The volume–outcome relationship in laparoscopic cholecystectomy: a population-based study using propensity score matching

Background

The volume–outcome relationship has been validated previously for surgical procedures and cancer treatments. However, no studies have longitudinally compared the relationships between volume and outcome, and none have systematically compared laparoscopic cholecystectomy (LC) surgery outcomes in Taiwan. This study purposed to explore the relationship between volume and hospital treatment cost after LC.

Methods

This cohort study retrospectively analyzed 247,751 LCs performed from 1998 to 2009. Hospitals were classified as low-, medium-, and high-volume hospitals if their annual number of LCs were 1–29, 30–84, ≥85, respectively. Surgeons were classified as low-, medium-, and high-volume surgeons if their annual number of LCs were 1–10, 11–24, ≥25, respectively. Hierarchical linear regression model and propensity score were used to assess the relationship between volume and hospital treatment cost.

Results

The mean hospital treatment cost was US $2,504.53, and the average hospital costs for high-volume hospitals/surgeons were 33/47 % lower than those for low-volume hospitals and surgeons. When analyzed by propensity score, the hospital treatment cost differed significantly between high-volume hospitals/surgeons and low/medium-volume hospitals/surgeons (2,073.70 vs. 2,350.91/2,056.73 vs. 2,553.76, P < 0.001).

Conclusions

Analysis using a hierarchical linear regression model and propensity score found an association between high-volume hospitals and surgeons and hospital treatment cost in LC patients. Moreover, the significant factors associated with hospital resource utilization for this procedure include age, gender, comorbidity, hospital type, hospital volume, and surgeon volume. Additionally, analysis of the treatment strategies adopted at high-volume hospitals or by high-volume surgeons may improve overall hospital treatment cost.     

Volume–Outcome Associations after Major Hepatectomy for Hepatocellular Carcinoma: a Nationwide Taiwan Study

Objective

The objective of this study was to explore volume–outcome associations after major hepatectomy for hepatocellular carcinoma (HCC).

Methods

This population-based cohort study retrospectively analyzed 23,107 major hepatectomies for HCC patients from 1998 to 2009. Relationships between hospital/surgeon volume and patient outcome were analyzed by propensity score matching (PSM). Five-year overall survival (OS) was estimated by Kaplan–Meier method, and differences were compared by log-rank test.

Results

The mean length of stay (LOS) after major hepatectomy was 18.1 days, and the mean hospital cost was US$5,088.2. After PSM, the mean OS in high- and low-volume hospitals was 71.1 months (standard deviation (SD) 0.7 months) and 68.6 months (SD 0.6 months), respectively; the mean OS in high- and low-volume surgeons was 78.5 months (SD 0.7 months) and 66.9 months (SD 0.7 months), respectively. The PSM analysis showed that treatment by high-volume hospitals and treatment by high-volume surgeons were both associated with significantly shorter LOS, lower hospital cost, and longer survival compared to their low-volume counterparts (P?<?0.001).

Conclusions

The results of this nationwide study support the regionalization of HCC treatment by hospital volume and by surgeon volume. High surgeon volume revealed both short- and long-term benefits. The applicability of PSM in volume–outcome analysis may also be confirmed.     

Evidence-Based Thresholds for the Volume and Length of Stay Relationship in Total Hip Arthroplasty: Outcomes and Economies of Scale

Background

Several studies have indicated that high-volume surgeons and hospitals deliver higher value care. However, no evidence-based volume thresholds currently exist in total hip arthroplasty (THA). The primary objective of this study was to establish meaningful thresholds taking patient outcomes into consideration for surgeons and hospitals performing THA. A secondary objective was to examine the market share of THAs for each surgeon and hospital strata.

Impact of Surgeon and Hospital Volume on Mortality,Length of Stay,and Cost of Pancreaticoduodenectomy

Background

Improved mortality rates following pancreaticoduodenectomy by high-volume surgeons and hospitals have been well documented, but less is known about the impact of such volumes on length of stay and cost. This study uses data from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) to examine the effect of surgeon and hospital volume on mortality, length of stay, and cost following pancreaticoduodenectomy while controlling for patient-specific factors.

