Hospital Volume and the Costs Associated with Surgery for Pancreatic Cancer (original) (raw)
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Determinants of outcomes in pancreatic surgery and use of hospital resources
Journal of Surgical Oncology, 2011
Background and Objectives: Outcomes for patients undergoing major pancreatic surgery have improved, but a subset of patients that significantly utilize more resources exists. Variables that can lead to an increase in resource utilization in patients undergoing pancreatic surgery were identified. Methods: Patients undergoing pancreatic surgery for neoplasms were identified from the NSQIP database (2006)(2007)(2008). Indices associated with increased resource utilization that we included were operative time (OT), length of stay (LOS), intraoperative RBC transfusion, return to operating room, and occurrence of postoperative complications. Analysis of covariance and multivariable logistic regression were performed. Results: The 4,306 included patients had a median age of 66 years and 50.3% were males. The 30-day morbidity and mortality were 29.3% and 3.2%, respectively. Median OT was 362 min and median LOS was 10 days. Malignancy, neoadjuvant radiation, and medical co-morbidities were associated with increased OT (P < 0.0001 for all). Declining preoperative functional status was the most important predictor of LOS (P < 0.0001). Age, male gender, hypertension, severe COPD, and higher BMI were significantly associated with postoperative complications (P < 0.050 for all). Conclusions: Morbidity after pancreatic surgery remains high. Age, obesity, performance status, medical co-morbidities, and neoadjuvant radiation affect outcomes and may lead to increased use of hospital resources.
Journal of the American College of Surgeons, 2009
BACKGROUND: The relationship between hospital volume and perioperative mortality in pancreaticoduodenectomy has been well established. We studied whether associations exist between hospital volume and hospital clinical resources and between both of these factors to mortality to help explain this relationship. STUDY DESIGN: This two-part study reviewed publicly available hospital information from the Leapfrog Group, HealthGrades, and hospital Web sites. Hospitals were evaluated for Leapfrog ICU staffing criteria and Safe Practice Score; HealthGrades five-star rating for complex gastrointestinal procedures and operations; and presence of a general surgery residency, gastroenterology fellowship, and interventional radiology. Evaluation used trend analysis and multiple logistic regression analysis. The second part determined the mortality rate for pancreaticoduodenectomy using inpatient mortality data from the National Inpatient Sample and Leapfrog. Hospitals were categorized by low volume (Յ 10/year), high volume (Ն 11/year), strong clinical support (presence of all support factors), and weak clinical support (absence of any factor). Data were correlated by number of pancreatic resections per hospital, hospital system clinical resources, and operative mortality.
World Journal of Surgery, 2019
Background: Pancreatectomy for malignancy is associated with improved outcomes when performed at high volume centers. The goal of this study was to assess pancreatectomy outcomes for premalignant cystic lesions as a function of hospital volume. Methods: The Healthcare Cost and Utilization Project (HCUP) was queried for all pancreatectomies performed in California from 2003 to 2011. Cases were stratified, separating benign versus malignant disease. Hospitals were categorized as low (≤25 pancreatectomies/year; LV) or high (>25; HV) volume centers. Perioperative morbidity, mortality, and length of stay were compared in HV vs. LV centers. Results: There were 7,554 pancreatectomies performed in 201 hospitals during the study period, where 5,652 (75%) procedures were performed for malignancy, 338 (4%) for chronic pancreatitis and 1,564 (21%) for benign/premalignant cysts. The majority of pancreatectomies for cystic disease were performed at LV centers (65%). There were no significant differences in length of stay (7 vs. 8 days; p=0.6), or 90-day readmission rates (12.8% vs. 12.9%; p=1.0) in HV versus LV centers. However, there were higher surgical (46.2% LV vs. 41.1% HV, p=0.05) and medical (13.3% LV vs. 9.2% HV; p=0.017) complications at LV centers. Most importantly, there was a four-fold higher in-hospital mortality at LV centers (2.36% vs. 0.55%; p = 0.007). Conclusion: Pancreatic resection for benign lesions at HV hospitals is associated with significantly lower morbidity and mortality, suggesting that when feasible, patients should seek care at high volume centers for these semi-elective surgeries. Terms of use and reuse: academic research for non-commercial purposes, see here for full terms. https://www.springer.com/aamterms-v1
Journal of the American College of Surgeons, 2018
An initiative was established to improve value-based care for pancreatic surgery in a large nonprofit health system. Cost data were presented bimonthly to a hepatobiliary clinical performance group via videoconference. The direct costs were calculated for all patients undergoing distal pancreatectomy (DP) and pancreaticoduodenectomy (PD) between January 2014 and July 2017. Median length of stay, 30-day and 90-day mortality rates, readmission rate, and costs were stratified by surgeon volume using 2 published criteria: "volume pledge" criteria (≥5 PDs/year) and Leapfrog criteria (≥11 PDs/year). There were 270 DPs and 526 PDs performed in 14 hospitals spanning 4 states. Median PD costs were lower for high-volume surgeons (≥5 PDs/year), 21,026vs21,026 vs 21,026vs24,706 (p = 0.005). High-volume surgeons had a shorter length of stay (9 days vs 11 days; p < 0.001) for PD and DP (6 days vs 7 days; p = 0.001). Increased costs for low-volume surgeons included operative/anesthesia costs ($7,32...
