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Kalata S, Schaefer SL, Nuliyahu U, Ibrahim AM, Nathan H. Low-Volume Elective Surgery and Outcomes in Medicare Beneficiaries Treated at Hospital Networks. JAMA Surg 2024; 159:203-210. [PMID: 38150228 PMCID: PMC10753440 DOI: 10.1001/jamasurg.2023.6542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/09/2023] [Indexed: 12/28/2023]
Abstract
Importance Minimum volume standards have been advocated as a strategy to improve outcomes for certain surgical procedures. Hospital networks could avoid low-volume surgery by consolidating cases within network hospitals that meet volume standards, thus optimizing outcomes while retaining cases and revenue. The rates of compliance with volume standards among hospital networks and the association of volume standards with outcomes at these hospitals remain unknown. Objective To quantify low-volume surgery and associated outcomes within hospital networks. Design, Setting, and Participants This cross-sectional study used Medicare Provider Analysis and Review data to examine fee-for-service beneficiaries aged 66 to 99 years who underwent 1 of 10 elective surgical procedures (abdominal aortic aneurysm repair, carotid endarterectomy, mitral valve repair, hip or knee replacement, bariatric surgery, or resection for lung, esophageal, pancreatic, or rectal cancers) in a network hospital from 2016 to 2018. Hospital volume for each procedure (calculated with the use of the National Inpatient Sample) was compared with yearly hospital volume standards for that procedure recommended by The Leapfrog Group. Networks were then categorized into 4 groups according to whether or not that hospital or another hospital in the network met low-volume standards for that procedure. Data were analyzed from February to June 2023. Exposure Receipt of surgery in a low-volume hospital within a network. Main Outcomes and Measures Primary outcomes were postoperative complications, 30-day readmission, and 30-day mortality, stratified by the volume status of the hospital and network type. The secondary outcome was the availability of a different high-volume hospital within the same network or outside the network and its proximity to the patient (based on hospital referral region and zip code). Results In all, data were analyzed for 950 079 Medicare fee-for-service beneficiaries (mean [SD] age, 74.4 [6.5] years; 621 138 females [59.2%] and 427 931 males [40.8%]) who underwent 1 049 069 procedures at 2469 hospitals within 382 networks. Of these networks, 380 (99.5%) had at least 1 low-volume hospital performing the elective procedure of interest. In 35 137 of 44 011 procedures (79.8%) that were performed at low-volume hospitals, there was a hospital that met volume standards within the same network and hospital referral region located a median (IQR) distance of 29 (12-60) miles from the patient's home. Across hospital networks, there was 43-fold variation in rates of low-volume surgery among the procedures studied (from 1.5% of carotid endarterectomies to 65.0% of esophagectomies). In adjusted analyses, postoperative outcomes were inferior at low-volume hospitals compared with hospitals meeting volume standards, with a 30-day mortality of 8.1% at low-volume hospitals vs 5.5% at hospitals that met volume standards (adjusted odds ratio, 0.67 [95% CI, 0.61-0.73]; P < .001). Conclusions and Relevance Findings of this study suggest that most US hospital networks had hospitals performing low-volume surgery that is associated with inferior surgical outcomes despite availability of a different in-network hospital that met volume standards within a median of 29 miles for the vast majority of patients. Strategies are needed to help patients access high-quality care within their networks, including avoidance of elective surgery at low-volume hospitals. Avoidance of low-volume surgery could be considered a process measure that reflects attention to quality within hospital networks.
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Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Sara L. Schaefer
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Ushapoorna Nuliyahu
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew M. Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
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Tjioe KC, Miranda-Galvis M, Johnson MS, Agrawal G, Balas EA, Cortes JE. The interaction between social determinants of health and cervical cancer survival: A systematic review. Gynecol Oncol 2024; 181:141-154. [PMID: 38163384 DOI: 10.1016/j.ygyno.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 12/17/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE This systematic review aimed to investigate what are the most relevant social determinants of health (SDH), how they are measured, how they interact among themselves and what is their impact on the outcomes of cervical cancer patients. METHODS Search was performed in PubMed, Scopus, Web of Science, Embase, Cochrane, and Google Scholar databases from January 2001 to September 2022. The protocol was registered at PROSPERO (CRD42022346854). We followed the PICOS strategy: Population- Patients treated for cervical cancer in the United States; Intervention - Any SDH; Comparison- None; Outcome measures- Cancer treatment outcomes related to the survival of the patients; Types of studies- Observational studies. Two reviewers extracted the data following the PRISMA guidelines. Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies was used for risk of bias (ROB) assessment. RESULTS Twenty-four studies were included (22 had low and 2 had moderate ROB). Most manuscripts analyzed data from public registries (83.3%) and only one SDH (54.17%). The SDH category of Neighborhood was not included in any study. Although the SDH were measured differently across the studies, not being married, receiving treatment at a low-volume hospital, and having public insurance (Medicaid or Medicare) or not being insured was associated with shorter survival of cervical cancer patients in most studies. CONCLUSIONS There is a deficit in the number of studies comprehensively assessing the impact of SDH on cervical cancer treatment-related outcomes. Marital status, hospital volume and health insurance status are potential predictors of worse outcome.
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Affiliation(s)
- Kellen Cristine Tjioe
- Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | | | - Marian Symmes Johnson
- Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Gagan Agrawal
- School of Computing, University of Georgia, Athens, GA, USA
| | - E Andrew Balas
- Department of Interdisciplinary Health Sciences, Augusta University, Augusta, GA, USA
| | - Jorge E Cortes
- Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA, USA.
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Aguilera C, Kalam KA, Chesney K, Donoho D. The Relationship Between Procedural Volume, Hospital Quality, and Postoperative Mortality in Pediatric Neurosurgery: Review of the Literature. World Neurosurg 2024; 182:e764-e771. [PMID: 38092348 DOI: 10.1016/j.wneu.2023.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Studies of neurosurgical pediatric patients associate treatment at low-volume hospitals and by low-volume surgeons with increased odds of adverse outcomes. Although these associations suggest that increased centralization of care could be considered, we evaluate whether confounding endogenous factors mitigate against the proposed outcome benefits. METHODS Literature review of English language articles from 1999 to 2021. We included articles that assessed volume-outcome effects in pediatric neurosurgical patients. RESULTS Twelve papers were included from 1999 to 2021. Primary outcomes included mortality (9), length of stay (LOS) (6), complications (4), and shunt revision/failure rates (3). Volume was measured at the hospital level (8) and at the surgeon level (6). Four papers found that higher volume hospitals had lower odds of mortality. Two papers found that hospitals with higher volume had fewer complications. Two papers found that higher volume surgeons had decreased mortality (odds ratio [OR] 0.09-0.3). One paper found that high-volume surgeons had fewer complications (-2.4%; P = 0.006). After controlling for hospital factors (HF), two out of 7 analyses remained significant. Five analyses did not control for HF. CONCLUSIONS The literature consistently demonstrates a relationship between higher hospital and surgeon volume and better outcomes for pediatric neurosurgical patients. Of the 7 articles that assessed HF, only 2 analyses found that surgical volume remained associated with better outcomes. No reports assessed the degree of centralization already present. The call for centralization of pediatric care should be tempered until variables such as hospital factors, distribution of cases, and clinical thresholds can be defined and studied.
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Affiliation(s)
- Carlos Aguilera
- Georgetown School of Medicine, Washington, District of Columbia, USA.
| | - Kazi A Kalam
- Georgetown School of Medicine, Washington, District of Columbia, USA
| | - Kelsi Chesney
- Georgetown School of Medicine, Washington, District of Columbia, USA
| | - Daniel Donoho
- Department of Neurosurgery, George Washington School of Medicine, Washington, District of Columbia, USA; Division of Neurosurgery, Children's National Hospital, Washington, District of Columbia, USA
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Kalifi M, Deguelte S, Faron M, Afchain P, de Mestier L, Lecomte T, Pasquer A, Subtil F, Alghamdi K, Poncet G, Walter T. The Need for Centralization for Small Intestinal Neuroendocrine Tumor Surgery: A Cohort Study from the GTE-Endocan-RENATEN Network, the CentralChirSINET Study. Ann Surg Oncol 2023; 30:8528-8541. [PMID: 37814184 DOI: 10.1245/s10434-023-14276-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/22/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND The concept of surgical centralization is becoming more and more accepted for specific surgical procedures. OBJECTIVE The aim of this study was to evaluate the relationship between procedure volume and the outcomes of surgical small intestine (SI) neuroendocrine tumor (NET) resections. METHODS We conducted a retrospective national study that included patients who underwent SI-NET resection between 2019 and 2021. A high-volume center (hvC) was defined as a center that performed more than five SI-NET resections per year. The quality of the surgical resections was evaluated between hvCs and low-volume centers (lvCs) by comparing the number of resected lymph nodes (LNs) as the primary endpoint. RESULTS A total of 157 patients underwent surgery in 33 centers: 90 patients in four hvCs and 67 patients in 29 lvCs. Laparotomy was more often performed in hvCs (85.6% vs. 59.7%; p < 0.001), as was right hemicolectomy (64.4% vs. 38.8%; p < 0.001), whereas limited ileocolic resection was performed in 18% of patients in lvCs versus none in hvCs. A bi-digital palpation of the entire SI length (95.6% vs. 34.3%, p < 0.001), a cholecystectomy (93.3% vs. 14.9%; p < 0.001), and a mesenteric mass resection (70% vs. 35.8%; p < 0.001) were more often performed in hvCs. The proportion of patients with ≥8 LNs resected was significantly higher (96.3% vs. 65.1%; p < 0.001) in hvCs compared with lvCs, as was the proportion of patients with ≥12 LNs resected (87.8% vs. 52.4%). Furthermore, the number of patients with multiple SI-NETs was higher in the hvC group compared with the lvC group (43.3% vs. 25.4%), as were the number of tumors in those patients (median of 7 vs. 2; p < 0.001). CONCLUSIONS Optimal SI-NET resection was significantly more often performed in hvCs. Centralization of surgical care of SI-NETs is recommended.
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Affiliation(s)
- Maroin Kalifi
- Department of Digestive Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon Cedex 03, France
| | - Sophie Deguelte
- Department of Digestive Surgery, Reims University Hospital, Robert Debré Hospital, Reims, France
| | - Matthieu Faron
- Departments of Surgical Oncology and Statistics, Gustave Roussy Cancer Campus® Grand Paris, Villejuif, France
| | - Pauline Afchain
- Department of Oncology, CHU Saint-Antoine, APHP, Paris, France
| | - Louis de Mestier
- Department of Pancreatology and Digestive Oncology, ENETS Centre of Excellence, Beaujon Hospital (APHP Nord), Université Paris-Cité, Clichy, France
| | - Thierry Lecomte
- Department of Hepato-Gastroenterology and Digestive Oncology, University Hospital of Tours, UMR INSERM 1069, Tours University, Tours, France
| | - Arnaud Pasquer
- Department of Digestive Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon Cedex 03, France
| | - Fabien Subtil
- Gastroenterology and Technologies for Health, Research Unit INSERM UMR 1052 CNRS UMR 5286, Cancer Research Center of Lyon, Lyon, France
- Department of Biostatistic, Hospices Civils de Lyon, Lyon, France
| | | | - Gilles Poncet
- Department of Digestive Surgery, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon Cedex 03, France.
- Gastroenterology and Technologies for Health, Research Unit INSERM UMR 1052 CNRS UMR 5286, Cancer Research Center of Lyon, Lyon, France.
- Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne Cedex, France.
- Pavillon D, Chirurgie Digestive, Hôpital Edouard Herriot, Lyon Cedex 03, France.
| | - Thomas Walter
- Department of Gastroenterology and Digestive Oncology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon Cedex 03, France
- Gastroenterology and Technologies for Health, Research Unit INSERM UMR 1052 CNRS UMR 5286, Cancer Research Center of Lyon, Lyon, France
- Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne Cedex, France
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Welke KF, Karamlou T, O'Brien SM, Dearani JA, Tweddell JS, Kumar SR, Romano JC, Backer CL, Pasquali SK. Contemporary Relationship Between Hospital Volume and Outcomes in Congenital Heart Surgery. Ann Thorac Surg 2023; 116:1233-1239. [PMID: 37652353 DOI: 10.1016/j.athoracsur.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 07/19/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Studies examining the volume-outcome relationship in congenital heart surgery (CHS) are more than a decade old. Since then, mortality has declined, and case-mix adjustment has evolved. We determined the current relationship between hospital CHS volume and outcomes. METHODS Patients aged ≤18 years undergoing index operations in The Society of Thoracic Surgeons-Congenital Heart Surgery Database (2017-2020) were included. Associations between annual hospital volume and case-mix-adjusted operative mortality, major complications, failure to rescue (FTR), and postoperative length of stay (PLOS) were assessed using Bayesian hierarchical models, overall, by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category, and for the Norwood procedure. RESULTS Across 101 centers (76,714 index operations), median annual volume was 144 operations/y. Operative mortality was 2.7%. Lower-volume hospitals had higher mortality, with an apparent transition zone at ∼190 operations/y (95% credible interval [CrI], 115-450 operations/y), below which a sustained uptick in the estimated odds of death occurred. Odds of death compared with a 450 operations/y reference were 50 operations/y (odds ratio [OR], 1.84; 95% CrI, 1.41-2.37), 100 operations/y (OR, 1.37; 95% CrI, 1.08-1.71), 200 operations/y (OR, 0.92; 95% CrI, 0.1-1.18), 300 operations/y (OR, 0.89; 95% CrI, 0.76-1.04). The volume-outcome effect was more apparent for STAT 4 to 5 than STAT 1 to 3 operations. In the overall cohort, PLOS and complications were similar across hospital volumes, whereas FTR rates were higher at lower-volume hospitals. Lower-volume hospitals had worse outcomes after the Norwood procedure, most notably mortality and FTR. CONCLUSIONS Hospital volume is associated with mortality and FTR after CHS. The relationship is strongest for high-risk operations. These data can inform ongoing initiatives to improve CHS care.
