Investigation of the relationship between volume and mortality for surgical procedures performed in New York State hospitals

Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures

BACKGROUND

There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications.

METHODS

We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879).

RESULTS

The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis.

CONCLUSION

We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.

Is surgical treatment of hepatocellular carcinoma at high-volume centers worth the additional cost?

BACKGROUND

Case volume has been associated with improved outcomes for patients undergoing treatment for hepatocellular carcinoma, often with higher hospital expenditures. We sought to define the cost-effectiveness of hepatocellular carcinoma treatment at high-volume centers.

METHODS

Patients diagnosed with hepatocellular carcinoma from 2013 to 2017 were identified from Medicare Standard Analytic Files. High-volume centers were defined as the top decile of facilities performing hepatectomies in a year. A multivariable generalized linear model with gamma distribution and a restricted mean survival time model were used to estimate costs and survival differences relative to high-volume center status. The incremental cost-effectiveness ratio was used to define the additional cost incurred for a 1-year incremental gain in survival.

RESULTS

Among 13,666 patients, 8,467 (62.0%) were treated at high-volume centers. Median expenditure was higher ($19,148, interquartile range $15,280-$29,128) among patients treated at high-volume centers versus low-volume centers ($18,209, interquartile range $14,959-$29,752). Despite similar median length-of-stay (6 days, interquartile range 4-9), a slightly higher proportion of patients were discharged to home from high-volume centers (n = 4,903, 57.9%) versus low-volume centers (n = 2,868, 55.2%) (P = .002). A 0.14-year (95% confidence interval 0.06-0.22) (1 month and 3 weeks) survival benefit was associated with an incremental cost of $1,070 (95% confidence interval $749-$1,392) among patients undergoing surgery at high-volume centers. The incremental cost-effectiveness ratio for treatment at a high-volume center was $7,951 (95% confidence interval $4,236-$21,217) for an additional year of survival, which was below the cost-effective threshold of $21,217.

CONCLUSION

Surgical care at high-volume centers offers the potential to deliver cancer care in a more cost-effective and value-based manner.

Specialized Thoracic Adapted Recovery Model for Thoracic Organ Recovery: a 15-Year Review

BACKGROUND

To review outcomes from a regionalized heart and lung transplant service over a 15-year period.

METHODS

Data on organ procurements made by the Specialized Thoracic Adapted Recovery (STAR) team. The STAR team staff recorded data from November 2, 2004 to June 30, 2020, were reviewed.

RESULTS

The STAR teams recovered thoracic organs from 1118 donors between November 2004 and June 2020. The teams recovered 978 hearts, 823 bilateral lungs, 89 right lungs and 92 left lungs, and 8 heart and lung sets. A total of 79% of hearts and 76.1% of lungs were transplanted, whereas 2.5% of hearts and 5.1% of lungs were declined; the remainder were used for research, valves, or abandoned. A total of 47 transplantation centers received at least 1 heart, and 37 centers received at least 1 lung during this period. The 24-hour graft survival among organs recovered by STAR teams was 100% for lungs and 99% for hearts.

CONCLUSIONS

A specialized regional thoracic organ procurement team may improve transplantation rates.

Hepatopancreatic Surgeons Versus Pancreatic Surgeons: Does Surgical Subspecialization Impact Patient Care and Outcomes?

BACKGROUND

Hepatopancreatic (HP) surgeon and hospital procedural volume may vary relative to liver or pancreas cases. We sought to investigate the impact of surgeon and hospital pancreatic subspecialization on patient outcomes.

METHODS

Patients who underwent pancreatic surgery between 2013-2017 were identified from the Medicare Standard Analytic Files. The surgery subspecialization index (SSI) was calculated to signify surgeon and hospital pancreatic subspecialization, and categorized as low, intermediate, and high SSI. The association of SSI with Textbook Outcome (TO) and its components, failure to rescue (FTR), discharge to home and index admission expenditures was assessed with mixed-effects multivariable logistic regression.