Methods

Data included 3,137 pancreaticoduodenectomies from the NIS performed between 2004 and 2008. Using logistic regression, the relationship between surgeon volume, hospital volume, and postoperative mortality, length of stay, and cost was estimated while accounting for patient factors.

Results

After controlling for patient characteristics, patients of high-volume surgeons at high-volume hospitals had a significantly lower risk of mortality compared to low-volume surgeons at low-volume hospitals (OR 0.32, p?<?0.001). Patients of high-volume surgeons at high-volume hospitals also had a five day shorter length of stay (p?<?0.001), as well as significantly lower costs (US$12,275, p?<?0.001).

Conclusions

The results of this study, which simultaneously accounted for surgeon volume, hospital volume, and potential confounding patient characteristics, suggest that both surgeon and hospital volume have a significant effect on outcomes following pancreaticoduodenectomy, affecting not only mortality rates but also lengths of stay and costs.

     

Temporal trends and volume-outcome associations in periampullary cancer patients: a propensity score–adjusted nationwide population-based study

Background

The purpose of this study was to evaluate temporal trends in the incidence of pancreaticoduodenectomy (PD) with periampullary cancers and the impact of hospital volume and surgeon volume on patient outcomes and to explore predictors of these outcomes.

Methods

This population-based cohort study retrospectively analyzed 4,039 PD procedures performed from 1998 to 2009. The odds ratio and 95% confidence interval were calculated to assess the relative change rate. Hierarchical regression models were used to predict these outcomes.

Results

The incidence of PDs per 10⁵ persons increased from .97 to 1.89, whereas the length of stay and hospital treatment cost declined. Current treatment in a low-volume hospital and current treatment by a low-volume surgeon showed significant positive associations with these outcomes (P < .001).

Conclusions

The data indicate that analysis and emulation of the treatment strategies used by high-volume hospitals and high-volume surgeons may reduce overall hospital resource use. Because high-volume hospitals and surgeons consistently achieve superior outcomes of PD, their treatment strategies should be carefully analyzed and emulated.     

Access to high-volume surgeons and the opportunity cost of performing radical prostatectomy by low-volume providers

Background

Evidence suggests that redirecting surgeries to high-volume providers may be associated with better outcomes and significant societal savings. Whether such referrals are feasible remains unanswered.

Cost-Effectiveness in Hepatic Lobectomy: the Effect of Case Volume on Mortality,Readmission, and Cost of Care

Objective(s)

Higher-volume centers demonstrate better perioperative outcomes for complex surgical interventions, though resource utilization implications of this hospital-level variation are unclear. We hypothesized that for hepatic lobectomy, higher operative volume correlates with better outcomes and lower costs.

Methods

From 2009 to 2011, 4163 patients undergoing hepatic lobectomy were identified from the University HealthSystems Consortium database. Univariate, multivariate logistic regression, and decision analytic models were constructed to identify differences in hospital utilization and cost. Cost included both index and readmission hospitalizations, when applicable.

Results

The annual number of hepatic lobectomies performed by the institutions within the study ranged from 1 to 86. The median age of the 4163 patients was 58 years with a roughly equal gender split (M/F 49 %:51 %) and a racial breakdown which reflected that of the general US population. For all patients, the overall perioperative mortality rate was 2.3 % and the 30-day readmission rate was 13.4 %. Hospitals performing >30 hepatic lobectomies per year had significantly lower mortality and readmission rates than those hospitals performing ≤15 lobectomies annually (both p?<?0.05). On multivariate analysis, higher severity of illness (odd ratio (OR) 2.13, 95 % confidence interval (CI) [1.48–3.07], p?<?0.001), discharge to rehab (OR 1.84, [1.28–2.64], p?<?0.001), home with home health care (OR 1.38, [1.08–1.76], p?=?0.01), and surgery at a low-volume hospital (OR 1.49, [1.18–1.88], p?<?0.001) were significant predictors of readmission. Conversely, surgical intervention at high-volume centers was associated with decreased risk of readmission (OR 0.67, [0.53–0.85], p?<?0.001). When both index and readmission costs were considered, per-patient cost at low-volume centers was 21.9 % higher than at high-volume centers ($19,669 vs. $16,137). Sensitivity analyses adjusting for perioperative mortality and readmission at all centers did not significantly change the analysis.