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Affiliation(s)
- Karl F Welke
- Division of Pediatric Cardiothoracic Surgery, Atrium Health Levine Children's Hospital, Charlotte, North Carolina.
| | - Tara Karamlou
- Department of Pediatric Cardiac Surgery and the Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, Cleveland Ohio
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - James S Tweddell
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
| | - Jennifer C Romano
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Kentucky; Cardiothoracic Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sara K Pasquali
- Division of Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, Michigan
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Veziant J, Boudis F, Lenne X, Bruandet A, Eveno C, Nuytens F, Piessen G. Outcomes Associated With Esophageal Perforation Management: Results From a French Nationwide Population-based Cohort Study. Ann Surg 2023; 278:709-716. [PMID: 37497641 DOI: 10.1097/sla.0000000000006048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To evaluate outcomes associated with esophageal perforation (EP) management at a national level and determine predictive factors of 90-day mortality (90dM), failure-to-rescue (FTR), and major morbidity (MM, Clavien-Dindo 3-4). BACKGROUND EP remains a challenging clinical emergency. Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized. METHODS Data from patients admitted to hospitals with EP were extracted from the French medico-administrative database (2012-2021). Etiology, management strategies, and short and long-term outcomes were analyzed. A cutoff value of the annual EP management caseload affecting FTR was determined using the "Chi-squared Automatic Interaction Detector" method. Random effects logistic regression model was performed to assess independent predictors of 90dM, FTR, and MM. RESULTS Among 4765 patients with EP, 90dM and FTR rates were 28.0% and 19.4%, respectively. Both remained stable during the study period. EP was spontaneous in 68.2%, due to esophageal cancer in 19.7%, iatrogenic postendoscopy in 7.3%, and due to foreign body ingestion in 4.7%. Primary management consisted of surgery (n = 1447,30.4%), endoscopy (n = 590,12.4%), isolated drainage (n = 336,7.0%), and conservative management (n = 2392,50.2%). After multivariate analysis, besides age and comorbidity, esophageal cancer was predictive of both 90dM and FTR. An annual threshold of ≥8 EP managed annually was associated with a reduced 90dM and FTR rate. In France, only some university hospitals fulfilled this condition. Furthermore, primary surgery was associated with a lower 90dDM and FTR rate despite an increase in MM. CONCLUSIONS We provide evidence for the referral of EP to high-volume centers with multidisciplinary expertise. Surgery remains an effective treatment for EP.
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Affiliation(s)
- Julie Veziant
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
| | - Fabio Boudis
- Department of Medical Information, Lille University Hospital, Lille, France
| | - Xavier Lenne
- Department of Medical Information, Lille University Hospital, Lille, France
| | - Amelie Bruandet
- Department of Medical Information, Lille University Hospital, Lille, France
| | - Clarisse Eveno
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
- University of Lille, CNRS, Inserm, Chu Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
| | - Frederiek Nuytens
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Az Groeninge Hospital, Kortrijk, Belgium
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
- University of Lille, CNRS, Inserm, Chu Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
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Adil EA, Francisco S, Morgan E, Kawai K, Cunningham MJ. Juvenile Nasopharyngeal Angiofibroma: Outcomes Analysis Based Upon Hospital Volume. Laryngoscope 2023; 133:3216-3220. [PMID: 36896888 DOI: 10.1002/lary.30640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/06/2023] [Accepted: 02/21/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To evaluate the management of juvenile nasopharyngeal angiofibroma (JNA) from a national perspective with outcomes comparison based on hospital volume. STUDY DESIGN Ten-year Pediatric Health Information Systems (PHIS) data analysis. METHODS The PHIS database was queried for the diagnosis of JNA. Data regarding demographics, surgical approach, embolization, length of stay, charges, readmission, and revision surgery was collected and analyzed. Hospitals were classified as low volume if fewer than 10 cases and high volume if greater than or equal to 10 cases during the study period. A random effects model compared outcomes based on hospital volume. RESULTS A total of 287 JNA patients were identified with a mean age of 13.8 (± 2.7) years. Nine hospitals were classified as high volume, accounting for a total of 121 patients. The mean length of hospitalization, blood transfusion rate, and 30-day readmissions did not differ significantly by hospital volume. Patients cared for at high-volume institutions were less likely to require postoperative mechanical ventilation (8.3% vs. 25.0%; adjusted RR = 0.32; 95% CI 0.14-0.73; p < 0.01) or return to the operating room for residual disease than patients admitted to low-volume hospitals (7.4% vs. 20.5%; adjusted RR = 0.38; 95% CI 0.18-0.79; p = 0.01). CONCLUSIONS The management of JNA is complex from both an operative and perioperative management standpoint. Over the past decade, nearly half (42.2%) of JNA patients have been managed at nine institutions in the United States. These centers have significantly lower rates of postoperative mechanical ventilation and the need for revision surgery. LEVEL OF EVIDENCE 3 Laryngoscope, 133:3216-3220, 2023.
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Affiliation(s)
- Eelam A Adil
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Francisco
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Ella Morgan
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Cunningham
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Thalji SZ, Cortina CS, Frebault J, Cho Y, Thorgerson A, Bergom CR, Huang CC, Kong AL. Associations Between Hospital Volume and Overall Survival After Surgery in Older Patients with Breast Cancer. Ann Surg Oncol 2023; 30:6462-6470. [PMID: 37314545 DOI: 10.1245/s10434-023-13725-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 05/23/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND High-volume hospitals (HVHs) are associated with improved overall survival (OS) following surgery for breast cancer compared with low-volume hospitals (LVHs). We examined this association in patients age ≥ 80 years and described patient and treatment characteristics associated with HVHs. PATIENTS AND METHODS The National Cancer Database was queried for women age ≥ 80 years who underwent surgery for stage I-III breast cancer between 2005 and 2014. Hospital volume was defined as the average number of cases during the year of the patient's index operation and the year prior. Hospitals were categorized into HVHs and LVHs using penalized cubic spline analysis of OS. A cutoff of ≥ 270 cases/year defined HVHs. RESULTS Among 59,043 patients, 9110 (15%) were treated at HVHs and 49,933 (85%) at LVHs. HVHs were associated with more non-Hispanic Black and Hispanic patients, earlier stage disease (stage I 54.9% vs. 52.6%, p < 0.001), higher rates of breast-conserving surgery (BCS) (68.3% vs. 61.4%, p < 0.001), and adjuvant radiation (37.5% vs. 36.1%, p = 0.004). Improved OS was associated with surgery at a HVH (HR 0.85, CI 0.81-0.88), along with receipt of adjuvant chemotherapy (HR 0.73, CI 0.69-0.77), endocrine therapy (HR 0.70, CI 0.68-0.72), and radiation (HR 0.66, CI 0.64-0.68). CONCLUSIONS Among patients with breast cancer age ≥ 80 years, undergoing surgery at a HVH was associated with improved OS. Patients who completed surgery at HVHs had earlier stage disease and more commonly received adjuvant radiation when appropriate. Processes of care at HVHs should be identified to improve outcomes in all settings.
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Affiliation(s)
- Sam Z Thalji
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 W, Watertown Plank Road, Milwaukee, WI, USA
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 W, Watertown Plank Road, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Julia Frebault
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 W, Watertown Plank Road, Milwaukee, WI, USA
| | - Youngjoo Cho
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
- Department of Applied Statistics, Konkuk University, Seoul, Republic of Korea
| | - Abigail Thorgerson
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Carmen R Bergom
- Department of Radiation Oncology, Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
- School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Chiang-Ching Huang
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 W, Watertown Plank Road, Milwaukee, WI, USA.
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA.
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Bansal K, Pawar S, Gupta T, Gilani F, Khera S, Kolte D. Association Between Hospital Volume and 30-Day Readmissions After Transcatheter Mitral Valve Edge-to-Edge Repair. Am J Cardiol 2023; 203:149-156. [PMID: 37499594 DOI: 10.1016/j.amjcard.2023.06.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/21/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023]
Abstract
Data on the association between hospital procedural volume and 30-day readmissions after mitral valve transcatheter edge-to-edge repair (mTEER) are limited. We used the 2019 Nationwide Readmissions Database to identify hospitals that performed at least 5 mTEERs. Hospitals were categorized based on tertiles of annual mTEER volume as low-volume (5 to 13), medium-volume (14 to 28), and high-volume (29 to 171). Multivariable hierarchical logistic regression models and restricted cubic spline analyses were used to examine the association between hospital mTEER volume and 30-day readmissions. Median (interquartile range) annual hospital mTEER volume was 20 (11.5 to 34). Of 234 hospitals included in the study, 77 (32.9%), 77 (32.9%), and 80 (34.2%) were categorized as low-volume, medium-volume, and high-volume. Of 5,574 index mTEER procedures included in this study, 634 (11.4%), 1,353 (24.3%), and 3,587 (64.3%) were performed at low-volume, medium-volume, and high-volume centers, respectively. In the overall study cohort, rates of 30-day all-cause readmissions after mTEER were 13.2%. In multivariable analyses, there was no significant association between hospital mTEER volume (as a categorical variable) and 30-day all-cause or cause-specific (cardiac, non-cardiac, heart failure) readmissions. Similarly, no significant relation was observed between hospital mTEER volume as a continuous variable and 30-day all-cause or cause-specific readmissions in restricted cubic spline analysis. In conclusion, in a nationally representative sample of 234 hospitals with >5,500 mTEER procedures, we found no association between annual hospital mTEER volume and 30-day all-cause or cause-specific readmissions.
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Affiliation(s)
- Kannu Bansal
- Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Shubhadarshini Pawar
- Department of Medicine, Shree Vighanaharta Superspeciality Hospital, Dhule, India
| | - Tanush Gupta
- Division of Cardiology, Department of Medicine, University of Vermont Medical Center, Burlington, Vermont
| | - Fahad Gilani
- Division of Cardiovascular Medicine, Catholic Medical Center, Manchester, New Hampshire
| | - Sahil Khera
- Division of Interventional Cardiology, Mount Sinai Hospital, New York, New York
| | - Dhaval Kolte
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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10
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Romatoski KS, Chung SH, de Geus SWL, Papageorge MV, Woods AP, Rasic G, Ng SC, Tseng JF, Sachs TE. Combined High-Volume Common Complex Cancer Operations Safeguard Long-Term Survival in a Low-Volume Individual Cancer Operation Setting. Ann Surg Oncol 2023; 30:5352-5360. [PMID: 37310536 DOI: 10.1245/s10434-023-13680-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/08/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND We previously demonstrated the importance of combined complex surgery volume on short-term outcomes of high-risk cancer operations. This study investigates the impact of combined common complex cancer operation volume on long-term outcomes at hospitals with low cancer-specific operation volumes. PATIENTS AND METHODS A retrospective cohort of National Cancer Data Base (2004-2019) patients undergoing surgery for hepatocellular carcinoma, non-small cell lung cancers, or pancreatic, gastric, esophageal, or rectal adenocarcinomas was utilized. Three separate cohorts were established: low-volume hospitals (LVH), mixed-volume hospitals (MVH) with low-volume individual cancer operations and high-volume total complex operations, and high-volume hospitals (HVH). Survival analyses were performed for overall, early-, and late-stage disease. RESULTS The 5 year survival was significantly better at MVH and HVH compared with LVH, for all operations except late-stage hepatectomy (HVH survival > LVH and MVH). The 5 year survival probability was similar between MVH and HVH for operations on late-stage cancers. Early and overall survival for gastrectomy, esophagectomy, and proctectomy were equivalent between MVH and HVH. While early and overall survival for pancreatectomy were benefited by HVH over MVH, the opposite was true for lobectomy/pneumonectomy, which were benefited by MVH over HVH; however, none of these differences were likely to have an effect clinically. Only hepatectomy patients demonstrated statistical and clinical significance in 5 year survival at HVH compared with MVH for overall survival. CONCLUSIONS MVH hospitals performing sufficient complex common cancer operations demonstrate similar long-term survival for specific high-risk cancer operations to HVH. MVH provide an adjunctive model to the centralization of complex cancer surgery, while maintaining quality and access.
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Affiliation(s)
- Kelsey S Romatoski
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sophie H Chung
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Susanna W L de Geus
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Marianna V Papageorge
- Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Alison P Woods
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gordana Rasic
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Sing Chau Ng
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA.
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11
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Bercow AS, Rauh-Hain JA, Melamed A, Mazina V, Growdon WB, Del Carmen MG, Goodman A, Bouberhan S, Randall T, Sisodia R, Bregar A, Eisenhauer EL, Minami C, Molina G. Association of hospital-level factors with utilization of sentinel lymph node biopsy in patients with early-stage vulvar cancer. Gynecol Oncol 2023; 169:47-54. [PMID: 36508758 DOI: 10.1016/j.ygyno.2022.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate utilization of sentinel lymph node biopsy (SLNB) for early-stage vulvar cancer at minority-serving hospitals and low-volume facilities. METHODS Between 2012-2018, individuals with T1b vulvar squamous cell carcinoma were identified using the National Cancer Database. Patient, facility, and disease characteristics were compared between patients undergoing SLNB or inguinofemoral lymph node dissection (IFLD). Multivariable logistic regression, adjusted for patient, facility, and disease characteristics, was used to evaluate factors associated with SLNB. Kaplan-Meier survival analysis using log rank test and Cox regression was performed. RESULTS Of the 3,532 patients, 2,406 (68.1%) underwent lymph node evaluation, with 1,704 (48.2%) undergoing IFLD and 702 (19.8%) SLNB. In a multivariable analysis, treatment at minority-serving hospitals (OR 0.39, 95% CI 0.19-0.78) and low-volume hospitals (OR 0.44, 95% CI 0.28-0.70) were associated with significantly lower odds of undergoing SLNB compared to receiving care at non-minority-serving and high-volume hospitals, respectively. While SLNB utilization increased over time for the entire cohort and stratified subgroups, use of the procedure did not increase at minority-serving hospitals. After controlling for patient and tumor characteristics, SLNB was not associated with worse OS compared to IFLD in patients with positive (HR 1.02, 95% CI 0.63-1.66) or negative (HR 0.92, 95% CI 0.70-1.21) nodal pathology. CONCLUSIONS For patients with early-stage vulvar cancer, treatment at minority-serving or low-volume hospitals was associated with significantly decreased odds of undergoing SLNB. Future efforts should be concentrated toward ensuring that all patients have access to advanced surgical techniques regardless of where they receive their care.
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Affiliation(s)
- Alexandra S Bercow
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America.
| | - J Alejandro Rauh-Hain
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Alexander Melamed
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Varvara Mazina
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Whitfield B Growdon
- Division of Gynecologic Oncology, New York University Langone Medical Center, New York, NY, United States of America
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Sara Bouberhan
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Thomas Randall
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Rachel Sisodia
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Amy Bregar
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Eric L Eisenhauer
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Christina Minami
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Breast Surgery, Department of Surgery, Dana-Farber/Brigham and Women's Hospital, Boston, MA, United States of America
| | - George Molina
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America
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12
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Uttinger KL, Reibetanz J, Diers J, Baum P, Pietryga S, Hendricks A, Schütze L, Baumann N, Wiegering V, Lock J, Dischinger U, Seyfried F, Fassnacht M, Germer CT, Wiegering A. Volume-outcome relationship in adrenal surgery from 2009-2017 in Germany-a retrospective study. Eur J Endocrinol 2023; 188:6979716. [PMID: 36651160 DOI: 10.1093/ejendo/lvac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/30/2022] [Accepted: 12/08/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Adrenal resections are rare procedures of a heterogeneous nature. While recent European guidelines advocate a minimum annual caseload for adrenalectomies (6 per surgeon), evidence for a volume-outcome relationship for this surgery remains limited. DESIGN A retrospective analysis of all adrenal resections in Germany between 2009 and 2017 using hospital billing data was performed. Hospitals were grouped into three tertiles of approximately equal patient volume. METHODS Descriptive, univariate, and multivariate analyses were applied to identify a possible volume-outcome relationship (complications, complication management, and mortality). RESULTS Around 17 040 primary adrenal resections were included. Benign adrenal tumors (n = 8,213, 48.2%) and adrenal metastases of extra-adrenal malignancies (n = 3582, 21.0%) were the most common diagnoses. Six hundred and thirty-two low-volume hospitals performed an equal number of resections as 23 high-volume hospitals (median surgeries/hospital/year 3 versus 31, P < .001). Complications were less frequent in high-volume hospitals (23.1% in low-volume hospitals versus 17.3% in high-volume hospitals, P < .001). The most common complication was bleeding in 2027 cases (11.9%) with a mortality of 4.6% (94 patients). Overall in-house mortality was 0.7% (n = 126). Age, malignancy, an accompanying resection, complications, and open surgery were associated with in-house mortality. In univariate analysis, surgery in high-volume hospitals was associated with lower mortality (OR: 0.47, P < .001). In a multivariate model, the tendency remained equal (OR: 0.59, P = .104). Regarding failure to rescue (death in case of complications), there was a trend toward lower mortality in high-volume hospitals. CONCLUSIONS The annual caseload of adrenal resections varies considerably among German hospitals. Our findings suggest that surgery in high-volume centers is advantageous for patient outcomes although fatal complications are rare.