RESULTS

Among 19,625 patients, most pancreatic procedures were characterized by high SSI (Low SSI: 27.7%, Intermediate SSI: 34.7%, High SSI: 37.7%). Notably, higher SSI was associated with greater odds of achieving a TO [Intermediate SSI: OR 1.16 (95%CI 1.06-1.27); High SSI: OR 1.23 (95%CI 1.11-1.35)] as well as being discharged home, and  lower odds of experiencing FTR. Furthermore, this association persisted in both low-volume [referent: Low SSI; Intermediate SSI: OR 1.14 (95%CI 1.01-1.28); High SSI: OR 1.15 (95%CI 1.02-1.31)] and high-volume hospitals [referent: Low SSI; Intermediate SSI: OR 1.16 (95%CI 1.01-1.32); High SSI: OR 1.26 (95%CI 1.09-1.45)].

CONCLUSIONS

Greater pancreatic subspecialization was associated with improved postoperative outcomes following pancreatic resection. Amidst increasing efforts to improve quality of care, surgical subspecialization may play a role in determining patient outcomes regardless of total surgeon or hospital volume.

The Effect of Clinical Volume on Annual and Per-Patient Encounter Medical Malpractice Claims Risk

OBJECTIVES

The relationship between medical malpractice risk and one of the fundamental characteristics of physician practice, clinical volume, remains undefined. This study examined how the annual and per-patient encounter medical malpractice claims risk varies with clinical volume.

METHODS

Clinical volume was determined using health insurance charges and was linked at the physician level to malpractice claims data from a malpractice insurer. The annual medical malpractice claims risk was expressed as the percent of physicians with a malpractice claim, and the per-encounter medical malpractice claims risk was expressed as malpractice claims per 1000 patient encounters. Both of these malpractice claims risk metrics were analyzed as a function of clinical volume, using linear and spline regression.

RESULTS

As clinical volume increased, the percent of physicians with a malpractice claim increased linearly. Among all physicians studied, for each decile increase in clinical volume, there was a 0.373% increase in physicians with a malpractice claim (95% confidence interval, 0.301%-0.446%; P < 0.0001). As clinical volume increased, the rate of malpractice claims per 1000 patient encounters decreased. This relationship between clinical volume and per-encounter claims risk was nonlinear. There was a clinical volume threshold, below which decreasing clinical volume was associated with increasing per-encounter claims risk, and above which claims risk no longer significantly varied with increases in clinical volume.

CONCLUSIONS

Clinical volume is a crucial determinant of physician malpractice risk, with higher-volume physicians having higher annual risk but lower per-encounter risk. Clinical volume data should be incorporated into analyses of malpractice risk.

Should Interventional Cardiologists Super-Subspecialize?: Moving From Patient Selection to Operator Selection

The field of interventional cardiology has expanded rapidly. As a result, four evolving areas have evolved - peripheral vascular interventions, structural heart interventions, adult congenital heart intervention, and chronic total occlusion. The complexity of these procedures and the number of devices available has grown rapidly. In addition, the professional and public expectations of procedural success and of minimizing case-avoidance have also grown. Specific issues include volume-outcome relationships, maintaining currency and proficiency, accessibility to specialized procedures, and the need to maintain a fundamental level of expertise in acute coronary interventions.

Bridging Two Worlds: Application of Organizational Theory to Cardiac Surgery

BACKGROUND

This review summarizes applications of organizational theory and management research to cardiac surgery as it relates to patient outcomes and the adoption of new technology.

METHODS

A total of 17 papers published in top organizational theory and management journals from 2000-2020 that examined the cardiac surgery care setting were included. Findings were classified according to two major outcomes of interest: patient care and new technology adoption patterns. Findings were further stratified based on whether predictors of these outcomes were individual-, team-, or organizational-level factors.

RESULTS

A growing number of studies in the organizational theory and management literature has been using the cardiovascular care setting as a research context. Applying the various theoretical lens of organizational theory, these studies have studied how individual-, team-, and organizational-level factors influence 1) patient care outcomes such as patient mortality rates, readmission rates, post-surgery complication rates, surgery duration, and length-of-stay and 2) the adoption of new technologies or the abandonment of old technologies. Examples of these factors include task specialization, multi-siting, attribution, team familiarity dispersion, distribution of failure, workload, responsibility complementarity, expertise, team learning processes, technology status, organizational missions, and organizational status.