Conclusions

These data, for the first time, demonstrate that hospital volume in hepatic lobectomy is an important, modifiable risk factor for readmission and cost. To optimize resource utilization, patients undergoing complex hepatic surgery should be directed to higher-volume surgical institutions.

     

Comparison of the outcomes for laparoscopic gastrectomy performed by the same surgeon between a low-volume hospital and a high-volume center

Background

The volume–outcome relationship in laparoscopic surgery is controversial. This study was designed to identify differences in laparoscopic gastrectomy outcomes between a low-volume hospital and a high-volume center and to provide guidelines for overcoming the problems associated with a low-volume hospital.

Methods

From April 2009 to November 2012, one surgeon performed 134 totally laparoscopic distal gastrectomies (TLDGs) at a high-volume center (HVC; ASAN Medical Center) and at a low-volume hospital (LVH; Hanyang University Guri Hospital). All laparoscopically assisted gastrectomies were excluded from this study. During the early period of laparoscopic gastrectomy at the low-volume hospital, TLDG with Roux-en-Y gastrojejunostomy (RYGJ) was performed according to the surgeon’s choice. The reconstruction method was classified as gastroduodenostomy (GD) or RYGJ. Early surgical outcomes achieved at the LVH were investigated and compared with those obtained at the HVC.

Results

The early surgical outcomes differed significantly between the two hospitals. In particular, the postoperative complication rate for the patients who underwent TLDG RYGJ at the LVH was higher than at the HVC (LVH 15.4 % vs. HVC 0 %; p = 0.037). Furthermore, significant differences were observed in the mean operation time (TLDG GD: LVH 141.0 min vs. HVC 117.4 min, p = 0.001; TLDG RYGJ: LVH 186.3 min vs. HVC 134.6 min, p = 0.009) and length of hospital stay (TLDG GD: LVH 8.1 days vs. HVC 7.2 days, p = 0.044; TLDG RYGJ: LVH 11.5 day vs. HVC 6.8 day, p = 0.009).

Conclusions

Although all the operations were performed by one experienced surgeon, the early surgical outcomes differed significantly between the low- and high-volume hospitals. Low-volume hospitals often lack well-trained surgical professionals such as first assistants and scrub nurses. Therefore, the authors recommend that a surgeon who works at an LVH should assess potential personnel shortages and find a solution before operating.     

Surgical Management Trends for Cholangiocarcinoma in the USA 1998–2009

Background

Surgical advancements have improved outcomes for cholangiocarcinoma (CCA) patients, but this expertise is not uniformly available. This research examines CCA surgical treatment patterns.

Methods

A retrospective analysis of the U.S. Nationwide Inpatient Sample from 1998?C2009 identified CCA patients at high-volume (HV) versus low-volume (LV) hospitals, and teaching versus nonteaching hospitals. We performed multinomial and multivariate logistic regressions to compare differences of surgical treatment between HV vs. LV hospitals, and teaching vs. nonteaching hospitals. Liver resection (LR), pancreaticoduodenectomy, bile duct (BD) resection, and combined liver/BD resection were considered more aggressive therapy than BD stent or bypass.

Results

A total of 32,561 patients with CCA were identified. The proportion receiving surgery declined from 36 to 30?%. There was no increase in the proportion of LRs or combined liver/BD resection. Patients at HV or teaching hospitals were more likely to receive surgical treatment [odds ratio (OR), 1.3, p?<?0.001; OR, 1.4, p?<?0.001].

Discussion

Despite increasing evidence that surgical resection increases survival, the number of patients receiving surgery has decreased. Although combined liver/BD resection has been advocated as standard management for proximal CCA, the practice has not increased. All patients with CCA should be considered for assessment at a HV teaching hospital.     

Implications of Hospital Volume on Costs Following Esophagectomy in the United States

Background

With increasing focus on health care quality and cost containment, volume-based referral strategies have been proposed to improve value in high-cost procedures, such as esophagectomy. While the effect of hospital volume on outcomes has been demonstrated, our goal was to evaluate the economic consequences of volume-based referral practices for esophagectomy.