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Affiliation(s)
- Konstantin L Uttinger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
- Department of Visceral, Transplant, Thoracic and Vascular Surgery at Leipzig University Hospital, 04103 Leipzig, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Johannes Diers
- Department of Internal Medicne, Marienkrankenhaus, 22087 Hamburg, Germany
| | - Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, 62196 Heidelberg, Germany
| | - Sebastian Pietryga
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Anne Hendricks
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Leon Schütze
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Nikolas Baumann
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Verena Wiegering
- Department of Pediatrics, Ped. Hematology, Oncology and Stem Cell Transplantation, at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Johann Lock
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Ulrich Dischinger
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Center, 97080 Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Center, 97080 Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery at Würzburg University Hospital, 97080 Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg Medical Center, 97080 Würzburg, Germany
- Department of Biochemistry and Molecular Biology, University of Würzburg, 97080 Würzburg, Germany
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13
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Wang C, Lindquist K, Krumholz H, Hsia RY. Trends in the likelihood of receiving percutaneous coronary intervention in a low-volume hospital and disparities by sociodemographic communities. PLoS One 2023; 18:e0279905. [PMID: 36652416 PMCID: PMC9847957 DOI: 10.1371/journal.pone.0279905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/17/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Over the past two decades, percutaneous coronary intervention (PCI) capacity has increased while coronary artery disease has decreased, potentially lowering per-hospital PCI volumes, which is associated with less favorable patient outcomes. Trends in the likelihood of receiving PCI in a low-volume center have not been well-documented, and it is unknown whether certain socioeconomic factors are associated with a greater risk of PCI in a low-volume facility. Our study aims to determine the likelihood of being treated in a low-volume PCI center over time and if this likelihood differs by sociodemographic factors. METHODS We conducted a retrospective cohort study of 374,066 hospitalized patients in California receiving PCI from January 1, 2010, to December 31, 2018. Our primary outcome was the likelihood of PCI discharges at a low-volume hospital (<150 PCI/year), and secondary outcomes included whether this likelihood varied across different sociodemographic groups and across low-volume hospitals stratified by high or low ZIP code median income. RESULTS The proportion of PCI discharges from low-volume hospitals increased from 5.4% to 11.0% over the study period. Patients of all sociodemographic groups considered were more likely to visit low-volume hospitals over time (P<0.001). Latinx patients were more likely to receive PCI at a low-volume hospital compared with non-Latinx White in 2010 with a 166% higher gap in 2018 (unadjusted proportions). The gaps in relative risk (RR) between Black, Latinx and Asian patients versus non-Latinx white increased over time, whereas the gap between private versus public/no insurance, and high versus low income decreased (interaction P<0.001). In low-income ZIP codes, patients with Medicaid were less likely to visit low-volume hospitals than patients with private insurance in 2010; however, this gap reversed and increased by 500% in 2018. Patients with low income were more likely to receive PCI at low-volume hospitals relative to patients with high income in all study years. CONCLUSIONS The likelihood of receiving PCI at low-volume hospitals has increased across all race/ethnicity, insurance, and income groups over time; however, this increase has not occurred evenly across all sociodemographic groups.
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Affiliation(s)
- Christina Wang
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Karla Lindquist
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Harlan Krumholz
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, United States of America
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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14
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Ratnayake B, Pendharkar SA, Connor S, Koea J, Sarfati D, Dennett E, Pandanaboyana S, Windsor JA. Patient volume and clinical outcome after pancreatic cancer resection: A contemporary systematic review and meta-analysis. Surgery 2022; 172:273-283. [PMID: 35034796 DOI: 10.1016/j.surg.2021.11.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/02/2021] [Accepted: 11/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatic cancer remains a highly fatal disease with a 5-year overall survival of less than 10%. In seeking to improve clinical outcomes, there is ongoing debate about the weight that should be given to patient volume in centralization models. The aim of this systematic review is to examine the relationship between patient volume and clinical outcome after pancreatic resection for cancer in the contemporary literature. METHODS The Google Scholar, PubMed, and Cochrane Library databases were systematically searched from February 2015 until June 2021 for articles reporting patient volume and outcomes after pancreatic cancer resection. RESULTS There were 46 eligible studies over a 6-year period comprising 526,344 patients. The median defined annual patient volume thresholds varied: low-volume 0 (range 0-9), medium-volume 9 (range 3-29), high-volume 19 (range 9-97), and very-high-volume 28 (range 17-60) patients. The latter 2 were associated with a significantly lower 30-day mortality (P < .001), 90-day mortality (P < .001), overall postoperative morbidity (P = .005), failure to rescue rate (P = .006), and R0 resection rate (P = .008) compared with very-low/low-volume hospitals. Centralization was associated with lower 30-day mortality in 3 out of 5 studies, while postoperative morbidity was similar in 4 out of 4 studies. Median survival was longer in patients traveling greater distance for pancreatic resection in 2 out of 3 studies. Median and 5-year survival did not differ between urban and rural settings. CONCLUSION The contemporary literature confirms a strong relationship between patient volume and clinical outcome for pancreatic cancer resection despite expected bias toward more complex surgery in high-volume centers. These outcomes include lower mortality, morbidity, failure-to-rescue, and positive resection margin rates.
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Affiliation(s)
- Bathiya Ratnayake
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand; HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand. https://twitter.com/ProfJohnWindsor
| | - Sayali A Pendharkar
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - Saxon Connor
- Department of Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Jonathan Koea
- Upper GI Unit, Northshore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Diana Sarfati
- Department of Public Health, University of Otago, Dunedin, New Zealand; Cancer Control Agency, Te Aho O Te Kahu, Ministry of Health, New Zealand
| | - Elizabeth Dennett
- Cancer Control Agency, Te Aho O Te Kahu, Ministry of Health, New Zealand
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK; Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand; HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand.
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15
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de Geus SW, Papageorge MV, Woods AP, Wilson S, Ng SC, Merrill A, Cassidy M, McAneny D, Tseng JF, Sachs TE. A Rising Tide Lifts All Boats: Impact of Combined Volume of Complex Cancer Operations on Surgical Outcomes in a Low-Volume Setting. J Am Coll Surg 2022; 234:981-988. [PMID: 35703786 PMCID: PMC9204842 DOI: 10.1097/xcs.0000000000000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Centralization for complex cancer surgery may not always be feasible owing to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts postoperative outcomes at hospitals that are low-volume for a specific high-risk cancer operation. STUDY DESIGN Patients who underwent pneumonectomy, esophagectomy, gastrectomy, hepatectomy, pancreatectomy, or proctectomy were identified from the National Cancer Database (2004-2017). For every operation, 3 separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low volume for the individual cancer operation but high volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation. RESULTS LVH was significantly (all p ≤ 0.01) predictive for 30-day mortality compared with HVH across all operations: pneumonectomy (9.5% vs 7.9%), esophagectomy (5.6% vs 3.2%), gastrectomy (6.8% vs 3.6%), hepatectomy (5.9% vs 3.2%), pancreatectomy (4.7% vs 2.3%), and proctectomy (2.4% vs 1.3%). Patients who underwent surgery at MVH and HVH demonstrated similar 30-day mortality: esophagectomy (3.2 vs 3.2%; p = 0.993), gastrectomy (3.2% vs 3.6%; p = 0.637), hepatectomy (3.8% vs 3.2%; p = 0.233), pancreatectomy (2.8% vs 2.3%; p = 0.293), and proctectomy (1.2% vs 1.3%; p = 0.843). Patients who underwent pneumonectomy at MVH demonstrated lower 30-day mortality compared with HVH (5.4% vs 7.9%; p = 0.045). CONCLUSION Patients who underwent complex operations at MVH had similar postoperative outcomes to those at HVH. MVH provide a model for the centralization of complex cancer surgery for patients who do not receive their care at HVH.
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Affiliation(s)
- Susanna Wl de Geus
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Marianna V Papageorge
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Alison P Woods
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Woods)
| | - Spencer Wilson
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Sing Chau Ng
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Andrea Merrill
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Michael Cassidy
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - David McAneny
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Jennifer F Tseng
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Teviah E Sachs
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
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16
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Mentias A, Keshvani N, Desai MY, Kumbhani DJ, Sarrazin MV, Gao Y, Kapadia S, Peterson ED, Mack M, Girotra S, Pandey A. Risk-Adjusted, 30-Day Home Time After Transcatheter Aortic Valve Replacement as a Hospital-Level Performance Metric. J Am Coll Cardiol 2022; 79:132-144. [PMID: 35027108 PMCID: PMC10535368 DOI: 10.1016/j.jacc.2021.10.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patient-centric measures of hospital performance for transcatheter aortic valve replacement (TAVR) are needed. OBJECTIVES This study evaluated 30-day, risk-adjusted home time as a hospital performance metric for patients who underwent TAVR. METHODS This study identified 160,792 Medicare beneficiaries who underwent elective TAVR from 2015 to 2019. Home time was calculated for each patient as the number of days alive and spent outside the hospital, skilled nursing facility (SNF), and long-term acute care facility for 30 days after the TAVR procedure date. Correlations between risk-adjusted, 30-day home time and other metrics (30-day, risk-adjusted readmission rate [RSRR], 30-day, risk-adjusted mortality rate [RSMR], and annual TAVR volume) were estimated using Pearson's correlation. Meaningful upward or downward reclassification (≥2 quartile ranks) in hospital performance based on quartiles of risk-adjusted, 30-day home time compared with quartiles of other measures were assessed. RESULTS Median risk-adjusted, 30-day home time was 27.4 days (interquartile range [IQR]: 26.3-28.5 days). The largest proportion of days lost from 30-day home time was hospital stay after TAVR and SNF stay. An inverse correlation was observed between hospital-level, risk-adjusted, 30-day home time and 30-day RSRR (r = -0.465; P < 0.001) and 30-day RSMR (r = -0.3996; P < 0.001). The use of the 30-day, risk-adjusted home time was associated with reclassification in hospital performance rank hospitals compared with other metrics (9.1% up-classified, 11.2% down-classified vs RSRR; 9.1% up-classified, 10.3% down-classified vs RSMR; and 20.1% up-classified, 19.3% down-classified vs annual TAVR volume). CONCLUSIONS Risk-adjusted, 30-day home time represents a novel patient-centered performance metric for TAVR hospitals that may provide a complimentary assessment to currently used metrics.
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Affiliation(s)
- Amgad Mentias
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Milind Y Desai
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Dharam J Kumbhani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mary Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA; Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Yubo Gao
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA; Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Samir Kapadia
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Eric D Peterson
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Michael Mack
- Division of Cardiology, Baylor Scott and White Health, Plano, Texas, USA
| | - Saket Girotra
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA; Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Uttinger KL, Riedmeier M, Reibetanz J, Meyer T, Germer CT, Fassnacht M, Wiegering A, Wiegering V. Adrenalectomies in children and adolescents in Germany - a diagnose related groups based analysis from 2009-2017. Front Endocrinol (Lausanne) 2022; 13:914449. [PMID: 35966067 PMCID: PMC9363694 DOI: 10.3389/fendo.2022.914449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/05/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Adrenalectomies are rare procedures especially in childhood. So far, no large cohort study on this topic has been published with data on to age distribution, operative procedures, hospital volume and operative outcome. METHODS This is a retrospective analysis of anonymized nationwide hospital billing data (DRG data, 2009-2017). All adrenal surgeries (defined by OPS codes) of patients between the age 0 and 21 years in Germany were included. RESULTS A total of 523 patient records were identified. The mean age was 8.6 ± 7.7 years and 262 patients were female (50.1%). The majority of patients were between 0 and 5 years old (52% overall), while 11.1% were between 6 and 11 and 38.8% older than 12 years. The most common diagnoses were malignant neoplasms of the adrenal gland (56%, mostly neuroblastoma) with the majority being younger than 5 years. Benign neoplasms in the adrenal gland (D350) account for 29% of all cases with the majority of affected patients being 12 years or older. 15% were not defined regarding tumor behavior. Overall complication rate was 27% with a clear higher complication rate in resection for malignant neoplasia of the adrenal gland. Bleeding occurrence and transfusions are the main complications, followed by the necessary of relaparotomy. There was an uneven patient distribution between hospital tertiles (low volume, medium and high volume tertile). While 164 patients received surgery in 85 different "low volume" hospitals (0.2 cases per hospital per year), 205 patients received surgery in 8 different "high volume" hospitals (2.8 cases per hospital per year; p<0.001). Patients in high volume centers were significant younger, had more extended resections and more often malignant neoplasia. In multivariable analysis younger age, extended resections and open procedures were independent predictors for occurrence of postoperative complications. CONCLUSION Overall complication rate of adrenalectomies in the pediatric population in Germany is low, demonstrating good therapeutic quality. Our analysis revealed a very uneven distribution of patient volume among hospitals.