CONCLUSIONS

Well-established and studied principles from the fields of organizational theory and management research can provide unique and valuable insights into how care processes, individual attributes, systems-related factors, and the interplay between such factors affect cardiac surgical patient outcomes and clinical care. Expanding collaboration between these fields and clinicians in cardiac surgery seems prudent.

Use of Preoperative Imaging in Primary Hyperparathyroidism

CONTEXT

Preoperative imaging is performed routinely to guide surgical management in primary hyperparathyroidism, but the optimal imaging modalities are debated.

OBJECTIVE

Our objectives were to evaluate which imaging modalities are associated with improved cure rate and higher concordance rates with intraoperative findings. A secondary aim was to determine whether additive imaging is associated with higher cure rate.

DESIGN, SETTING, AND PATIENTS

This is a retrospective cohort review of 1485 adult patients during a 14-year period (2004-2017) at an academic tertiary referral center that presented for initial parathyroidectomy for de novo primary hyperparathyroidism.

MAIN OUTCOME MEASURES

Surgical cure rate, concordance of imaging with operative findings, and imaging performance.

RESULTS

The overall cure rate was 94.1% (95% confidence interval, 0.93-0.95). Cure rate was significantly improved if sestamibi/single-photon emission computed tomography (SPECT) was concordant with operative findings (95.9% vs. 92.5%, P = 0.010). Adding a third imaging modality did not improve cure rate (1 imaging type 91.8% vs. 2 imaging types 94.4% vs. 3 imaging types 87.2%, P = 0.59). Despite having a low number of cases (n = 28), 4-dimensional (4D) CT scan outperformed (higher sensitivity, specificity, positive predictive value, negative predictive value) all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas.

CONCLUSIONS

Preoperative ultrasound combined with sestamibi/SPECT were associated with the highest cure and concordance rates. If pathology was not found on ultrasound and sestamibi/SPECT, additional imaging did not improve the cure rate or concordance. 4D CT scan outperformed all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas, but these findings were underpowered.

A Nationwide Study Assessing Preventable Hospitalization Rate on Mortality After Major Cardiovascular Surgery

Despite the use of various factors to measure hospital quality, most measures have not resulted in long-term improvements in patient outcomes. This study's purpose is to determine the effect of a previously unassessed measure of quality of care-a hospital's preventable hospitalization rate-on 30-day mortality at both the hospital and individual levels after three major cardiovascular surgery procedures. This is a population-based study using Taiwan's National Health Insurance database. We retrieved data from 2001 to 2014 for patients who had undergone abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft, or aortic valve replacement (AVR). Preventable hospitalizations are hospitalizations for 11 chronic conditions that are considered preventable with effective primary care. The outcome was 30-day surgical mortality. Our dataset contained 65,863 patients who had undergone surgery for one of the three cardiovascular procedures. Preventable hospitalization rate was significantly associated with higher hospital mortality rates for all procedures. At the patient level, the adjusted odds of mortality after AAA repair were increased 55% (P < 0.01) for every 2% increase in the preventable hospitalization rate. For coronary artery bypass graft, preventable hospitalization was not a significant predictor of mortality, but rather patient factors and surgeon factors were significant. For AVR, the adjusted odds of mortality were increased 7% (P < 0.01) for every 1% increase in preventable hospitalization rate. High preventable hospitalization rate may serve as a hospital quality measure that could signal increased odds of mortality for selected cardiovascular procedures, especially for higher risk-lower volume procedures such as AAA repair and AVR.

The impact of hospital grade, hospital-volume, and surgeon-volume on outcomes for adults undergoing appendicectomy

INTRODUCTION

Acute Appendicitis and appendicectomy are common surgical emergencies worldwide. However, there is a lack of published data on the impact of hospital grade, surgeon- and hospital-volumes on patient outcomes following appendicectomy.

AIM

To establish if hospital grade, hospital-volume, or surgeon-volume impacted patient outcomes following appendicectomy.