Methods

The nationwide inpatient sample (NIS) was queried for the years 2004–2013 for all patients undergoing esophagectomy. Patients were stratified by hospital volume quartile and substratified by preoperative risk and age. Clustered multivariable hierarchical logistic regression analysis was used to assess adjusted costs and mortality.

Results

In total, 9270 patients were clustered based on annual hospital volume quartiles of <?7, 7 to 22, 23 to 87, and >?87 esophagectomies. After stratification by patient variables, high-volume centers performed esophagectomies in high-risk patients at the same cost as low-volume centers without significant difference in resource utilization. Overall, mortality decreased across volume quartiles (lowest 8.9 versus highest 3.6%, p?<?0.0001). The greatest volume-mortality differences were observed among patients aged between 70 and 80 years (lowest 12.2 versus highest 6.2%, p?=?0.009). Patients with high preoperative risk also derived mortality benefits with increasing hospital volume (lowest 17.5 versus highest 11.8%, p?<?0.0001).

Conclusions

This study demonstrates that the mortality improvements for high-risk patients undergoing esophagectomy at high-volume centers do not come at increased costs. These results suggest that health systems should consider selectively referring high-risk patients to high-volume centers within their region.

     

Endoscopic submucosal dissection for gastric cancer: the influence of hospital volume on complications and length of stay

Background

Little information is available about the relationship between hospital volume and the clinical outcome of endoscopic submucosal dissection (ESD) for gastric cancer. The purpose of this study was to investigate the influence of hospital volume on clinical outcomes of ESD using a national administrative database.

Methods

A total of 27,385 patients treated with ESD for gastric cancer were referred to 867 hospitals between 2009 and 2011 in Japan. We collected patients’ data from the administrative database to compare ESD-related complications and length of stay (LOS) in relation to hospital volume. Hospital volume was categorized into three groups based on the number of cases treated over the study period: low-volume hospitals (LVHs, <50 cases), medium-volume hospitals (MVHs, 50–100 cases), and high-volume hospitals (HVHs, >100 cases). These analyses were performed for each location of gastric cancer [upper (cardia and fundus), middle (body), and lower third (antrum and pylorus)].

Results

Significant differences in ESD-related complications among the three hospital volume categories were observed for upper gastric cancer (6.5 % in LVHs vs. 5.2 % in MVHs vs. 3.4 % in HVHs; p = 0.017). Multiple logistic regression revealed that HVHs were significantly associated with decreased relative risk of ESD-related complications in upper gastric cancer (odds ratio for HVHs 0.51; 95 % confidence interval, 0.31–0.83, p = 0.007). However, no significant differences for ESD-related complications were seen for middle and lower gastric cancers among the different hospital volume categories (p > 0.05). Additionally, hospital volume was significantly associated with a decreasing LOS for all locations of gastric cancers (p < 0.001).

Conclusions

The present study has demonstrated that hospital volume was mainly associated with clinical outcome in patients with ESD for upper gastric cancer. Further studies for successive monitoring of outcomes of ESD should be conducted in the near future.     

Benefit in regionalization of care for patients treated with nephrectomy: a Nationwide Inpatient Sample

Purpose

To provide in absolute terms a quantification of regionalization of care from low- to high-volume hospitals in patients treated with nephrectomy for non-metastatic renal cell carcinoma.

Methods

Relying on the Nationwide Inpatient Sample, 48,172 patients with non-metastatic renal cell carcinoma undergoing nephrectomy were identified. All analyses focused on five specific endpoints: intraoperative complications, postoperative complications, blood transfusions, prolonged hospitalization, and in-hospital mortality. First, multivariable logistic regression models for prediction of the aforementioned endpoints were fitted among high-volume hospitals treated patients. Second, obtained coefficients from such models were applied onto low-volume hospitals treated individuals. Potentially avoidable events were computed through differences between observed and predicted adverse events. The number needed to treat was generated.