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Affiliation(s)
- Konstantin L. Uttinger
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg, Germany
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, Leipzig University Hospital, Leipzig, Germany
| | - Maria Riedmeier
- Department of Pediatrics, Ped. Hematology, Oncology and Stem Cell Transplantation, Würzburg University Hospital, Würzburg, Germany
| | - Joachim Reibetanz
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg, Germany
| | - Thomas Meyer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg, Germany
| | - Christoph Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg, Germany
- Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
| | - Martin Fassnacht
- Department of Endocrine Medicine, Würzburg University Hospital, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, Würzburg University Hospital, Würzburg, Germany
- Comprehensive Cancer Centre Mainfranken, University of Würzburg Medical Centre, Würzburg, Germany
- Department of Biochemistry and Molecular Biology , University of Würzburg, Würzburg, Germany
| | - Verena Wiegering
- Department of Pediatrics, Ped. Hematology, Oncology and Stem Cell Transplantation, Würzburg University Hospital, Würzburg, Germany
- *Correspondence: Verena Wiegering,
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18
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Pollock C, Soder S, Ezer N, Ferraro P, Lafontaine E, Martin J, Nasir B, Liberman M. Impact of Volume on Mortality and Hospital Stay After Lung Cancer Surgery in a Single-Payer System. Ann Thorac Surg 2021; 114:1834-1841. [PMID: 34736929 DOI: 10.1016/j.athoracsur.2021.09.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 09/12/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is a literature gap for hospitals in single-payer healthcare systems quantifying the influence of hospital volume on outcomes following major lung cancer resection. We aimed to determine the effect of hospital volume on mortality, and length of stay (LOS). METHODS A retrospective cohort study using administrative, population-based data from a single-payer universal healthcare system was performed in adults with non-small cell lung cancer who underwent lobectomy or pneumonectomy between 2008 and 2017. Hospital volume was defined as the average annual number of major lung resections performed at each institution. Length of stay and post-operative mortality was compared using multivariable linear and non-linear regression between hospital volume categories and continuously. Adjusted association between hospital volume and post-operative mortality was determined by multivariable logistic regression. RESULTS 10,831 lung resections were performed: 1237 pneumonectomies; 9594 lobectomies. Patients undergoing lobectomy at high-volume hospitals had shorter median LOS (6 vs 8 days, p = 0.001) compared with low-volume hospitals. After adjusting for confounders, surgery at a high-volume center was significantly associated with shorter LOS after lobectomy and overall resections (p=<0.001), but not after pneumonectomy (p=0.787). Surgery at a high-volume center was positively associated with improved 90-day mortality in lobectomy and overall procedures (OR 0.607; [0.399-0.925]; and 0.632 [0.441-0.904], respectively). Volume was not a predictor of 90-day mortality after pneumonectomy (OR 0.533 [0.257-1.104], p=0.090). CONCLUSIONS Surgery at a high-volume center was positively correlated with improved 90-day survival and shorter hospital LOS. The results support regionalized lung cancer care in a single-payer healthcare system.
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Affiliation(s)
- Clare Pollock
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Stephan Soder
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Nicole Ezer
- Division of Respirology, Department of Medicine, McGill University Health Center, Center for Outcomes Research and Evaluation, Research Institute, Montreal, Quebec, Canada
| | - Pasquale Ferraro
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Edwin Lafontaine
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Jocelyne Martin
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Basil Nasir
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Moishe Liberman
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada.
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19
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Gandjian M, Williamson C, Sanaiha Y, Hadaya J, Tran Z, Kim ST, Revels S, Benharash P. Continued Relevance of Minimum Volume Standards for Elective Esophagectomy: A National Perspective. Ann Thorac Surg 2021; 114:426-433. [PMID: 34437854 DOI: 10.1016/j.athoracsur.2021.07.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/11/2021] [Accepted: 07/19/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite minimum volume recommendations, the majority of esophagectomies are performed at centers with fewer than 20 annual cases. The present study examined the impact of institutional esophagectomy volume on in-hospital mortality, complications and resource use following esophageal resection. METHODS The 2010-2018 Nationwide Readmissions Database was queried to identify all adult patients undergoing esophagectomy for malignancy. Hospitals were categorized as high-volume (HVH) if performing at least 20 esophagectomies annually, and low-volume (LVH) if fewer. Multivariable models were developed to study the impact of volume on outcomes of interest which included in-hospital mortality, complications, duration of hospitalization (LOS), inflation adjusted costs, readmissions, and non-home discharge. RESULTS Of an estimated 23,176 hospitalizations, 45.6% occurred at HVH. Incidence of esophagectomy increased significantly along with median institutional case load over the study period, while the proportion on hospitals considered HVH remained steady at approximately 7.4%. After adjusting for relevant patient and hospital characteristics, HVH was associated with decreased mortality (AOR=0.65), LOS (β=-1.83 days), pneumonia (AOR=0.69), prolonged ventilation (AOR=0.50), sepsis (AOR=0.80), and tracheostomy (AOR=0.66), but increased odds of non-home discharge (AOR=1.56, all P<0.01), with LVH as reference. CONCLUSIONS Many clinical outcomes of esophagectomy are improved with no increment in costs when performed at centers with an annual caseload of at least 20, as recommended by patient advocacy organizations. These findings suggest that centralization of esophageal resections to high-volume centers may be congruent with value-based care models.
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Affiliation(s)
- Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Samuel T Kim
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Sha'shonda Revels
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
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20
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Luijten JCHBM, Nieuwenhuijzen GAP, Sosef MN, de Hingh IHJT, Rosman C, Ruurda JP, van Duijvendijk P, Heisterkamp J, de Steur WO, van Laarhoven HWM, Besselink MG, Groot Koerkamp B, van Santvoort HC, Lemmens VEP, Vissers PAJ. Impact of nationwide centralization of oesophageal, gastric, and pancreatic surgery on travel distance and experienced burden in the Netherlands. Eur J Surg Oncol 2021; 48:348-355. [PMID: 34366174 DOI: 10.1016/j.ejso.2021.07.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study aims to assess the impact of nationwide centralization of surgery on travel distance and travel burden among patients with oesophageal, gastric, and pancreatic cancer according to age in the Netherlands. As centralization of care increases to improve postoperative outcomes, travel distance and experienced burden might increase. MATERIALS AND METHODS All patients who underwent surgery between 2006 and 2017 for oesophageal, gastric and pancreatic cancer in the Netherlands were included. Travel distance between patient's home address and hospital of surgery in kilometres was calculated. Questionnaires were used to assess experienced travel burden in a subpopulation (n = 239). Multivariable ordinal logistic regression models were constructed to identify predictors for longer travel distance. RESULTS Over 23,838 patients were included, in whom median travel distance for surgical care increased for oesophageal cancer (n = 9217) from 18 to 28 km, for gastric cancer (n = 6743) from 9 to 26 km, and for pancreatic cancer (n = 7878) from 18 to 25 km (all p < 0.0001). Multivariable analyses showed an increase in travel distance for all cancer types over time. In general, patients experienced a physical and social burden, and higher financial costs, due to traveling extra kilometres. Patients aged >70 years travelled less often independently (56% versus 68%), as compared to patients aged ≤70 years. CONCLUSION With nationwide centralization, travel distance increased for patients undergoing oesophageal, gastric, and pancreatic cancer surgery. Younger patients travelled longer distances and experienced a lower travel burden, as compared to elderly patients. Nevertheless, on a global scale, travel distances in the Netherlands remain limited.
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Affiliation(s)
- J C H B M Luijten
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | | | - M N Sosef
- Department of Surgery, Zuyderland Hospital, Heerlen, the Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - C Rosman
- Department of Surgery, Radboudumc, Nijmegen, the Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - J Heisterkamp
- Department of Surgery, Elisabeth Tweesteden Hospital, Tilburg, Embraze Regional Cancer Network, the Netherlands
| | - W O de Steur
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - H W M van Laarhoven
- Department of Medical Oncology, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - H C van Santvoort
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Surgery, Sint. Antonius, Nieuwegein, the Netherlands
| | - V E P Lemmens
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; Department of Public Health, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - P A J Vissers
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands.
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21
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Fong ZV, Hashimoto DA, Jin G, Haynes AB, Perez N, Qadan M, Ferrone CR, Castillo CFD, Warshaw AL, Lillemoe KD, Traeger LN, Chang DC. Simulated Volume-Based Regionalization of Complex Procedures: Impact on Spatial Access to Care. Ann Surg 2021; 274:312-318. [PMID: 31449139 PMCID: PMC7032992 DOI: 10.1097/sla.0000000000003574] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This study simulates the regionalization of pancreatectomies to assess its impact on spatial access in terms of patient driving times. BACKGROUND Although policies to regionalize complex procedures to high-volume centers may improve outcomes, the impact on patient access is unknown. METHODS Patients who underwent pancreatectomies from 2005 to 2014 were identified from California's statewide database. Round-trip driving times between patients' home ZIP code and hospital addresses were calculated via Google Maps. Regionalization was simulated by eliminating hospitals performing <20 pancreatectomies/yr, and reassigning patients to the next closest hospital that satisfied the volume threshold. Sensitivity analyses were performed for New York and Medicare patients to assess for influence of geography and insurance coverage, respectively. RESULTS Of 13,317 pancreatectomies, 6335 (47.6%) were performed by hospitals with <20 cases/yr. Patients traveled a median of 49.8 minutes [interquartile range (IQR) 30.8-96.2] per round-trip. A volume-restriction policy would increase median round-trip driving time by 24.1 minutes (IQR 4.5-53.5). Population in-hospital mortality rates were estimated to decrease from 6.7% to 2.8% (P < 0.001). Affected patients were more likely to be racial minorities (44.6% vs 36.5% of unaffected group, P < 0.001) and covered by Medicaid or uninsured (16.3% vs 9.8% of unaffected group, P < 0.001). Sensitivity analyses revealed a 17.8 minutes increment for patients in NY (IQR 0.8-47.4), and 27.0 minutes increment for Medicare patients (IQR 6.2-57.1). CONCLUSIONS A policy that limits access to low-volume pancreatectomy hospitals will increase round-trip driving time by 24 minutes, but up to 54 minutes for 25% of patients. Population mortality rates may improve by 1.5%.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Ginger Jin
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Alex B Haynes
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Numa Perez
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Lara N Traeger
- Behavioral Medicine Service, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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22
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Park HSM. Leveraging Surgical Case Volume in Improving Cancer Care Outcomes: Where Do We Go From Here? J Natl Compr Canc Netw 2021; 19:577-579. [PMID: 34030129 DOI: 10.6004/jnccn.2021.7045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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23
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Jogerst KM, Chang YHH, Etzioni DA, Mathur AK, Habermann EB, Wasif N. Identifying the Optimal case-volume threshold for pancreatectomy in contemporary practice. Am J Surg 2021; 223:318-324. [PMID: 33775411 DOI: 10.1016/j.amjsurg.2021.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/15/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND The volume-mortality association led to regionalization recommendations for pancreatic surgery. Mortality following pancreatectomy has declined, but case-volume thresholds remain unchanged. METHODS Patients undergoing pancreatectomy from 2004 to 2013 were identified in the National Cancer Database (NCDB). Hospitals were divided into low (LV), medium (MV), and high-volume (HV) strata using 30-day mortality quartiles and logistic regression with cubic splines. Adjusted absolute difference and odds of 30-day mortality between strata were calculated. RESULTS Annual volumes for LV, MV, and HV were <4, 4-18 and > 18 cases using quartiles and <6, 6-18 and > 18 using cubic splines. Absolute 30-day mortality trended downwards, with differential improvements for MV and LV. Benchmark 30-day mortality for hospitals with >18 cases was 2.8%. For this benchmark, the case-volume threshold decreased from 31 in 2004 to 6 in 2013. CONCLUSION Differential improvement in 30-day mortality at LV and MV hospitals led to similar 30-day mortality odds at MV and HV hospitals by 2013.
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Affiliation(s)
- Kristen M Jogerst
- Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Yu-Hui H Chang
- Department of Biostatistics, Mayo Clinic Arizona, 13400 East Shea Blvd, Scottsdale, AZ, 85259, USA; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First St. SW, Rochester, MN, 55905, USA.
| | - David A Etzioni
- Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First St. SW, Rochester, MN, 55905, USA.
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First St. SW, Rochester, MN, 55905, USA.
| | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First St. SW, Rochester, MN, 55905, USA.
| | - Nabil Wasif
- Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA.
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24
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Dhruva SS, Ross JS, Mortazavi BJ, Hurley NC, Krumholz HM, Curtis JP, Berkowitz AP, Masoudi FA, Messenger JC, Parzynski CS, Ngufor CG, Girotra S, Amin AP, Shah ND, Desai NR. Use of Mechanical Circulatory Support Devices Among Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock. JAMA Netw Open 2021; 4:e2037748. [PMID: 33616664 PMCID: PMC7900859 DOI: 10.1001/jamanetworkopen.2020.37748] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Mechanical circulatory support (MCS) devices, including intravascular microaxial left ventricular assist devices (LVADs) and intra-aortic balloon pumps (IABPs), are used in patients who undergo percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated by cardiogenic shock despite limited evidence of their clinical benefit. OBJECTIVE To examine trends in the use of MCS devices among patients who underwent PCI for AMI with cardiogenic shock, hospital-level use variation, and factors associated with use. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the CathPCI and Chest Pain-MI Registries of the American College of Cardiology National Cardiovascular Data Registry. Patients who underwent PCI for AMI complicated by cardiogenic shock between October 1, 2015, and December 31, 2017, were identified from both registries. Data were analyzed from October 2018 to August 2020. EXPOSURES Therapies to provide hemodynamic support were categorized as intravascular microaxial LVAD, IABP, TandemHeart, extracorporeal membrane oxygenation, LVAD, other devices, combined IABP and intravascular microaxial LVAD, combined IABP and other device (defined as TandemHeart, extracorporeal membrane oxygenation, LVAD, or another MCS device), or medical therapy only. MAIN OUTCOMES AND MEASURES Use of MCS devices overall and specific MCS devices, including intravascular microaxial LVAD, at both patient and hospital levels and variables associated with use. RESULTS Among the 28 304 patients included in the study, the mean (SD) age was 65.4 (12.6) years and 18 968 were men (67.0%). The overall MCS device use was constant from the fourth quarter of 2015 to the fourth quarter of 2017, although use of intravascular microaxial LVADs significantly increased (from 4.1% to 9.8%; P < .001), whereas use of IABPs significantly decreased (from 34.8% to 30.0%; P < .001). A significant hospital-level variation in MCS device use was found. The median (interquartile range [IQR]) proportion of patients who received MCS devices was 42% (30%-54%), and the median proportion of patients who received intravascular microaxial LVADs was 1% (0%-10%). In multivariable analyses, cardiac arrest at first medical contact or during hospitalization (odds ratio [OR], 1.82; 95% CI, 1.58-2.09) and severe left main and/or proximal left anterior descending coronary artery stenosis (OR, 1.36; 95% CI, 1.20-1.54) were patient characteristics that were associated with higher odds of receiving intravascular microaxial LVADs only compared with IABPs only. CONCLUSIONS AND RELEVANCE This study found that, among patients who underwent PCI for AMI complicated by cardiogenic shock, overall use of MCS devices was constant, and a 2.5-fold increase in intravascular microaxial LVAD use was found along with a corresponding decrease in IABP use and a significant hospital-level variation in MCS device use. These trends were observed despite limited clinical trial evidence of improved outcomes associated with device use.