METHODS

Using the National Quality Assurance and Improvement System (NQAIS) data for all appendicectomies performed in Ireland between January 2014 and November 2017 were examined. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care and re-admission rates were collected and analysed.

RESULTS

During the study period, 15,896 adult appendicectomies were performed, 14,521 were laparoscopic procedures. Patients treated in district general hospitals (DGHs) had lower LOS (2.96 v 3.37 days, p < 0.0001) than patients treated in tertiary referral hospitals (TRHs), had lower rates of laparoscopic procedures (87.38% v 95.56% p < 0.0001) and higher admission rates to critical care (1.91% v 0.75% p < 0.0001). No significant outcome difference was seen between those treated by high-volume (>62 cases/year) or low volume surgeons (<20 cases/year). Patients treated in high-volume hospitals (>260 cases/year) had higher rates of laparoscopic procedures (94.9% v 83.5%, p < 0.0001), lower rates of admission to critical care (0.85% v 2.25%, p < 0.0001) and lower 7-day re-admission rates (2.54% v 3.55%, p = 0.02) than those operated in low-volume hospitals (<161 cases/year).

CONCLUSION

Patients operated on in high-volume hospitals benefit from higher rates of laparoscopic surgery and fewer critical care admissions. No significant difference in outcome was noted in those patients operated upon by high- or low-volume surgeons or based on hospital grade.

The Outcome of Cemented Acetabular Components in Total Hip Arthroplasty for Osteoarthritis Defines a Proficiency Threshold: Results of 22,956 Cases From the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

The declining popularity of cemented acetabular components is incongruous, given the published results of prostheses implanted using contemporary techniques. The outcome of arthroplasty has previously been demonstrated to correlate with surgeon experience and volume of practice. We aim to explore if surgeon volume alters outcomes of cemented acetabular components based on survivorship data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR).

METHODS

An observational study was undertaken using a cohort of 22,956 patients with a primary diagnosis of osteoarthritis in the period 2003-2016 in whom cemented acetabular components were implanted. The cohort was stratified by age (greater than or less than 65 years) and annualized surgical volume of ≤10, >10-≤25, and >25 cases.

RESULTS

Stratified by age and volume, there was a protective benefit against revision conveyed at volume thresholds of 10 cases per annum and 25 cases per annum for patients ≥65 years of age and <65 years of age, respectively.

CONCLUSION

Cemented total hip arthroplasty has excellent survivorship out to 15 years based on AOANJRR data. This survivorship is further improved if surgeons perform a higher volume of cases, with >25 cases conferring the greatest benefit. The AOANJRR data set is used to define best practice; surgeons who choose to utilize cemented acetabular fixation should be encouraged to perform this technique in adequate volumes to minimize revision risk and ensure the preservation of this important surgical skill set.

Physician-Level Variation in Outcomes of Mechanically Ventilated Patients

RATIONALE

Physicians are increasingly being held accountable for patient outcomes, yet their specific contribution to the outcomes remains uncertain.

OBJECTIVES

To determine variation in outcomes of mechanically ventilated patients among intensivists, as well as associations between intensivist experience and patient outcomes.

METHODS

We performed a retrospective cohort study of mechanically ventilated Medicare fee-for-service patients in acute care hospitals in Pennsylvania using administrative, clinical, and physician data from Centers for Medicare and Medicaid Services and the American Medical Association from 2008 and 2009. We identified intensivists by training background, board certification, and claims for services provided to patients admitted to an intensive care unit. We assigned patients to intensivists for outcome attribution based on submitted claims for critical care and in-patient services. We estimated the physician-specific adjusted odds ratios (ORs) for 30-day mortality using a hierarchical model with a random effect for physician, adjusted for patient and hospital characteristics. We tested for independent association of physician experience with patient outcomes using mixed-effects regression for the primary outcome of 30-day mortality. We defined physician experience in two ways: years since training completion ("duration") and annual number of mechanically ventilated patients ("volume").

