Importance of hospital versus surgeon volume in predicting outcomes for gastric bypass procedures

BackgroundA relationship between surgical volume and improved surgical outcomes has been described in gastric bypass patients but the relative importance of surgeon versus hospital volume is unknown. Our objective was to examine whether in-hospital and 30-day mortality are determined more by surgeon volume or hospital volume or whether each has an independent effect. A retrospective cohort study was performed of all hospitals in Pennsylvania providing gastric bypass surgery from 1999 to 2003.MethodsData from the Pennsylvania Health Care Cost Containment Council included 14,714 gastric bypass procedures in patients aged >18 years. In-hospital and 30-day mortality were stratified by hospital volume categories (high [≥300], medium [125–299], and low [<125]) and surgeon volume categories (high [≥50] and low [<50]). Multivariate analyses were performed using logistic regression analysis to control for patient demographics and severity.ResultsHigh-volume surgeons at high-volume hospitals had the lowest in-hospital mortality rates of all categories (.12%) and low-volume surgeons at low-volume hospitals had the poorest outcomes (.57%). The same trend was observed for 30-day mortality (.30% versus .98%). After controlling for other covariates, high-volume surgeons at high-volume hospitals also had significantly lower odds of both in-hospital (odds ratio 20, P = .002) and 30-day mortality (odds ratio .30, P = .001). This relationship held true even after excluding surgeons who only performed procedures within a single year.ConclusionIn Pennsylvania, both higher surgeon and hospital volume were associated with better outcomes for bariatric surgical procedures. Although a high-surgeon volume correlated with lowered mortality, we also found that high-volume hospitals demonstrated improved outcomes, highlighting the importance of factors other than surgical expertise in determining the outcomes.     

Provider volume and outcomes for oncological procedures

BACKGROUND: Oncological procedures may have better outcomes if performed by high-volume providers. METHODS: A review of the English language literature incorporating searches of the Medline, Embase and Cochrane collaboration databases was performed. Studies were included if they involved a patient cohort from 1984 onwards, were community or population based, and assessed health outcome as a dependent variable and volume as an independent variable. The studies were also scored quantifiably to assess generalizability with respect to any observed volume-outcome relationship and analysed according to organ system; numbers needed to treat were estimated where possible. RESULTS: Sixty-eight relevant studies were identified and a total of 41 were included, of which 13 were based on clinical data. All showed either an inverse relationship, of variable magnitude, between provider volume and mortality, or no volume-outcome effect. All but two clinical reports revealed a statistically significant positive relationship between volume and outcome; none demonstrated the opposite. CONCLUSION: High-volume providers have a significantly better outcome for complex cancer surgery, specifically for pancreatectomy, oesphagectomy, gastrectomy and rectal resection.     

The importance of surgeon experience for clinical and economic outcomes from thyroidectomy.

OBJECTIVE: To determine whether individual surgeon experience is associated with improved short-term clinical and economic outcomes for patients with benign and malignant thyroid disease who underwent thyroid procedures in Maryland between 1991 and 1996. SUMMARY BACKGROUND DATA: There is a prevailing belief that surgeon experience affects patient outcomes in endocrine surgery, but there is a paucity of objective evidence outside of clinical series published by experienced surgeons that supports this view. METHODS: A cross-sectional analysis of all patients who underwent thyroidectomy in Maryland between 1991 and 1996 was conducted using a computerized statewide hospital discharge data base. Surgeons were categorized by volume of thyroidectomies over the 6-year study period: A (1 to 9 cases), B (10 to 29 cases), C (30 to 100 cases), and D (>100 cases). Multivariate regression was used to assess the relation between surgeon caseload and in-hospital complications, length of stay, and total hospital charges, adjusting for case mix and hospital volume. RESULTS: The highest-volume surgeons (group D) performed the greatest proportion of total thyroidectomies among the 5860 discharges, and they were more likely to operate on patients with cancer. After adjusting for case mix and hospital volume, highest-volume surgeons had the shortest length of stay (1.4 days vs. 1.7 days for groups B and C and 1.9 days for group A) and the lowest complication rate (5.1 % vs. 6.1% for groups B and C and 8.6% for group A). Length of stay and complications were more determined by surgeon experience than hospital volume, which had no consistent association with outcomes. CONCLUSIONS: Individual surgeon experience is significantly associated with complication rates and length of stay for thyroidectomy.     