Results

Low-volume hospitals treated individuals were between 11 and 28 % more likely to succumb to an adverse outcome (all P < 0.001). Differences between observed and predicted adverse outcome rates were all in favor of high-volume hospitals, except for in-hospital mortality. Potentially avoidable intraoperative complications, postoperative complications, blood transfusions, prolonged hospitalization, and in-hospital mortality rates were 1.4, 5.6, 7.6, 24.0, and 0.7 %, respectively. Thus, for every 71, 18, 13, 4, and 143 nephrectomies that are redirected to high-volume hospitals, 1 intraoperative complication, postoperative complication, blood transfusion, prolonged hospitalization, and in-hospital mortality could be potentially avoided.

Conclusions

Regionalization from low- to high-volume hospitals for patients undergoing a nephrectomy is associated with important benefits, for both the payer and patient’s perspectives.     

A study of 11,003 patients with hypertrophic pyloric stenosis and the association between surgeon and hospital volume and outcomes

Aim

The availability of large clinical databases allows for careful evaluation of surgical practices, indicators of quality improvement, and cost. We used a large clinical database to compare the effect of surgeon and hospital volume for the care of children with hypertrophic pyloric stenosis (HPS).

Methods

Patients with International Classification of Diseases-9 codes for HPS and pyloromyotomy were selected from the 1994 to 2000 National Inpatient Samples database. Multiple and logistic regression models were used to evaluate the risk-adjusted association between provider volume and outcomes.

Results

Postoperative complications occurred in 2.71% of patients. Patients operated on by low- and intermediate-volume surgeons were more likely to have complications compared with those operated on by high-volume surgeons (95% confidence interval [CI], 1.25-3.78 and 95% CI, 1.25-2.69, respectively). Patients operated at low-volume hospitals were 1.6 times more likely to have complications compared with those operated at intermediate- or high-volume hospitals (95% CI, 1.19-2.20). Procedures performed at high-volume hospitals were less expensive than those at intermediate-volume hospitals by a margin of $910 (95% CI, $443-$1377).

Conclusions

These data represent the largest study to date on the epidemiology, complication rate, and cost for care for HPS. Patients treated by both high-volume surgeons and at high-volume hospitals have improved outcomes at less cost.     

A Qualitative Assessment of a Provincial Quality Improvement Strategy for Pancreatic Cancer Surgery

Purpose

A study released in Ontario, Canada (1999) found a positive relationship between surgical volume and patient outcomes after pancreatic resection for cancer. In response, a province-level quality improvement (QI) strategy was initiated, which included the development and dissemination of a standards document and an audit and feedback exercise with surgeons. We assessed perceptions and actions of Ontario surgeons to this QI strategy.

Methods

We conducted semistructured interviews with surgeons and chiefs of surgery at three types of hospitals providing pancreatic cancer surgery, including hospitals that provided high volumes of surgery after 2001, hospitals that provided low volumes of surgery after 2001, and hospitals that provided low volumes of surgery before 2001 and stopped after year 2001. High-volume hospitals performed ten or more surgeries annually. The interview guide was based on Pathman’s model of physician practice change (i.e., awareness, agreement, adoption, and adherence). Grounded theory guided data collection and analysis.

Results

Twenty-four interviews were completed. All groups were aware of the 1999 province-level QI strategy and agreed in principle with the standards document recommendations. Many surgeons had concerns regarding the number of cases necessary to be considered high-volume. Decisions to cease pancreas cancer surgery were occurring before 1999 and made at the surgeon level, often with input from the chief of surgery, but rarely with input from hospital administration.

Conclusions

Surgeons were aware of and agreed in principle with the province-level QI strategy for pancreas cancer surgery. Decisions to continue or cease performing surgery were made by individual surgeons.     

The effect of annual surgical caseload on the rates of in-hospital pneumonia and other in-hospital outcomes after radical prostatectomy

Purpose

To examine the effect of annual surgical caseload (ASC) on contemporary in-hospital pneumonia (IHP) rates and three other in-hospital outcomes after radical prostatectomy (RP).