Centralization of Services and Reduction of Adverse Events in Pancreatic Cancer Surgery
World Journal of Surgery, 2013
Background The perioperative period is critical in the outcome for patients with pancreatic cancer. The aim of the present analysis was to examine adverse events in patients dying under surgical care in relation to changes in the organization of pancreatic cancer surgery. Methods From 1996 to 2005, 1,033 patients with pancreatic cancer, mean age of 71 years (range 21-97 years) died under surgical care. The incidence, mortality, and number of operations for pancreatic cancer remained stable across the time period, but the proportion of patients undergoing surgery in the five specialist cancer centers increased from 50 to 80 % (p \ 0.001). Prior to death 260 (25 %) patients underwent operation and 96 (9 %) had endoscopic retrograde cholangiopancreatography (ERCP). There was a significant rise in ERCP (p = 0.03) and a decrease in non-resectional operations (p = 0.001). Results Since 1996, 52 (15 %) patients in whom 90 adverse events were recorded died following surgical intervention: 28 adverse events related to the perioperative period with 15 due to direct procedure complications such as bleeding or anastomotic leak; 13 were attributed to decision making around the choice or timing of the procedure. The postoperative mortality after curative pancreatic resection reduced from 3.5 to 1.8 %. Identified adverse events fell significantly in patients who died relating to the operative period (median of 3 per annum [1994-2000] to 1 per annum [2001-2005]) (p = 0.014) and medical care (3-0) (p = 0.003). Conclusions Continuous peer review audit has demonstrated a reduction in the number of adverse events in patients dying with pancreatic cancer under surgical care as increased numbers of patients treated in specialist cancer centers.
Volume–outcome relationship in pancreatic surgery
British Journal of Surgery, 2015
Background: Volume-outcome relationships related to major surgery may be of limited value if observation ends at the point of discharge without taking transfers and later events into consideration. Methods: The volume-outcome relationship in patients who underwent pancreatic surgery between 2008 and 2010 was assessed using claims data for all inpatient episodes from Germany's largest provider of statutory health insurance covering about 30 per cent of the population. Multiple logistic regression models with random effects were used to analyse the effect of hospital volume (using volume quintiles) on 1-year mortality, adjusting for age, sex, primary disease, type of surgery and co-morbidities. Additional outcomes were in-hospital (including transfer to other hospitals until final discharge) and 90-day mortality. Results: Of 9566 patients identified, risk-adjusted 1-year mortality was significantly higher in the three lowest-volume quintiles compared with the highest-volume quintile (odds ratio 1⋅73, 1⋅53 and 1⋅37 respectively). A similar, but less pronounced, effect was demonstrated for in-hospital and 90-day mortality. The effect of hospital volume on 1-year mortality was comparable to the effect of co-morbid conditions such as renal failure. Conclusion: Although mortality related to pancreatic surgery is influenced by many factors, this study demonstrated lower mortality at 1 year in high-volume centres in Germany.