bile leak 0.9%, bowel injury 0.21%, haemorrhage 0.16% and death 0.1%. Conversion rates were significantly lower in re-audit data (p=0.027), but remained lowest for the highest volume sub-specialist surgeons (p=0.016). CONCLUSIONS Concentrating expertise to those surgeons with interest and commitment to laparoscopic cholecystectomy service led to standardisation and reduction in conversion rates. There is correlation between volume of surgery and outcomes.
Collapse
Affiliation(s)
- S Andrews
- Royal Devon and Exeter Foundation Trust, Barrack Road, Exeter, Devon EX2 5DW, UK.
| |
Collapse
|
50
|
Desai A, Bekelis K, Ball PA, Lurie J, Mirza SK, Tosteson TD, Zhao W, Weinstein JN. Variation in outcomes across centers after surgery for lumbar stenosis and degenerative spondylolisthesis in the spine patient outcomes research trial. Spine (Phila Pa 1976) 2013; 38:678-91. [PMID: 23080425 PMCID: PMC4031041 DOI: 10.1097/brs.0b013e318278e571] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively collected database. OBJECTIVE To examine whether short- and long-term outcomes after surgery for lumbar stenosis (SPS) and degenerative spondylolisthesis (DS) vary across centers. SUMMARY OF BACKGROUND DATA Surgery has been shown to be of benefit for both SPS and DS. For both conditions, surgery often consists of laminectomy with or without fusion. Potential differences in outcomes of these overlapping procedures across various surgical centers have not yet been investigated. METHODS Spine Patient Outcomes Research Trial cohort participants with a confirmed diagnosis of SPS or DS undergoing surgery were followed from baseline at 6 weeks, 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Baseline characteristics and short- and long-term outcomes were analyzed. RESULTS A total of 793 patients underwent surgery. Significant differences were found between centers with regard to patient race, body mass index, treatment preference, neurological deficit, stenosis location, severity, and number of stenotic levels. Significant differences were also found in operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and wound infection. When baseline differences were adjusted for, significant differences were still seen between centers in changes in patient functional outcome (Short Form-36 bodily pain and physical function, and Oswestry Disability Index) at 1 year after surgery. In addition, the cumulative adjusted change in the Oswestry Disability Index Score at 4 years significantly differed among centers, with Short Form-36 scores trending toward significance. CONCLUSION There is a broad and statistically significant variation in short- and long-term outcomes after surgery for SPS and DS across various academic centers, when statistically significant baseline differences are adjusted for. The findings suggest that the choice of center affects outcome after these procedures, although further studies are required to investigate which center characteristics are most important.
Collapse
Affiliation(s)
- Atman Desai
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
| | | | | | | | | | | | | | | |
Collapse
|