RESULTS

We assigned 345 physicians to 11,268 patients. The 30-day mortality was 43% and median hospital length of stay was 11 days (interquartile range = 6-18). The physician adjusted OR varied from 0.72 to 1.64 (median = 0.99; interquartile range = 0.92-1.09). A total of 48% of physicians was outliers, with an adjusted OR significantly different from 1. However, among intensivists, physician experience was not associated with 30-day mortality (duration OR = 1.00 per additional year; 95% confidence interval = 1.00-1.01; volume OR = 1.00 per additional patient; 95% confidence interval = 1.00-1.00).

CONCLUSIONS

Intensivists independently contribute to outcomes of Medicare patients who undergo mechanical ventilation, as evidenced by the variation in risk-adjusted mortality across intensivists. However, physician experience does not underlie this relationship between intensivists, suggesting the need to identify modifiable physician factors to improve outcomes.

Hospital Volume and Operative Mortality for General Surgery Operations Performed Emergently in Adults

OBJECTIVE

This study aimed to answer 2 questions: first, to what degree does hospital operative volume affect mortality for adult patients undergoing 1 of 10 common emergency general surgery (EGS) operations? Second, at what hospital operative volume threshold will nearly all patients undergoing an emergency operation realize the average mortality risk?

BACKGROUND

Nontrauma surgical emergencies are an underappreciated public health crisis in the United States; redefining where such emergencies are managed may improve outcomes. The field of trauma surgery established regionalized systems of care in part because studies demonstrated a clear relationship between hospital volume and survival for traumatic emergencies. Such a relationship has not been well-studied for nontrauma surgical emergencies.

METHODS

Retrospective cohort study of all acute care hospitals in California performing nontrauma surgical emergencies. We employed a novel use of an ecological analysis with beta regression to investigate the relationship between hospital operative volume and mortality.

RESULTS

A total of 425 acute care hospitals in California performed 165,123 EGS operations. Risk-adjusted mortality significantly decreased as volume increased for all 10 EGS operations (P < 0.001 for each); the relative magnitude of this inverse relationship differed substantially by procedure. Hospital operative volume thresholds were defined and varied by operation: from 75 cases over 2 years for cholecystectomy to 7 cases for umbilical hernia repair.

CONCLUSIONS

Survival rates for nontrauma surgical emergencies were improved when operations were performed at higher-volume hospitals. The use of ecological analysis is widely applicable to the field of surgical outcomes research.

Study of the evolution and variability of nontraumatic orthopedic surgeries in Brazil-9 years of follow-up: A database study

In Brazil, there are no epidemiological statistics that map nontraumatic orthopedic injuries, their rate of variability, distribution by specialty, fatality rate, and the economic impact that these lesions and their consequences can bring to the country. The objective of this study was to evaluate the rates of variability for skills, deaths, mortality, and the economic impact of nontraumatic orthopedic surgeries in Brazil from 2008 to 2016.This is a descriptive study conducted through the analysis of data relating to the indicators of hospital production regarding orthopedic procedures of the Department of Informatics of the Unified Health System (Departamento de Informática do Sistema Único de saúde-DATASUS) between 2008 and 2016. The level of significance was 5%.There was a predominance of hospitalizations for surgery of the lower limbs, which also resulted in the largest number of deaths. The surgical mortality rate recorded for the hip also needs to be considered. In general, there is a national increase in the number of orthopedic surgeries performed, accompanied by a concomitant increase in the number of deaths and mortality of the population exposed.We observed a growing demand for hospitalization with a consequent increase in lethality and deaths. We can conclude that between 2008 and 2016, the number of hospitalizations for elective nontraumatic orthopedic surgical procedures increased significantly, driven mainly by lower limb surgeries, along with the cost of the Unified Health System (Sistema Único de Saúde-SUS) for these surgeries.