The relationships of surgeon volume and specialty with outcomes following pediatric thyroidectomy

BackgroundPrevious studies of pediatric thyroidectomies suggest a volume-outcome relationship, but none have focused exclusively on pediatric surgical specialists. Our objective was to examine the effects of pediatric surgeon volume and specialty on post-thyroidectomy outcomes.MethodsThe Pediatric Health Information System was queried for patients ≤ 21 years who underwent partial or total thyroidectomy between 2005 and 2016. Multivariable logistic regression with propensity score weighting was used to assess the relationships between surgeon volume or specialty and 90-day thyroidectomy-specific complications. High-volume surgeons/hospitals were defined as those in the top tertile of annual thyroidectomies.ResultsThe inclusion criteria were met by 3149 patients. Patients treated by higher-volume surgeons had significantly fewer complications than those treated by lower-volume surgeons (15.0% vs. 19.2%, p = 0.01). Patients with thyroid cancer also had less morbidity when treated by higher-volume surgeons compared to lower-volume surgeons (25.0% vs. 35.1%, p = 0.03), as did children with Graves' disease (19.8% vs. 29.3%, p = 0.007). Patients managed by pediatric surgeons had fewer complications than those managed by pediatric otolaryngologists across all patients (14.0% vs. 22.5%, p < 0.001) and among cancer (25.3% vs. 42.1%, p < 0.001) and Graves' patients (20.1% vs. 37.3%, p < 0.001) specifically.ConclusionsMorbidity following pediatric thyroidectomy is associated with surgeon volume.Type of StudyPrognostic Study.Level of EvidenceLevel II.     

The surgical learning curve for artificial urinary sphincter procedures compared to typical surgeon experience

Background

The artificial urinary sphincter (AUS) is a well-established treatment for male stress urinary incontinence.

Objective

We aimed to characterize the surgical learning curve for reoperation rates after AUS implantation.

Design, setting, and participants

The study cohort consisted of 65 602 adult males who received an AUS between 1988 and 2008, constituting close to 90% of all operations conducted during that time. Data on reoperations were obtained from the manufacturer, which requires documentation for warranty coverage.

Measurements

Surgeon experience was calculated as the number of original AUS implants performed prior to the index patient's surgery. Multivariable logistic regression models were used to examine the association between experience and reoperative rates, adjusted for case mix.

Results and limitations

There was a slow but steady decrease in reoperative rates with increasing surgeon experience (p = 0.020), showing no plateau through 200 procedures. The risk of reoperation for a surgeon with five prior cases was 24.0%, which decreased to 18.1% for a surgeon with 100 prior implants (absolute risk difference [ARD]: 5.9%; 95% confidence interval [CI], 1.3–10.1%) and to 13.2% for a surgeon with 200 prior implants (ARD: 10.7%; 95% CI, 2.6–16.6%). Two-thirds of contemporary patients (having AUS procedure between years 2000 and 2008) saw a surgeon who had done ≤25 prior AUS implants; only 9% saw a surgeon with ≥100 prior procedures.

Conclusions

The learning curve for AUS surgery appears to be very long and without an obvious plateau. This is in contrast to typical surgeon experience, suggesting a considerable burden of avoidable reoperations. Efforts to flatten the learning are urgently needed.     

Impact of surgeon and hospital volume on outcomes of radical prostatectomy

An emerging body of literature has established a relationship between case volume and outcomes after radical prostatectomy (RP). Such findings come in the context of an already well-established association between both surgeon and hospital case volume in the field of cardiovascular surgery and for several high-risk cancer operations. The purpose of this review is to identify and summarize the seminal studies to date that investigate the impact of RP volume on patient outcomes.We performed a literature search of the English language studies available through PubMed that pertain to this topic. Thirteen original studies and a meta-analysis were found, which focus on the impact of hospital RP volume on surgical outcomes (including length of stay, perioperative complication rate, perioperative mortality, readmission rate, and several long term measures of treatment effect). Eight studies were identified that interrogated the relationship between individual surgeon case volume and outcomes.Across multiple outcome metrics, there is a pervasive association between higher hospital RP case volume and improved outcomes. Increasing individual surgeon volume may also portend better outcomes, not only perioperatively, but even with respect to long-term cancer control and urinary function. While most data arise from retrospective cohort studies, these studies, for the most part, are of sound design, show an impressive magnitude of effect, and demonstrate an impact on outcome that is proportional to surgical volume.Further research should focus on finding a means by which to translate these observations into improvements in the quality of prostate cancer care. To address differences in outcome between low volume and high volume surgeons, some have proposed and implemented subspecialization within practice groups, while others have looked toward subspecialty certification for urologic oncologists. With regard to differences in hospital volume, regionalization of care has been proposed as a solution, but is fraught with pitfalls. It may be more pragmatic and, ultimately more beneficial to patients, however, to identify processes of care that are already in place at high volume hospitals and implement them at lower volume centers. Similarly, we advocate careful studies to identify successful surgical techniques of high volume surgeons and efforts to disseminate these techniques.