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Affiliation(s)
- Sanket S. Dhruva
- University of California, San Francisco School of Medicine, San Francisco
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Bobak J. Mortazavi
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Computer Science and Engineering, Texas A&M University, College Station
- Center for Remote Health Technologies and Systems, Texas A&M University, College Station
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nathan C. Hurley
- Department of Computer Science and Engineering, Texas A&M University, College Station
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alyssa P. Berkowitz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Frederick A. Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - John C. Messenger
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Craig S. Parzynski
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Che G. Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Digital Health Sciences, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Saket Girotra
- Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
| | - Amit P. Amin
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
| | - Nihar R. Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Kaneko H, Itoh H, Yotsumoto H, Kiriyama H, Kamon T, Fujiu K, Morita K, Michihata N, Jo T, Takeda N, Morita H, Yasunaga H, Komuro I. Impact of hospital volume on clinical outcomes of hospitalized heart failure patients: analysis of a nationwide database including 447,818 patients with heart failure. BMC Cardiovasc Disord 2021; 21:49. [PMID: 33494701 PMCID: PMC7836495 DOI: 10.1186/s12872-021-01863-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hospital volume is known to be associated with outcomes of patients requiring complicated medical care. However, the relationship between hospital volume and prognosis of hospitalized patients with heart failure (HF) remains not fully understood. We aimed to clarify the impact of hospital volume on clinical outcomes of hospitalized HF patients using a nationwide inpatient database. METHODS AND RESULTS We studied 447,818 hospitalized HF patients who were admitted from January 2010 and discharged until March 2018 included in the Japanese Diagnosis Procedure Combination database. According to the number of patients, patients were categorized into three groups; those treated in low-, medium-, and high-volume centers. The median age was 81 years and 238,192 patients (53%) were men. Patients who had New York Heart Association class IV symptom and requiring inotropic agent within two days were more common in high volume centers than in low volume centers. Respiratory support, hemodialysis, and intra-aortic balloon pumping were more frequently performed in high volume centers. As a result, length of hospital stay was shorter, and in-hospital mortality was lower in high volume centers. Lower in-hospital mortality was associated with higher hospital volume. Multivariable logistic regression analysis fitted with generalized estimating equation indicated that medium-volume group (Odds ratio 0.91, p = 0.035) and high-volume group (Odds ratio 0.86, p = 0.004) had lower in-hospital mortality compared to the low-volume group. Subgroup analysis showed that this association between hospital volume and in-hospital mortality among overall population was seen in all subgroups according to age, presence of chronic renal failure, and New York Heart Association class. CONCLUSION Hospital volume was independently associated with ameliorated clinical outcomes of hospitalized patients with HF.
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Affiliation(s)
- Hidehiro Kaneko
- The Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
- The Department of Advanced Cardiology, The University of Tokyo, Tokyo, Japan.
| | - Hidetaka Itoh
- The Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Haruki Yotsumoto
- The Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroyuki Kiriyama
- The Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tatsuya Kamon
- The Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Katsuhito Fujiu
- The Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
- The Department of Advanced Cardiology, The University of Tokyo, Tokyo, Japan
| | - Kojiro Morita
- The Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- The Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Nobuaki Michihata
- The Department of Health Services Research, The University of Tokyo, Tokyo, Japan
| | - Taisuke Jo
- The Department of Health Services Research, The University of Tokyo, Tokyo, Japan
| | - Norifumi Takeda
- The Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroyuki Morita
- The Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hideo Yasunaga
- The Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- The Department of Cardiovascular Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Bansal A, Jain V, Kumar A, Shekhar S, Reed GW, Krishnaswamy A, Harb SC, Kalra A, Puri R, Kapadia SR. Impact of Hospital Procedural Volume on Outcomes Following Balloon Aortic Valvuloplasty. Am J Cardiol 2021; 138:120-122. [PMID: 33045201 DOI: 10.1016/j.amjcard.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/05/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Agam Bansal
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vardhmaan Jain
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ashish Kumar
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shashank Shekhar
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Grant W Reed
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amar Krishnaswamy
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Serge C Harb
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ankur Kalra
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rishi Puri
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Harrison S, Sun T, Kamel MK, Cleary C, Stiles BM, Altorki NK, Sedrakyan A. Do individual surgeon volumes affect outcomes in thoracic surgery?†. Eur J Cardiothorac Surg 2020; 56:770-777. [PMID: 30927422 DOI: 10.1093/ejcts/ezz095] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/20/2019] [Accepted: 02/26/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Minimum volume standards for thoracic surgical procedures have been advocated to improve outcomes. However, such standards are controversial within the thoracic surgery literature, and the methodology to determine cut points between high- and low-volume hospitals has been criticized. Furthermore, while multiple studies have examined hospital volume and its relationship with outcomes, there have been very few attempts to study this issue from the perspective of the individual thoracic surgeon. The aim of this study was to determine if surgeon volume is associated with differences in outcomes using a large state-wide database. METHODS The study utilized the New York State Department of Health Statewide Planning and Research Cooperative (SPARCS) data for analysis. Patients who underwent major lung resections including sublobar resection, lobectomy and pneumonectomy from 1995 to 2014 were included and were categorized into 3 subgroups based on the extent of resection. Patient characteristics included age, gender, race, insurance and comorbidities. Surgeon information was obtained by using a unique identifier. Average annual surgical volumes of sublobar resection, lobectomy and pneumonectomy were calculated separately and grouped into 3 categories based on the tertiles. Demographic data and comorbidities were compared between the various volume groups to analyse the resulting complications. Primary outcomes were in-hospital mortality and 30-day readmission. RESULTS There were a total of 99 576 major lung resections performed between 1995 and 2014 in the SPARCS database. Among these, the majority were wedge or segmental resections (n = 54 953, 55.2%) followed by lobectomy (n = 40 421, 40.6%) and pneumonectomy (n = 4202, 4.2%). In-hospital mortality was significantly greater for low-volume surgeons compared to high-volume surgeons for all resection groups. Additionally, low-volume surgeons had higher 30-day readmission rates for patients undergoing lobectomy and pneumonectomy. However, low-volume surgeons as a group were more likely to operate on black patients and patients with Medicaid, and black race was an independent predictor of mortality across all resection groups. The vast majority of surgeons performing lobectomy (89.5%) were in the low-volume group. CONCLUSIONS Low-volume surgeons had higher rates of in-hospital mortality compared to their high-volume counterparts. However, the vast majority of surgeons performing lobectomy (89.5%) were in the low-volume group, and low-volume surgeons operated on higher percentages of black patients. These findings suggest that minimal volume standards would significantly impact the current delivery of thoracic surgery in the US.
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Affiliation(s)
- Sebron Harrison
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
- Department of Cardiothoracic Surgery, New York Presbyterian-Brooklyn Methodist Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Tiany Sun
- Department of Health Policy and Research, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Mohamed K Kamel
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Corbin Cleary
- Department of Cardiothoracic Surgery, New York Presbyterian-Brooklyn Methodist Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Brendon M Stiles
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Nasser K Altorki
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Art Sedrakyan
- Department of Health Policy and Research, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
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Becher RD, Sukumar N, DeWane MP, Gill TM, Maung AA, Schuster KM, Stolar MJ, Davis KA. Regionalization of emergency general surgery operations: A simulation study. J Trauma Acute Care Surg 2020; 88:366-371. [PMID: 31804419 PMCID: PMC7472889 DOI: 10.1097/ta.0000000000002543] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND It has been theorized that a tiered, regionalized system of care for emergency general surgery (EGS) patients-akin to regional trauma systems-would translate into significant survival benefits. Yet data to support this supposition are lacking. The aim of this study was to determine the potential number of lives that could be saved by regionalizing EGS care to higher-volume, lower-mortality EGS institutions. METHODS Adult patients who underwent one of 10 common EGS operations were identified in the California Inpatient Database (2010-2011). An algorithm was constructed that "closed" lower-volume, higher-mortality hospitals and referred those patients to higher-volume, lower-mortality institutions ("closure" based on hospital EGS volume-threshold that optimized to 95% probability of survival). Primary outcome was the number of lives saved. Fifty thousand regionalization simulations were completed (5,000 for each operation) employing a bootstrap resampling method to proportionally redistribute patients. Estimates of expected deaths at the higher-volume hospitals were recalculated for every bootstrapped sample. RESULTS Of the 165,123 patients who underwent EGS operations over the 2-year period, 17,655 (10.7%) were regionalized to a higher-volume hospital. On average, 128 (48.8%) of lower-volume hospitals were "closed," ranging from 68 (22.0%) hospital closures for appendectomy to 205 (73.2%) for small bowel resection. The simulations demonstrated that EGS regionalization would prevent 9.7% of risk-adjusted EGS deaths, significantly saving lives for every EGS operation: from 30.8 (6.5%) deaths prevented for appendectomy to 122.8 (7.9%) for colectomy. Regionalization prevented 4.6 deaths per 100 EGS patient-transfers, ranging from 1.3 for appendectomy to 8.0 for umbilical hernia repair. CONCLUSION This simulation study provides important new insight into the concept of EGS regionalization, suggesting that 1 in 10 risk-adjusted deaths could be prevented by a structured system of EGS care. Future work should expand upon these findings using more complex discrete-event simulation models. LEVEL OF EVIDENCE Therapeutic/Care Management, level IV.
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Affiliation(s)
- Robert D Becher
- From the Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (R.D.B., M.P.D., A.A.M., K.M.S., K.A.D.), Yale School of Medicine; Yale Center for Analytical Sciences (N.S., M.J.S.), Yale School of Public Health; and Section of Geriatrics, Department of Internal Medicine (T.M.G.), Yale School of Medicine, New Haven, Connecticut
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Kowalewski M, Raffa GM, Zieliński K, Alanazi M, Gilbers M, Heuts S, Natour E, Bidar E, Schreurs R, Delnoij T, Driessen R, Sels JW, van de Poll M, Roekaerts P, Meani P, Maessen J, Suwalski P, Lorusso R. The impact of Centre's heart transplant status and volume on in-hospital outcomes following extracorporeal membrane oxygenation for refractory post-cardiotomy cardiogenic shock: a meta-analysis. BMC Cardiovasc Disord 2020; 20:10. [PMID: 31918663 PMCID: PMC6950870 DOI: 10.1186/s12872-019-01317-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 12/23/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Postcardiotomy cardiogenic shock (PCS) that is refractory to inotropic support remains a major concern in cardiac surgery and is almost universally fatal unless treated with mechanical support. While reported mortality rates on ECMO vary from center to center, aim of the current report is assess if the outcomes differ between centres according to volume and heart transplantation status. METHODS A systematic search was performed according to PRISMA statement using PubMed/Medline databases between 2010 and 2018. Relevant articles were scrutinized and included in the meta-analysis only if reporting in-hospital/30-day mortality and heart transplantation status of the centre. Paediatric and congenital heart surgery-related studies along with those conducted in the setting of veno-venous ECMO for respiratory distress syndrome were excluded. Differences were assessed by means of subgroup meta-analysis and meta-regression. RESULTS Fifty-four studies enrolling N = 4421 ECMO patients were included. Of those, 6 series were performed in non-HTx centres (204 pts.;4.6%). Overall 30-day survival (95% Confidence Intervals) was 35.3% (32.5-38.2%) and did not statistically differ between non-HTx: 33.3% (26.8-40.4%) and HTx centres: 35.7% (32.7-38.8%); Pinteraction = 0.531. There was no impact of centre volume on survival as well: ßcoef = 0.0006; P = 0.833. No statistical differences were seen between HTx and non-HTx with respect to ECMO duration, limb complications, reoperations for bleeding, kidney injury and sepsis. There were however significantly less neurological complications in the HTx as compared to non-HTx centres: 11.9% vs 19.5% respectively; P = 0.009; an inverse relationship was seen for neurologic complications in centres performing more ECMOs annually ßcoef = - 0.0066; P = 0.031. Weaning rates and bridging to HTx and/or VADs were higher in HTx facilities. CONCLUSIONS There was no apparent difference in survival after ECMO implantation for refractory PCS according to centre's ECMO volume and transplantation status. Potentially different risk profiles of patients in these centres must be taken account for before definite conclusions are drawn.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland.
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands.
- Cardiothoracic Research Centre, Innovative Medical Forum, Bydgoszcz, Poland.
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, ISMETT-IRCCS, Palermo, Italy
| | | | - Musab Alanazi
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Martijn Gilbers
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Sam Heuts
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Ehsan Natour
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Elham Bidar
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Rick Schreurs
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Thijs Delnoij
- Cardiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Rob Driessen
- Cardiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jan-Willem Sels
- Cardiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Marcel van de Poll
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Paul Roekaerts
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Paolo Meani
- Cardiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jos Maessen
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
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Hsu RCJ, Barclay M, Loughran MA, Lyratzopoulos G, Gnanapragasam VJ, Armitage JN. Impact of hospital nephrectomy volume on intermediate- to long-term survival in renal cell carcinoma. BJU Int 2020; 125:56-63. [PMID: 31206987 PMCID: PMC6973244 DOI: 10.1111/bju.14848] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the relationship between hospital volume and intermediate- and long-term patient survival for patients undergoing nephrectomy for renal cell carcinoma (RCC). PATIENTS AND METHODS Adult patients with RCC treated with nephrectomy between 2000 and 2010 were identified from the English Hospital Episode Statistics database and National Cancer Data Repository. Patients with nodal or metastatic disease were excluded. Hospitals were categorised into low- (LV; <20 cases/year), medium- (20-39 cases/year) and high-volume (HV; ≥40 cases/year), based on annual cases of RCC nephrectomy. Multivariable Cox regression analyses were used to calculate hazard ratios (HRs) for all-cause mortality by hospital volume, adjusting for patient, tumour and surgical characteristics. We assessed conditional survival over three follow-up periods: short (30 days to 1 year), intermediate (1-3 years) and long (3-5 years). We additionally explored whether associations between volume and outcomes varied by tumour stage. RESULTS A total of 12 912 patients were included. Patients in HV hospitals had a 34% reduction in mortality risks up to 1 year compared to those in LV hospitals (HR 0.66, 95% confidence interval 0.53-0.83; P < 0.01). Assuming causality, treatment in HV hospitals was associated with one fewer death in every 71 patients treated. Benefit of nephrectomy centralisation did not change with higher T stage (P = 0.17). No significant association between hospital volume and survival was observed beyond the first year. CONCLUSIONS Nephrectomy for RCC in HV hospitals was associated with improved survival for up to 1 year after treatment. Our results contribute new insights regarding the value of nephrectomy centralisation.