Methods

Between 1999 and 2008, 34,490 open RPs were performed in the state of Florida. First, logistic regression models predicting the rate of IHP were fitted. Second, other logistic regression models examined the association between IHP and three other outcomes: in-hospital mortality, hospital charges within the highest quartile, and length of stay (LOS) within the highest quartile. Covariates included ASC, age, race, baseline Charlson Comorbidity Index (CCI), interval between admission and surgery, as well as blood transfusion.

Results

The overall IHP rate was 0.5%. It was higher in patients operated within the low (0.7%) and intermediate (0.5%) ASC tertile versus high ASC tertile (0.2%, P?P?P?P?$37,333, and were 20-fold more likely to have a LOS >3?days (all P?Conclusions RP by high ASC surgeons exerts a protective effect on IHP rates. Additionally, IHP is associated with higher in-hospital mortality, prolonged LOS, and higher hospital charges.     

Stenting versus gastrojejunostomy for management of malignant gastric outlet obstruction: comparison of clinical outcomes and costs

Background

Although endoscopic stenting is increasingly performed, surgical gastrojejunostomy (GJ) is still considered the gold standard for relief of malignant gastric outlet obstruction (GOO). The aim of this study is to compare clinical outcomes and hospital costs between patients undergoing GJ or stenting for management of malignant GOO.

Methods

A retrospective claims analysis of the Medicare (MedPAR) database was conducted to identify all inpatient hospitalizations for GJ or endoscopic stenting for malignant GOO during 2007–2008. The main outcome measure evaluated using the MedPAR database was a comparison of the total length of hospital stay (LOS) and costs associated with both techniques. As MedPAR is a claims database that does not provide outcomes at patient level, a single-institution retrospective study was conducted to compare the rates of technical and treatment success, post-procedure LOS, and delayed complications per patient between the two techniques.

Results

The MedPAR claims data evaluated 425 stenting and 339 GJ hospitalizations. Compared with GJ, median LOS (8 vs. 16?days; p?<?0.0001) and median cost (US $15,366 vs. US $27,391; p?<?0.0001) per claim were both significantly lower for stenting. Stenting was more commonly performed at urban versus rural hospitals (89 % vs. 11?%; p?<?0.0001), teaching versus non-teaching hospitals (59?% vs. 41?%, p?=?0.0005), and academic institutions (56?% vs. 44?%; p?=?0.0157). The institutional patient data analysis included 29 patients who underwent stenting and 75 who underwent surgical GJ. While both modalities were technically successful and relieved gastric outlet obstruction in all cases, compared with surgical GJ, the median post-procedure LOS was significantly lower for enteral stenting (1.5 vs. 10.7?days, p?<?0.0001). There was no difference in rates of delayed complications between stenting and surgical GJ (13.8 % vs. 6.7?%; p?=?0.26).

Conclusions

While the technical and clinical outcomes of surgical GJ and endoscopic stenting appear comparable, stent placement is less costly and is associated with shorter length of hospital stay. Dissemination of endoscopic stenting beyond teaching, academic hospitals located in urban areas as a treatment for malignant GOO is important given its implications for patient care and resource utilization.     

Preceptorship and Proctorship as an Effective Way to Learn Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy has rapidly gained popularity as a procedure for morbidly obese patients. The goal of this project is to evaluate a training program for the laparoscopic sleeve gastrectomy (LSG), given to a group of surgeons by a specialized consultant in bariatric surgery.

Methods

The training process is divided in two parts. First, bringing the trainee surgeons to a specialized bariatric center to observe and take part in bariatric procedures with an experienced bariatric surgeon (preceptorship). Second, the consulting surgeon offers on-site training to all surgeons within their own hospital (proctorship). The support personnel (bariatric nurse, OR nurse, nutritionist) accompany the surgeon and are included in the training process. Finally, preoperative, intraoperative and postoperative data are compiled and analyzed.

Results

This study included 31 patients operated for LSG by the two newly trained surgeons after proctorship. Median age was 43 and mean BMI was 45.9. No leak, stricture, or mortality was found after the surgery. Mean surgical time was 94 min, and mean hospital length of stay was 3.9 days. Minor complications were seen during the follow-up at 1 to 3–6 months with excessive weight loss (EWL) of 62 % at 6 month.