What's in a name? Tensions between formal and informal communities of practice among regional subspecialty cancer surgeons

In 2007 the Cancer Care Ontario Hepatobiliary-Pancreatic (HPB) Community of Practice was formed during the wake of provincial regionalization of HPB services in Ontario, Canada. Despite being conceptualized within the literature as an educational intervention, communities of practice (CoP) are increasingly being adopted in healthcare as quality improvement initiatives. A qualitative case study approach using in-depth interviews and document analysis was employed to gain insight into the perceptions and attitudes of the HPB surgeons in the CoP. This study demonstrates how an engineered formal or idealized structure of a CoP was created in tension with the natural CoPs that HPB surgeons identified with during and after their training. This tension contributed to the inactive and/or marginal participation by some of the surgeons in the CoP. The findings of this study represent a cautionary tale for such future engineering attempts in two distinct ways: (1) a CoP in surgery cannot simply be created by regulatory agencies, rather they need to be supported in a way to evolve naturally, and (2) when the concept of CoPs is co-opted by governing bodies, it does not necessarily capture the power and potential of situated learning. To ensure CoP sustainability and effectiveness, we suggest that both core and peripheral members need to be more directly involved at the inception of the COP in terms of design, organization, implementation and ongoing management.

Embolisation for pulmonary arteriovenous malformation

BACKGROUND

Pulmonary arteriovenous malformations are abnormal direct connections between the pulmonary artery and pulmonary vein which result in a right-to-left shunt. They are associated with substantial morbidity and mortality mainly from the effects of paradoxical emboli. Potential complications include stroke, cerebral abscess, pulmonary haemorrhage and hypoxaemia. Embolisation is an endovascular intervention based on the occlusion of the feeding arteries the pulmonary arteriovenous malformations thus eliminating the abnormal right-to-left-shunting. This is an update of a previously published review.

OBJECTIVES

To determine the efficacy and safety of embolisation in patients with pulmonary arteriovenous malformations including a comparison with surgical resection and different embolisation devices.

SEARCH METHODS

We searched the Cystic Fibrosis and Genetic Disorders Group's Trials Register; date of last search: 10 April 2017.We also searched the following databases: the Australian New Zealand Clinical Trials Registry; ClinicalTrials.gov; International Standard Randomised Controlled Trial Number Register; International Clinical Trials Registry Platform Search Portal (last searched 27 August 2017). to be updatedWe checked cross-references and searched references from review articles.

SELECTION CRITERIA

Trials in which individuals with pulmonary arteriovenous malformations were randomly allocated to embolisation compared to no treatment, surgical resection or embolisation using a different embolisation device.

DATA COLLECTION AND ANALYSIS

Studies identified for potential inclusion were independently assessed for eligibility by two authors, with excluded studies further checked by a third author. No trials were identified for inclusion in the review and hence no analysis was performed.

MAIN RESULTS

There were no randomised controlled trials included in the review; one ongoing trial has been identified which may be eligible for inclusion in the future.

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials for embolisation of pulmonary arteriovenous malformations. However, randomised controlled trials are not always feasible on ethical grounds. Accumulated data from observational studies suggest that embolisation is a safe procedure which reduces morbidity and mortality. A standardised approach to reporting with long-term follow-up through registry studies can help to strengthen the evidence for embolisation in the absence of randomised controlled trials.

Acute Respiratory Distress Syndrome Cases Volume and ICU Mortality in Medical Patients

OBJECTIVES

To determine whether ICUs caring for higher volumes of acute respiratory distress syndrome patients would be associated with lower ICU mortality.

DESIGN

A 9-year multicenter retrospective cohort study of prospectively collected data.

SETTING

French medical ICUs.

PATIENTS

From 2004 to 2012, acute respiratory distress syndrome cases were identified from a coding system through a regional database (Collège des Utilisateurs de Données en Réanimation).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Volume was calculated as the cumulative annual mean number of acute respiratory distress syndrome cases. Severity (Simplified Acute Physiology Score 2) and ICU mortality between categories (low, medium, and high) of acute respiratory distress syndrome cases volume were analyzed. Multivariable analysis using mixed effects models was performed to adjust for severity of illness and confounding factors. Over the study period, 8,383 acute respiratory distress syndrome patients among 31 ICUs met the study inclusion criteria. Overall, Simplified Acute Physiology Score 2 (median [interquartile]) was 58 (43-74), whereas ICU mortality was 53.7%. Severity as assessed by Simplified Acute Physiology Score 2 (median [interquartile]) was significantly higher in high-volume ICUs (> 65 acute respiratory distress syndrome per year) as compared to low (≤ 29 acute respiratory distress syndrome per year) and medium-volume ICUs (> 29-65 acute respiratory distress syndrome per year): 61 (46-77) versus 55 (41-72) and 55.0 (40-72), respectively (p < 0.01). ICU mortality was similar across the acute respiratory distress syndrome volume categories (53.6%, 54.1%, and 53.3% in low-, medium-, and high-volume categories ICUs, respectively). After adjustment for confounders, acute respiratory distress syndrome case volume was independently associated with ICU mortality (odds ratio for log-transformed volume: 0.77 [95% CI, 0.62-0.96]; p = 0.02).