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Affiliation(s)
- Ray C. J. Hsu
- Academic Urology GroupDepartment of SurgeryCambridge Biomedical CampusUniversity of CambridgeCambridgeUK
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Matthew Barclay
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
| | - Molly A. Loughran
- Transforming Cancer Services TeamNational Health ServiceLondonUK
- National Cancer Registration and Analysis ServicePublic Health EnglandLondonUK
| | - Georgios Lyratzopoulos
- The Healthcare Improvement Studies (THIS) InstituteUniversity of CambridgeCambridgeUK
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) GroupDepartment of Behavioural Science and HealthUniversity College LondonLondonUK
| | - Vincent J. Gnanapragasam
- Academic Urology GroupDepartment of SurgeryCambridge Biomedical CampusUniversity of CambridgeCambridgeUK
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - James N. Armitage
- Department of UrologyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
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Marano A, Sodano B, Vitiello C, Martini AM, Baldassarre F, Siciliano A, Iannaci G. Sentinel lymph node biopsy with intraoperative touch imprint cytology (TIC) in breast cancer: experience of a mild-volume center. G Chir 2020; 41:94-98. [PMID: 32038018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Although considered the gold standard in treatment of EBC, sentinel node biopsy still remains a debated issue. What to do in case of positive sentinel node and the need of intraoperative histological examination are the most topics under discussion. In this study we have retrospectively evaluate our case series of 359 sentinel node biopsy in the managing of breast cancer from January 2011 to December 2018, focusing on the TIC technique for performing intraoperative examination. It results in 12,8% "FALSE NEGATIVE" rate, in which only 4,2% in macrometastases, with an overall sensitivity of 68,4% (macrometastases: 86%; micrometastases: 11%), overall specificity of 98,7% and an overall accuracy of 89,7%. The intraoperative examination of SLN allows to reduce delayed surgery procedures and greater therapeutic safety in case of mastectomy. The TIC method can be considered valid, simple and rapid in identifying macrometastases, also allowing to avoid under-staging. The low sensitivity for micrometastases is not a limit, considering that recent evidence has drastically reduced the indications for ALND in these cases. Further ongoing trials and the possible validation of NOMOGRAMMS and SCORE are necessary to identify low risk cases in which to definitively omit the ALND and/or even the SLNB itself.
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Mufarrih SH, Ghani MOA, Martins RS, Qureshi NQ, Mufarrih SA, Malik AT, Noordin S. Effect of hospital volume on outcomes of total hip arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2019; 14:468. [PMID: 31881918 PMCID: PMC6935169 DOI: 10.1186/s13018-019-1531-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/19/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND A shift in the healthcare system towards the centralization of common yet costly surgeries, such as total hip arthroplasty (THA), to high-volume centers of excellence, is an attempt to control the economic burden while simultaneously enhancing patient outcomes. The "volume-outcome" relationship suggests that hospitals performing more treatment of a given type exhibit better outcomes than hospitals performing fewer. This theory has surfaced as an important factor in determining patient outcomes following THA. We performed a systematic review with meta-analyses to review the available evidence on the impact of hospital volume on outcomes of THA. MATERIALS AND METHODS We conducted a review of PubMed (MEDLINE), OVID MEDLINE, Google Scholar, and Cochrane library of studies reporting the impact of hospital volume on THA. The studies were evaluated as per the inclusion and exclusion criteria. A total of 44 studies were included in the review. We accessed pooled data using random-effect meta-analysis. RESULTS Results of the meta-analyses show that low-volume hospitals were associated with a higher rate of surgical site infections (1.25 [1.01, 1.55]), longer length of stay (RR, 0.83[0.48-1.18]), increased cost of surgery (3.44, [2.57, 4.30]), 90-day complications (RR, 1.80[1.50-2.17]) and 30-day (RR, 2.33[1.27-4.28]), 90-day (RR, 1.26[1.05-1.51]), and 1-year mortality rates (RR, 2.26[1.32-3.88]) when compared to high-volume hospitals following THA. Except for two prospective studies, all were retrospective observational studies. CONCLUSIONS These findings demonstrate superior outcomes following THA in high-volume hospitals. Together with the reduced cost of the surgical procedure, fewer complications may contribute to saving considerable opportunity costs annually. However, a need to define objective volume-thresholds with stronger evidence would be required. TRIAL REGISTRATION PROSPERO CRD42019123776.
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Affiliation(s)
- Syed Hamza Mufarrih
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan.
| | | | | | | | | | - Azeem Tariq Malik
- Department of Orthopedics, Ohio State University, Columbus, Ohio, USA
| | - Shahryar Noordin
- Department of Orthopedic Surgery, Aga Khan University, Karachi, Pakistan
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Nally DM, Sørensen J, Valentelyte G, Hammond L, McNamara D, Kavanagh DO, Mealy K. Volume and in-hospital mortality after emergency abdominal surgery: a national population-based study. BMJ Open 2019; 9:e032183. [PMID: 31678953 PMCID: PMC6830600 DOI: 10.1136/bmjopen-2019-032183] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES: Emergency abdominal surgery (EAS) refers to high-risk intra-abdominal surgical procedures undertaken for acute gastrointestinal pathology. The relationship between hospital or surgeon volume and mortality of patients undergoing EAS is poorly understood. This study examined this relationship at the national level. DESIGN: This is a national population-based study using a full administrative inpatient dataset (National Quality Assurance Improvement System) from publicly funded hospitals in Ireland. SETTING: 24 public hospitals providing EAS services. PARTICIPANTS AND INTERVENTIONS: Patients undergoing EAS as identified by primary procedure codes during the period 2014-2018. MAIN OUTCOME MEASURES: The main outcome measure was adjusted in-hospital mortality following EAS in publicly funded Irish hospitals. Mortality rates were adjusted for sex, age, admission source, Charlson Comorbidity Index, procedure complexity, organ system and primary diagnosis. Differences in overall, 7-day and 30-day in-hospital mortality for hospitals with low (<250), medium (250-449) and high (450+) volume and surgical teams with low (<30), medium (30-59) and high (60+) volume during the study period were also estimated. RESULTS: The study included 10 344 EAS episodes. 798 in-hospital deaths occurred, giving an overall in-hospital mortality rate of 77 per 1000 episodes. There was no statistically significant difference in adjusted mortality rate between low and high volume hospitals. Low volume surgical teams had a higher adjusted mortality rate (85.4 deaths/1000 episodes) compared with high volume teams (54.7 deaths/1000 episodes), a difference that persisted among low volume surgeons practising in high volume hospitals. CONCLUSION: Patients undergoing EAS managed by high volume surgeons have better survival outcomes. These findings contribute to the ongoing discussion regarding configuration of emergency surgery services and emphasise the need for effective clinical governance regarding observed variation in outcomes within and between institutions.
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Affiliation(s)
- Deirdre M Nally
- Department of Surgical Affairs, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Jan Sørensen
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Gintare Valentelyte
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Laura Hammond
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
- National Clinical Programme in Surgery (NCPS), Royal College of Surgeons (RCSI), Dublin, Ireland
| | - Deborah McNamara
- National Clinical Programme in Surgery (NCPS), Royal College of Surgeons (RCSI), Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgical Affairs, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Ken Mealy
- National Clinical Programme in Surgery (NCPS), Royal College of Surgeons (RCSI), Dublin, Ireland
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Berger AA, Tan-Kim J, Menefee SA. Surgeon volume and reoperation risk after midurethral sling surgery. Am J Obstet Gynecol 2019; 221:523.e1-523.e8. [PMID: 31526790 DOI: 10.1016/j.ajog.2019.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Emerging research supports that fewer complications occur in patients who undergo surgery by higher surgical volume surgeons. The midurethral sling surgery has been involved in recent warnings and litigation, which further supports a need to understand features that enhance its safety and efficacy. OBJECTIVE The purpose of this study was to measure the impact of a surgeon's volume on their patient's rate of reoperation after midurethral sling surgery. STUDY DESIGN This was a retrospective cohort study that evaluated all surgeons who performed synthetic mesh midurethral sling surgery for stress urinary incontinence at a large managed care organization with >4.5 million members from 2005-2016. Physicians Current Procedural Terminology and International Classification of Diseases, version 9/10, codes were used to identify the procedures and the reoperations that were performed. The system-wide medical record was queried for demographic and perioperative data. The primary outcome was the overall reoperation rate after midurethral sling surgery. Concentration curves were used to identify the impact of a surgeon's surgical volume on their rate of reoperation. Demographics, characteristics, and reoperation of patients were compared with the use of chi-square test for categoric variables and Wilcoxon rank sum test for continuous variables. Poisson regression models with a robust error variance were used to calculate the unadjusted and the adjusted risk ratios of reoperation with the use of age, body mass index, marital status, race, parity, vaginal estrogen use, sling type, smoking, diabetes mellitus, and menopausal status as covariates. RESULTS Two hundred twenty-seven surgeons performed 13,404 midurethral sling surgeries over the study period; patients had a mean of 4.4 years of follow up. Higher-volume surgeons (>40 procedures/year, ≥95th percentile) performed 47% of the surgeries in this cohort and had an overall lower rate of reoperation (3.6% vs 4.2%; 95% confidence interval, 0.67-0.94; P=.04) compared with lower-volume surgeons. Higher-volume surgeons had a lower rate of reoperation for surgical failure (2.7% vs 3.6%; 95% confidence interval, 0.55-0.92; P<.01). Rates of reoperation for complications were similar between the 2 groups (1.1% vs 0.9%; 95% confidence interval, 0.82-1.13; P=.32). For patients whose condition required a reoperation secondary to complication, the rates of reoperation for urinary retention (0.9% vs 0.6%; P=.06), mesh exposure (0.2% vs 0.3%; P=.31), hemorrhage/bleeding (0.1% vs 0.0%; P=.11), pain (0.1% vs 0.1%; P=.52), and infection (0.0% vs 0.0%; P=.37) did not differ between higher- and lower-volume surgeons. The risk ratio for reoperation that compared higher- and lower-volume surgeons was 0.83 (95% confidence interval, 0.67-0.98; P=.01) in the adjusted model. CONCLUSION Although the reoperation rates were low for both higher- and lower-volume surgeons, higher-volume surgeons had lower overall rates of reoperation after midurethral sling surgery. This effect is seen most dramatically in reoperation for surgical failure, in which patients who have surgery with a higher-volume surgeon are 25% less likely to have postoperative stress urinary incontinence that leads to reoperation.
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Affiliation(s)
- Alexander A Berger
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of OB/GYN, Kaiser Permanente-San Diego, San Diego, CA; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Science, University of California San Diego, San Diego, CA.
| | - Jasmine Tan-Kim
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of OB/GYN, Kaiser Permanente-San Diego, San Diego, CA
| | - Shawn A Menefee
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of OB/GYN, Kaiser Permanente-San Diego, San Diego, CA
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Campos-Sañudo JA, Ballestero-Diego R, Zubillaga-Guerrero S, Rodríguez-Sanjuán JC, Asensio-Lahoz A, Monge-Miralles JM, Crespo-Santiago D. [Complications and mortality after radical nephrectomy in a low-volume hospital.]. ARCH ESP UROL 2019; 72:653-661. [PMID: 31475676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the complications and 30-day mortality rates following open radical nephrectomy and laparoscopic radical nephrectomy using the Clavien-Dindo classification system in a low-volume hospital. METHODS We conducted a retrospective analysis of 263 patients who underwent open or laparoscopic radical nephrectomy (1996-2016) in our local district general hospital. Postoperative complications and 30- day mortalities were evaluated using the Clavien-Dindo classification. The predictors of postoperative complications were assessed using multivariate logistic regression analysis. RESULTS We found that, compared to open radical nephrectomy, laparoscopic resulted in a significantly longer operative time (112.6±41 vs 199.3±61 minutes, p < 0.01) and a shorter hospital stay (8.5±2.4 vs 5.7±3 days, p < 0.001). The most common complications were bleeding or hematoma (4.9%) and problems associated with the wound (4.5%). There were no significant differences between the ORN and LRN groups in terms of complications based on the Clavien-Dindo classification. On multivariate analysis, a longer operative time (Odds Ratio, 1.009; 95% confidence interval, 1.002- 1.015; p = 0.010) and higher body mass index (Odds Ratio, 0.898; 95% confidence interval, 0.822-0.981; p = 0.017) were found to be significant predictors of complications after nephrectomy. CONCLUSIONS Our study demonstrated that complication and 30-day mortality rates were low. There was a greater number of low-grade complications, and there were no significant differences in these rates between open and laparoscopic radical nephrectomy. A longer operative time and a higher BMI were predictors of possible complications. We provide additional evidence to support the feasibility of performing open or laparoscopic radical nephrectomy in low-volume hospitals.
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Florio G, D'Amata G, Crovaro M, Musmeci L, Manzi F, Carnì P, Del Papa M. Utility of continuous intraoperative neural monitoring in thyroid surgery in a low volume centre. G Chir 2019; 40:455-458. [PMID: 32003730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This retrospective study, of a single surgeon's experience, evaluates the role of intraoperative neuromonitoring (IONM) for total thyroidectomy, in a low-volume district general hospital. 128 patients with normal preoperative vocal fold function underwent thyroid surgery with routine use of nerve monitoring. Patients were followed for 6 months after surgery, and postoperative Romanerve function was determined by fiberoptic laryngoscopy. One (0,8%) patient was found to have a unilateral vocal fold paralysis, but after 6 months this patient had regained vocal fold motion. The technique of intraoperative neuromonitoring in thyroid surgery is safe and reliable in excluding postoperative recurrent laryngeal nerve palsy; it has high accuracy, specificity, sensitivity and negative predictive value. Neuromonitoring is useful to identify the recurrent laryngeal nerve and it can be a useful adjunctive technique for reassuring surgeons of the functional integrity of the nerve. Its application can be particularly recommended for low-volume thyroid operation centres.
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Robin-Lersundi A, Abella Alvarez A, San Miguel Mendez C, Moreno Elalo-Olaso A, Cruz Cidoncha A, Aguilera Velardo A, Gordo Vidal F, García-Ureña MA. Multidisciplinary Approach to Treating Severe Acute Pancreatitis in a Low-Volume Hospital. World J Surg 2019; 43:2994-3002. [PMID: 31440777 DOI: 10.1007/s00268-019-05114-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Up to 25% of patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with a high death rate. To improve outcomes, patients may require interventional measures including surgical procedures. Multidisciplinary approach and best practice guidelines are important to decrease mortality. METHODS We have conducted a retrospective analysis from a prospectively maintained database in a low-volume hospital. A total of 1075 patients were attended for acute pancreatitis over a ten-year period. We have analysed 44 patients meeting the criteria for severe acute pancreatitis and for intensive care unit (ICU) admittance. Demographics and clinical data were analysed. Patients were treated according to international guidelines and a multidisciplinary flowchart for acute pancreatitis and a step-up approach for pancreatic necrosis. RESULTS Forty-four patients were admitted to the ICU due to severe acute pancreatitis. Twenty-five patients needed percutaneous drainage of peri-pancreatic or abdominal fluid collections or cholecystitis. Eight patients underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis and biliary sepsis or pancreatic leakage, and one patient received endoscopic trans-gastric endoscopic prosthesis for pancreatic necrosis. Sixteen patients underwent surgery: six patients for septic abdomen, four patients for pancreatic necrosis and two patients due to abdominal compartment syndrome. Four patients had a combination of surgical procedures for pancreatic necrosis and for abdominal compartment syndrome. Overall mortality was 9.1%. CONCLUSION Severe acute pancreatitis represents a complex pathology that requires a multidisciplinary approach. Establishing best practice treatments and evidence-based guidelines for severe acute pancreatitis may improve outcomes in low-volume hospitals.