Conclusions

This study showed the effectiveness of training provided through preceptorship/proctorship with a specialized consulting surgeon. The low complication rate and the weight loss achieved in only 6 months demonstrate the safety and efficacy of this learning method.     

Pancreaticoduodenectomy: Outcomes in a Low-Volume,Specialised Hepato Pancreato Biliary Unit

Background

This study was designed to evaluate the outcomes of pancreaticoduodenectomy (PD) at a low-volume specialised Hepato Pancreato Biliary (HPB) unit. Volume outcome analyses show significantly better results for patients undergoing PD at high-volume centres (Begg et al. JAMA 280:1747–1751, 1998; Finlayson et al. Arch Surg 138:721–725, 2003; Birkmeyer et al. N Engl J Med 346:1128–1137, 2002; Gouma et al. Ann Surg 232:786–795, 2000). Centralisation of PD seems to be the logical conclusion to be drawn from these results. In countries like Australia with a small and widely dispersed population, centralisation may not be always feasible. Alternative strategy would be to have similar systems in place to those in high-volume centres to achieve similar results at low-volume centres. Many Australian tertiary care centres perform low to medium volumes of PD (Chen et al. HPB 12:101–108, 2010; Kwok et al. ANZ J Surg 80:605–608, 2010; Barnett and Collier ANZ J Surg 76:563–568, 2006; Samra et al. Hepatobiliary Pancreat Dis Int 10:415–421, 2011). Most of these have a specialised HPB unit, accredited by the Australia and New Zealand Hepatic pancreatic and biliary association (ANZHPBA), as training units for post fellowship training in HPB surgery. It is imperative to perform outcome-based analyses in these units to ensure safety and high quality of care.

Methods

Retrospective analysis of database for periampullary carcinoma (1998 till date) was performed in an ANZHPBA accredited HPB unit based at a tertiary care teaching hospital in South Australia. Because age older than 74 years is shown to be a predictive marker of increased morbidity and mortality after a PD, we analysed the outcomes in this subset of patients separately.

Results

Fifty-three patients underwent PD in 14 years. Overall mortality was 3.8 %. The last in hospital mortality was in 1999. The morbidity rates and the oncologic outcomes were similar to those in high-volume units.

Conclusions

PD can be safely performed in a low-volume specialised unit at centres where the amenities and processes at high-volume centres can be replicated.     

Single-incision laparoscopic surgery: Impact on direct cost and resource utilization for right colectomy

Aim-Background

Single-incision laparoscopic (SIL) colectomy is feasible and safe. The impact of SIL technique on cost is unknown. This study compares direct cost and resource utilization of SIL right-colectomy to multiport laparoscopic (LAP) and hand-assisted laparoscopic (HAL) techniques. The purpose of this study is to determine whether the SIL technique affects cost and resource utilization in the operating room.

Study Design

Twenty-nine sequential SIL right-colectomy cases were performed between August 2009 and April 2010 and were case-matched for age, gender, body mass index (BMI), ASA score, previous abdominal surgery and pathology to an equivalent number of LAP and HAL right-colectomy cases. Outcome, resource utilization and direct cost were analyzed with a 90-day follow-up.

Results

Outcomes including conversion rates, postoperative morbidity, ER visits and readmissions were similar among groups. Primary hospitalization length of stay (LOS) was shorter for the SIL group (p<0.05); however, when including readmission days, LOS was equivalent among the three groups. Primary hospitalization cost was similar for SIL ($5920) and LAP ($6716) groups, but the cost for SIL was significantly lower than that for the HAL group ($7560; p<0.01). Total OR cost was similar for SIL ($3620) and LAP ($3931) groups, and both were lower than the HAL group ($4435; p<0.01). Total operating room time was equivalent among groups (164 to 176 min; p=0.31). The SIL technique was associated with a reduction in the number of additional ports, staplers, and stapler reloads (p<0.01) used. Total 90-day cost was equivalent among the three groups.

Conclusions

SIL right colectomy technique results in decreased direct cost for primary hospitalization and total OR cost compared to the HAL technique. Our data suggest this may be due, in part, to changes in practice patterns and resource utilization.