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Affiliation(s)
- Alvaro Robin-Lersundi
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain.
| | - Ana Abella Alvarez
- Department of Intensive Care Medicine, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
| | - Carlos San Miguel Mendez
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
| | - Almudena Moreno Elalo-Olaso
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
| | - Arturo Cruz Cidoncha
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
| | - Asunción Aguilera Velardo
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
| | - Federico Gordo Vidal
- Department of Intensive Care Medicine, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
- Grupo de Investigación en Patología Crítica, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Miguel-Angel García-Ureña
- Department of Surgery, Hospital Universitario del Henares, Avda. Marie Curie, s/n, 28822, Coslada, Madrid, Spain
- Grupo de Investigación en Pared Abdominal, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
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Nathan AS, Khatana SAM, Yeh RW, Groeneveld PW, Giri J. Hospital-Specific Mortality for Acute Myocardial Infarction Versus Emergency Percutaneous Coronary Intervention in New York State. JACC Cardiovasc Interv 2019; 12:898-899. [PMID: 31072516 DOI: 10.1016/j.jcin.2019.02.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/06/2019] [Accepted: 02/26/2019] [Indexed: 11/30/2022]
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SAIA M, BUJA A, FUSINATO R, FONZO M, BERTONCELLO C, BALDO V. Uncompleted Emergency Department Care (UEDC): a 5-year population-based study in the Veneto Region, Italy. J Prev Med Hyg 2019; 60:E18-E24. [PMID: 31041406 PMCID: PMC6477553 DOI: 10.15167/2421-4248/jpmh2019.60.1.1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 02/03/2019] [Indexed: 11/16/2022]
Abstract
Introduction Uncompleted visits to emergency departments (UEDC) are a patient safety concern. The purpose of this study was to investigate risk factors for UEDC, describing not only the sociodemographic characteristics of patients who left against medical advice (AMA) and those who left without being seen (LWBS), but also the characteristics of their access to the emergency department (ED) and of the hospital structure. Methods This was a cross sectional study on anonymized administrative data in a population-based ED database. Results A total of 9,147,415 patients attended EDs in the Veneto Region from 2011 to 2015. The UEDC rate was 28.7‰, with a slightly higher rate of AMA than of LWBS (15.3‰ vs 13.4‰). Age, sex, citizenship, and residence were sociodemographic factors associated with UEDC, and so were certain characteristics of access, such as mode of admission, type of referral, emergency level, waiting time before being seen, and type of medical issue (trauma or other). Some characteristics of the hospital structure, such as the type of hospital and the volume of patients managed, could also be associated with UEDC. Conclusion Cases of UEDC, which may involve patients who leave AMA and those who LWBS, differ considerably from other cases managed at the ED. The present findings are important for the purpose of planning and staffing health services. Decision-makers should identify and target the factors associated with UEDC to minimize walkouts from public hospital EDs.
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Affiliation(s)
- M. SAIA
- Veneto Region, Local Health Unit n. 6Padova, Italy
| | - A. BUJA
- Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, Italy
- Alessandra Buja, Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, via Loredan 18, 35131 Padova, Italy - Tel. +39 049 8275387 - E-mail:
| | - R. FUSINATO
- Department of Statistical Sciences, University of Padova, Italy
| | - M. FONZO
- Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, Italy
| | - C. BERTONCELLO
- Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, Italy
| | - V. BALDO
- Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, Italy
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Navathe AS, Liao JM, Dykstra SE, Wang E, Lyon ZM, Shah Y, Martinez J, Small DS, Werner RM, Dinh C, Ma X, Emanuel EJ. Association of Hospital Participation in a Medicare Bundled Payment Program With Volume and Case Mix of Lower Extremity Joint Replacement Episodes. JAMA 2018; 320:901-910. [PMID: 30193276 PMCID: PMC6142996 DOI: 10.1001/jama.2018.12345] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 08/06/2018] [Indexed: 12/23/2022]
Abstract
Importance Medicare's Bundled Payments for Care Improvement (BPCI) initiative for lower extremity joint replacement (LEJR) surgery has been associated with a reduction in episode spending and stable-to-improved quality. However, BPCI may create unintended effects by prompting participating hospitals to increase the overall volume of episodes paid for by Medicare, which could potentially eliminate program-related savings or prompt them to shift case mix to lower-risk patients. Objective To evaluate whether hospital BPCI participation for LEJR was associated with changes in overall volume and case mix. Design, Setting, and Participants Observational study using Medicare claims data and a difference-in-differences method to compare 131 markets (hospital referral regions) with at least 1 BPCI participant hospital (n = 322) and 175 markets with no participating hospitals (n = 1340), accounting for 580 043 Medicare beneficiaries treated before (January 2011-September 2013) and 462 161 after (October 2013-December 2015) establishing the BPCI initiative. Hospital-level case-mix changes were assessed by comparing 265 participating hospitals with a 1:1 propensity-matched set of nonparticipating hospitals from non-BPCI markets. Exposures Hospital BPCI participation. Main Outcomes and Measures Changes in market-level LEJR volume in the before vs after BPCI periods and changes in hospital-level case mix based on demographic, socioeconomic, clinical, and utilization factors. Results Among the 1 717 243 Medicare beneficiaries who underwent LEJR (mean age, 75 years; 64% women; and 95% nonblack race/ethnicity), BPCI participation was not significantly associated with a change in overall market-level volume. The mean quarterly market volume in non-BPCI markets increased 3.8% from 3.8 episodes per 1000 beneficiaries before BPCI to 3.9 episodes per 1000 beneficiaries after BPCI was launched. For BPCI markets, the mean quarterly market volume increased 4.4% from 3.6 episodes per 1000 beneficiaries before BPCI to 3.8 episodes per 1000 beneficiaries after BPCI was launched. The adjusted difference-in-differences estimate between the market types was 0.32% (95% CI, -0.06% to 0.69%; P = .10). Among 20 demographic, socioeconomic, clinical, and utilization factors, BPCI participation was associated with differential changes in hospital-level case mix for only 1 factor, prior skilled nursing facility use (adjusted difference-in-differences estimate, -0.53%; 95% CI, -0.96% to -0.10%; P = .01) in BPCI vs non-BPCI markets. Conclusions and Relevance In this observational study of Medicare beneficiaries who underwent LEJR, hospital participation in Bundled Payments for Care Improvement was not associated with changes in market-level lower extremity joint replacement volume and largely was not associated with changes in hospital case mix. These findings may provide reassurance regarding 2 potential unintended effects associated with bundled payments for LEJR.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Diagnosis-Related Groups
- Economics, Hospital
- Episode of Care
- Female
- Hospitals, High-Volume
- Hospitals, Low-Volume
- Humans
- Long-Term Care/statistics & numerical data
- Male
- Medicare/economics
- Rehabilitation Centers/statistics & numerical data
- Reimbursement Mechanisms
- Skilled Nursing Facilities/statistics & numerical data
- United States
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Affiliation(s)
- Amol S. Navathe
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Joshua M. Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Sarah E. Dykstra
- The Wharton School of Business, University of Pennsylvania, Philadelphia
| | - Erkuan Wang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Zoe M. Lyon
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yash Shah
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joseph Martinez
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- The Wharton School of Business, University of Pennsylvania, Philadelphia
| | - Dylan S. Small
- The Wharton School of Business, University of Pennsylvania, Philadelphia
| | - Rachel M. Werner
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Claire Dinh
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Xinshuo Ma
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ezekiel J. Emanuel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Schaumeier MJ, Hawkins AT, Hevelone ND, Sethi RKV, Nguyen LL. Association of Treatment for Critical Limb Ischemia with Gender and Hospital Volume. Am Surg 2018; 84:1069-1078. [PMID: 29981651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Critical limb ischemia (CLI) is a frequent and major vascular problem and can lead to amputation and death despite surgical revascularization. Women have been shown to have 3 to 4 per cent lower revascularization rates for CLI compared with men as well as inferior outcomes. We hypothesize that this difference is a result of women being more likely admitted to low-volume hospitals, which in turn perform fewer revascularizations. Prospective cohort study. Data from the Nationwide Inpatient Sample 2007 to 2010 were used to identify admissions with primary International Classification of Diseases-9 codes for CLI (International Classification of Diseases-9 codes: 440.22, 440.23, 440.24, 707.1, 707.10-707.15, or 707.19). Hospitals were grouped in quintiles by annual revascularization procedures. Bivariate analyses were performed and multivariable logistic regression was used to analyze the odds of revascularization, amputation, and mortality while controlling for patient and hospital-level factors. Of 113,631 admissions, 54,370 (47.8%) were women, who were more likely admitted to low-volume hospitals (very low: 49.6% vs very high: 47.1%; P < 0.001). Revascularization rates were lower in women (31.6% vs 35.1%, P < 0.001) across all volume quintiles, whereas the difference was greatest in the use of open surgical revascularization (12.5% vs 16.0%, P < 0.001). In multivariable analysis, female gender [odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83-0.92, P < 0.001] and very-low hospital volume (OR 0.21, 95% CI 0.17-0.26, P < 0.001) were both significantly associated with lower rates of revascularization. Women had lower odds of major amputation compared with men (OR 0.75, 95% CI 0.69-0.82, P < 0.001), whereas treatment in a very high-volume hospital was associated with increased odds for amputation (OR 1.37, 95% CI 1.09-1.73, P = 0.008). Neither gender nor hospital volume were independently associated with in-hospital mortality in the multivariable regression model. Women are more likely to be admitted to low-volume hospitals for treatment of CLI. Because of this, they are less likely to undergo revascularization, although they also had lower rates of major amputation.
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Manso M, Alexandre B, Antunes-Lopes T, Martins-da-Silva C, Cruz F. Is the adjustable transobturator system ATOMS® useful for the treatment of male urinary incontinence in low to medium volume urological centers? Actas Urol Esp 2018; 42:267-272. [PMID: 29174630 DOI: 10.1016/j.acuro.2017.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 07/03/2017] [Accepted: 07/04/2017] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Urinary incontinence (UI) is a complication of radical prostatectomy (RP) and transurethral resection of the prostate (TURP). The gold-standard treatment is the artificial urinary sphincter, however, new treatments have been investigated. OBJECTIVE To examine the outcome of an adjustable transobturator male system (ATOMS®) in men with UI after prostatic surgery in a low to medium volume continence center. MATERIALS AND METHODS Twenty-five men with UI were implanted with ATOMS® system between 2012 and 2014. The most common indication was UI after RP (92%), followed by UI after TURP (8%). Eleven patients (44%) had received adjuvant external beam radiotherapy (RT). Patients were considered to be 'dry' if they stopped wearing pads or needed just one protective pad per day; and improved if the daily number of pads used decreased by at least half. The Incontinence Quality of Life questionnaire (ICIQ-SF) was used, adding a verbal question about the satisfaction of the patient considering the outcome. RESULTS After a mean follow-up of 21.56 months, 64% were dry and 8% revealed a significant improvement. The success of the procedure was negatively correlated with the severity of the previous UI and with previous treatment with RT. Concerning patients satisfaction, 84% of the patients would repeat the procedure. CONCLUSION ATOMS® offers good rates of cure and improvement of UI after prostatic surgery with a reasonable rate of minor complications. The results of this study, performed in a low to medium volume continence center, are comparable to the results achieved in high volume continence centers.
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Affiliation(s)
- M Manso
- Urology Department, Centro Hospitalar São João, Porto, Portugal.
| | - B Alexandre
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - T Antunes-Lopes
- Urology Department, Centro Hospitalar São João, Porto, Portugal; i3S Institute for Innovation and Health Research, Porto, Portugal
| | - C Martins-da-Silva
- Urology Department, Centro Hospitalar São João, Porto, Portugal; Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - F Cruz
- Urology Department, Centro Hospitalar São João, Porto, Portugal; Faculdade de Medicina, Universidade do Porto, Porto, Portugal; i3S Institute for Innovation and Health Research, Porto, Portugal
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Jeschke E, Citak M, Günster C, Matthias Halder A, Heller KD, Malzahn J, Niethard FU, Schräder P, Zacher J, Gehrke T. Are TKAs Performed in High-volume Hospitals Less Likely to Undergo Revision Than TKAs Performed in Low-volume Hospitals? Clin Orthop Relat Res 2017; 475:2669-2674. [PMID: 28801816 PMCID: PMC5638741 DOI: 10.1007/s11999-017-5463-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 07/31/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND High-volume hospitals have achieved better outcomes for THAs and unicompartmental knee arthroplasties (UKAs). However, few studies have analyzed implant survival after primary TKA in high-volume centers. QUESTIONS/PURPOSES Is the risk of revision surgery higher when receiving a TKA in a low-volume hospital than in a high-volume hospital? METHODS Using nationwide billing data of the largest German healthcare insurer for inpatient hospital treatment, we identified 45,165 TKAs in 44,465 patients insured by Allgemeine Ortskrankenkasse who had undergone knee replacement surgery between January 2012 and December 2012. Revision rates were calculated at 1 and 2 years in all knees. The hospital volume was calculated using volume quintiles of the number of all knee arthroplasties performed in each center. We used multiple logistic regression to model the odds of revision surgery as a function of hospital volume. Age, sex, 31 comorbidities, and variables for socioeconomic status were included as independent variables in the model. RESULTS After controlling for socioeconomic factors, patient age, sex, and comorbidities, we found that having surgery in a high-volume hospital was associated with a decreased risk of having revision TKA within 2 years of the index procedure. The odds ratio for the 2-year revision was 1.6 (95% CI, 1.4-2.0; p < 0.001) for an annual hospital volume of 56 or fewer cases, 1.5 (95% CI, 1.3-1.7; p < 0.001) for 57 to 93 cases, 1.2 (95% CI, 1.0-1.3; p = 0.039) for 94 to 144 cases, and 1.1 (95% CI, 0.9-1.2; p = 0.319) for 145 to 251 cases compared with a hospital volume of 252 or more cases. CONCLUSIONS We found a clear association of higher risk for revision surgery when undergoing a TKA in a hospital where less than 145 arthroplasties per year were performed. The study results could help practitioners to guide potential patients in hospitals that perform more TKAs to reduce the overall revision and complication rates. Furthermore, this study underscores the importance of a minimum hospital threshold of arthroplasty cases per year to get permission to perform an arthroplasty. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Elke Jeschke
- Research Institute of the Local Health Care Funds (AOK), Berlin, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany.
| | - Christian Günster
- Research Institute of the Local Health Care Funds (AOK), Berlin, Germany
| | | | - Karl-Dieter Heller
- Department of Orthopaedic Surgery, Herzogin Elisabeth Hospital, Braunschweig, Germany
| | - Jürgen Malzahn
- Federal Association of the Local Health Care Funds, Berlin, Germany
| | | | - Peter Schräder
- Department of Orthopaedic Surgery, Kreisklinik Jugenheim, Jugenheim, Germany
| | | | - Thorsten Gehrke
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
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Fischer C, Lingsma H, Klazinga N, Hardwick R, Cromwell D, Steyerberg E, Groene O. Volume-outcome revisited: The effect of hospital and surgeon volumes on multiple outcome measures in oesophago-gastric cancer surgery. PLoS One 2017; 12:e0183955. [PMID: 29073140 PMCID: PMC5658198 DOI: 10.1371/journal.pone.0183955] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
Background Most studies showing a volume outcome effect in resection surgery for oesophago-gastric cancer were conducted before the centralisation of clinical services. This study evaluated the relation between hospital- and surgeon volume and different risk-adjusted outcomes after oesophago-gastric (OG) cancer surgery in England between 2011 and 2013. Methods In data from the National Oesophago-Gastric Cancer Audit from the UK, multivariable random-effects logistic regression models were used to quantify the effect of surgeon and hospital volume on three outcomes: 30-day and 90-day mortality and anastomotic leakage. The models included patient risk factors to adjust for differences in case-mix among hospitals and surgeons. The between-cluster heterogeneity was estimated with the median odds ratio (MOR). Results The study included patients treated at 42 hospitals and 329 surgeons. The median (interquartile range) of the annual hospital and surgeon volumes were 110 patients (82 to 137) and 13 patients (8 to 19), respectively. The overall rates for 30-day and 90-day mortality were 2.3% and 4.4% respectively, and the anastomotic leakage was 6.3%. Higher hospital volume was associated with lower 30-day mortality (OR: 0.94; 95% CI: 0.91–0.98) and lower anastomotic leakage rates (OR: 0.96; 95% CI: 0.93–0.98) but not 90-day mortality. Higher surgeon volume was only associated with lower anastomotic leakage rates (OR: 0.81; 95% CI: 0.72–0.92). Hospital volume explained a part of the between-hospital variation in 30-day mortality whereas surgeon volume explained part of the between-hospital variation in anastomotic leakage. Conclusions In the setting of centralized O-G cancer surgery in England, we could still observe an effect of volume on short-term outcomes. However, the effect is inconsistent, depending on the type of outcome measure under consideration, and much smaller than in previous studies. Efforts to centralise O-G cancer services further should carefully address the effects of both hospital and surgeon volume on the range of outcome measures that are relevant to patients.
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Affiliation(s)
- Claudia Fischer
- Erasmus MC, Department of Public Health, Rotterdam, The Netherlands
| | - Hester Lingsma
- Erasmus MC, Department of Public Health, Rotterdam, The Netherlands
| | - Niek Klazinga
- Amsterdam Medical Center, Department of Public Health, Amsterdam, The Netherlands
| | - Richard Hardwick
- Cambridge Oesophago-Gastric Centre, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - David Cromwell
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ewout Steyerberg
- Erasmus MC, Department of Public Health, Rotterdam, The Netherlands
| | - Oliver Groene
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- OptiMedis AG, Hamburg, Germany
- * E-mail:
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Htay H, Cho Y, Pascoe EM, Darssan D, Nadeau-Fredette AC, Hawley C, Clayton PA, Borlace M, Badve SV, Sud K, Boudville N, McDonald SP, Johnson DW. Multicenter Registry Analysis of Center Characteristics Associated with Technique Failure in Patients on Incident Peritoneal Dialysis. Clin J Am Soc Nephrol 2017; 12:1090-1099. [PMID: 28637862 PMCID: PMC5498362 DOI: 10.2215/cjn.12321216] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 04/04/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Technique failure is a major limitation of peritoneal dialysis. Our study aimed to identify center- and patient-level predictors of peritoneal dialysis technique failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All patients on incident peritoneal dialysis in Australia from 2004 to 2014 were included in the study using data from the Australia and New Zealand Dialysis and Transplant Registry. Center- and patient-level characteristics associated with technique failure were evaluated using Cox shared frailty models. Death-censored technique failure and cause-specific technique failure were analyzed as secondary outcomes. RESULTS The study included 9362 patients from 51 centers in Australia. The technique failure rate was 0.35 (95% confidence interval, 0.34 to 0.36) episodes per patient-year, with a sevenfold variation across centers that was mainly associated with center-level characteristics. Technique failure was significantly less likely in centers with larger proportions of patients treated with peritoneal dialysis (>29%; adjusted hazard ratio, 0.83; 95% confidence interval, 0.73 to 0.94) and more likely in smaller centers (<16 new patients per year; adjusted hazard ratio, 1.10; 95% confidence interval, 1.00 to 1.21) and centers with lower proportions of patients achieving target baseline serum phosphate levels (<40%; adjusted hazard ratio, 1.15; 95% confidence interval, 1.03 to 1.29). Similar results were observed for death-censored technique failure, except that center target phosphate achievement was not significantly associated. Technique failure due to infection, social reasons, mechanical causes, or death was variably associated with center size, proportion of patients on peritoneal dialysis, and/or target phosphate achievement, automated peritoneal dialysis exposure, icodextrin use, and antifungal use. The variation of hazards of technique failure across centers was reduced by 28% after adjusting for patient-specific factors and an additional 53% after adding center-specific factors. CONCLUSIONS Technique failure varies widely across centers in Australia. A significant proportion of this variation is related to potentially modifiable center characteristics, including peritoneal dialysis center size, proportion of patients on peritoneal dialysis, and proportion of patients on peritoneal dialysis achieving target phosphate level.
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Affiliation(s)
- Htay Htay
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Black J, Cotton T, Yeh JJ. Outpatient Total Thyroidectomy Is Safe for Moderate-Volume Surgeons. Am Surg 2017; 83:750-754. [PMID: 28738947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Traditionally, total thyroidectomy (TT) was an inpatient procedure, but recent trends indicate that patients are often discharged on the day of surgery. This has been proven safe for high-volume surgeons but has not been studied for low (<10 TT per year) and moderate volume surgeons (<24 TT per year). Retrospective review was performed for 414 total thyroidectomies between 2005 and 2013. Emergency department visits and readmissions within 30 days of surgery were captured, but were considered the same for the purpose of this analysis. Patients were identified as outpatient if the day of discharge matched the day of surgery. The groups were compared based on demographic variables, comorbidities, postop calcium supplementation, and serum calcium. We found that moderate-volume surgeons were more likely to perform outpatient TT than low-volume surgeons (31.6% vs 6.0%, P < 0.001), but there was no correlation between length of stay and readmission (P = 0.688). Readmitted patients had lower postop serum calcium (8.3 mg/dL) than patients who were not readmitted (8.8 mg/dL, P = 0.006). Our data show that moderate-volume surgeons performing outpatient TT have an acceptable safety profile with respect to emergency department visits and hospital readmissions, and that same day discharge had no bearing on readmission.
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Aquina CT, Fleming FJ, Becerra AZ, Xu Z, Hensley BJ, Noyes K, Monson JRT, Jusko TA. Explaining variation in ventral and inguinal hernia repair outcomes: A population-based analysis. Surgery 2017; 162:628-639. [PMID: 28528663 DOI: 10.1016/j.surg.2017.03.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/06/2017] [Accepted: 03/19/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND No study has evaluated the relative importance of patient, surgeon, and hospital-level factors on surgeon and hospital variation in hernia reoperation rates. This population-based retrospective cohort study evaluated factors associated with variation in reoperation rates for recurrence after initial ventral hernia repair and inguinal hernia repair. METHODS The Statewide Planning and Research Cooperative System identified initial ventral hernia repairs and inguinal hernia repairs in New York state from 2003-2009. Mixed-effects Cox proportional hazards analyses were performed assessing factors associated with surgeon/hospital variation in 5-year reoperation rates for hernia recurrence. RESULTS Among 78,267 ventral hernia repairs and 124,416 inguinal hernia repairs, the proportion of total variation in reoperation rates attributable to individual surgeons compared with hospitals was 87% for ventral hernia repairs and 92% for inguinal hernia repairs. In explaining variation in ventral hernia repair reoperation between surgeons, 19% was attributable to patient-level factors, 4% attributable to mesh placement, and 10% attributable to surgeon volume and type of board certification. In explaining variation in inguinal hernia repair reoperation between surgeons, 1.1% was attributable to mesh placement and 10% was attributable to surgeon volume and years of experience. However, 67% of the variation between surgeons for ventral hernia repair and 89% of the variation between surgeons for inguinal hernia repair remained unexplained by factors in the models. CONCLUSION The majority of variation in hernia reoperation rates is attributable to surgeon-level variation. This suggests that hernia recurrence may be an appropriate surgeon quality metric. While modifiable factors such as mesh placement and surgeon characteristics play roles in surgeon variation, future research should focus on identifying additional surgeon attributes responsible for this variation.
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Affiliation(s)
- Christopher T Aquina
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY.
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Adan Z Becerra
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - Zhaomin Xu
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Bradley J Hensley
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Katia Noyes
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - John R T Monson
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY; Center for Colon and Rectal Surgery, Florida Hospital Group, University of Central Florida College of Medicine, Orlando, FL
| | - Todd A Jusko
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
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Yen TWF, Pezzin LE, Li J, Sparapani R, Laud PW, Nattinger AB. Effect of hospital volume on processes of breast cancer care: A National Cancer Data Base study. Cancer 2017; 123:957-966. [PMID: 27861746 DOI: 10.1002/cncr.30413] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/31/2016] [Accepted: 10/03/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND The purpose of this study was to examine variations in delivery of several breast cancer processes of care that are correlated with lower mortality and disease recurrence, and to determine the extent to which hospital volume explains this variation. METHODS Women who were diagnosed with stage I-III unilateral breast cancer between 2007 and 2011 were identified within the National Cancer Data Base. Multiple logistic regression models were developed to determine whether hospital volume was independently associated with each of 10 individual process of care measures addressing diagnosis and treatment, and 2 composite measures assessing appropriateness of systemic treatment (chemotherapy and hormonal therapy) and locoregional treatment (margin status and radiation therapy). RESULTS Among 573,571 women treated at 1755 different hospitals, 38%, 51%, and 10% were treated at high-, medium-, and low-volume hospitals, respectively. On multivariate analysis controlling for patient sociodemographic characteristics, treatment year and geographic location, hospital volume was a significant predictor for cancer diagnosis by initial biopsy (medium volume: odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.05-1.25; high volume: OR = 1.30, 95% CI = 1.14-1.49), negative surgical margins (medium volume: OR = 1.15, 95% CI = 1.06-1.24; high volume: OR = 1.28, 95% CI = 1.13-1.44), and appropriate locoregional treatment (medium volume: OR = 1.12, 95% CI = 1.07-1.17; high volume: OR = 1.16, 95% CI = 1.09-1.24). CONCLUSIONS Diagnosis of breast cancer before initial surgery, negative surgical margins and appropriate use of radiation therapy may partially explain the volume-survival relationship. Dissemination of these processes of care to a broader group of hospitals could potentially improve the overall quality of care and outcomes of breast cancer survivors. Cancer 2017;123:957-66. © 2016 American Cancer Society.
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Affiliation(s)
- Tina W F Yen
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Liliana E Pezzin
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jianing Li
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rodney Sparapani
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Purushuttom W Laud
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ann B Nattinger
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Abstract
BACKGROUND Volume-to-outcome data have been studied in several complex surgical procedures, demonstrating improved outcomes at higher volume centers. Laparoscopic lysis of adhesions (LLOA) for small bowel obstruction (SBO) may result in better outcomes, but there is no information on the learning curve for this potentially complex case. This study evaluates the effect of institutional procedural volume on length of stay (LOS), outcomes, and costs in LLOA for SBOs. MATERIALS AND METHODS The Nationwide Inpatient Sample data set between 2000 and 2013 was queried for discharges for a diagnosis of SBO involving LLOA in adult patients. Patients with intra-abdominal malignancy and evidence of any other major surgical procedure during hospitalization were excluded. The procedural volume per hospital was calculated over the period, and high-volume hospitals were designated as those performing greater than five LLOA per year. Patient characteristics were described by hospital volume status using stratified cluster sampling tabulation and linear regression methods. LOS, total charges, and costs were reported as means with standard deviation and median values. P < 0.05 was considered significant. RESULTS A total of 9111 discharges were selected, which was representative of 43,567 weighted discharges nationally between 2000 and 2013. Over the study period, there has been a 450% increase in the number of LLOA performed. High-volume hospitals had significantly shorter LOS (mean: 4.92 ± standard error (SE) 0.13 d; median: 3.6) compared to low-volume hospitals (mean: 5.68 ± 0.06 d; median: 4.5). In multivariate analysis, high-volume status was associated with a decreased LOS of 0.72 d (P < 0.0001) as compared to low-volume status. Other significant predictors for decreased LOS included decreased age, decreased comorbidity, and the absence of small bowel resection. There was no significant association between volume status and total charges in multivariate or univariate models, but high-volume hospitals were associated with lower costs in multivariate models by approximately $984 (P = 0.017). CONCLUSIONS This study demonstrates that high hospital volume was associated with decreased LOS for LLOA in SBO. Although volume was not associated with differences in total charges, there was a small decrease in hospital costs.
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Affiliation(s)
- Raymond A Jean
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Kevin Y Pei
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | - Kimberly A Davis
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Henry MK, Zonfrillo MR, French B, Song L, Feudtner C, Wood JN. Hospital Variation in Cervical Spine Imaging of Young Children With Traumatic Brain Injury. Acad Pediatr 2016; 16:684-91. [PMID: 26854208 PMCID: PMC4974148 DOI: 10.1016/j.acap.2016.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/15/2016] [Accepted: 01/21/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Cervical imaging practices are poorly understood in young children with traumatic brain injury (TBI). We therefore sought to identify child-level and hospital-level factors associated with performance of cervical imaging of children with TBI from falls and abusive head trauma (AHT) and to describe across-hospital variation in cervical imaging performance. We hypothesized that imaging decisions would be influenced by hospital volume of young injured children. METHODS We performed a retrospective study of children younger than 2 years of age with TBI from 2009 to 2013 in the Premier Perspective Database. After adjustment for observed patient characteristics, we evaluated variation in advanced cervical imaging (computed tomography or magnetic resonance imaging) in children with AHT and TBI from falls. RESULTS Of 2347 children with TBI, 18.7% were from abuse and 57.1% were from falls. Fifteen percent of children with TBI underwent advanced cervical imaging. Moderate or severe head injuries were associated with increased odds of cervical imaging in AHT (odds ratio 7.10; 95% confidence interval 2.75, 18.35) and falls (odds ratio 2.25; 95% confidence interval 1.19, 4.27). There was no association between annual hospital volume of injured children and cervical imaging performance. The adjusted probability of imaging across hospitals ranged from 4.3% to 84.3% in AHT and 3.1 to 39.0% in TBI from falls (P < .001). CONCLUSIONS These results highlight variation across hospitals in adjusted probability of cervical imaging in AHT (nearly 20-fold) and TBI from falls (over 10-fold) not explained by observed patient characteristics. This variation suggests opportunities for further research to inform imaging practices.
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Affiliation(s)
- M Katherine Henry
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pa; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Mark R Zonfrillo
- Department of Emergency Medicine and Injury Prevention Center, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, RI
| | - Benjamin French
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pa
| | - Lihai Song
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pa; PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Chris Feudtner
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pa; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Joanne N Wood
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pa; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pa; PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
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