CONCLUSIONS

ICUs caring for higher volumes of acute respiratory distress syndrome cases were associated with lower ICU mortality.

Length of Stay and Cost in Patients Undergoing Orthognathic Surgery: Does Surgeon Volume Matter?

PURPOSE

The relations among procedure-specific annual surgeon volume, hospital length of stay (LOS), and hospital costs for patients undergoing the 2 most common orthognathic surgical (OGS) procedures, segmental osteoplasty or osteotomy of the maxilla (SOM) or open osteoplasty or osteotomy of the mandibular ramus (SOMR), are not known. The authors hypothesized that treatment by high-volume surgeons would be associated with decreased LOS and costs.

MATERIALS AND METHODS

All patients 8 to 64 years old who underwent elective SOM or SOMR were selected from the 2001 to 2009 Nationwide Inpatient Sample. Patients with missing vital status or payment mode status or who underwent more than 1 OGS procedure during the index hospitalization were excluded. Based on year- and procedure-specific annual surgeon volumes, the highest (highest quartile) and lowest (lowest quartile) procedure volume surgeon groups were compared. Multivariable logistic regression was used to study the relation between surgeon volume and extended patient LOS (defined as LOS ≥ 75th percentile). Generalized linear models with a log-link and gamma distribution were used to examine the association between surgeon volume and hospital costs. Models were adjusted for patient- and hospital-level factors and type of procedure (SOM or SOMR). Analysis was weighted to represent national-level estimates and an α value of 0.05 was used for all comparisons.

RESULTS

After weighting to the population level, 8,062 patients were included for study. Most were white (80.6%), female (61.4%), and privately insured (84.6%). Mean age was 26 years (standard deviation, 0.38 yr). After adjusting for potential confounders, patients treated by high-volume surgeons showed 40% lower odds of extended LOS (odds ratio = 0.60; 95% confidence interval [CI], 0.38-0.95; P = .032) and incurred substantially lower costs (-$1,484.74; 95% CI, -2,782.76 to -185.58; P = .025) compared with patients treated by low-volume surgeons.

CONCLUSION

These findings suggest that regionalization of patients to high-volume surgeons for OGS procedures could decrease LOS and incurred costs.

Simulated Regionalization of Heart and Lung Transplantation in the United States

We simulated the impact of regionalization of isolated heart and lung transplantation within United Network for Organ Sharing (UNOS) regions. Overall, 12 594 orthotopic heart transplantation (OHT) patients across 135 centers and 12 300 orthotopic lung transplantation (OLT) patients across 67 centers were included in the study. An algorithm was constructed that "closed" the lowest volume center in a region and referred its patients to the highest volume center. In the unadjusted analysis, referred patients were assigned the highest volume center's 1-year mortality rate, and the difference in deaths per region before and after closure was computed. An adjusted analysis was performed using multivariable logistic regression using recipient and donor variables. The primary outcome was the potential number of lives saved at 1 year after transplant. In adjusted OHT analysis, 10 lives were saved (95% confidence interval [CI] 9-11) after one center closure and 240 lives were saved (95% CI 209-272) after up to five center closures per region, with the latter resulting in 1624 total patient referrals (13.2% of OHT patients). For OLT, lives saved ranged from 29 (95% CI 26-32) after one center closure per region to 240 (95% CI 224-256) after up to five regional closures, but the latter resulted in 2999 referrals (24.4% of OLT patients). Increased referral distances would severely limit access to care for rural and resource-limited populations.

Does Specialization Improve Outcome in Abdominal Aortic Aneurysm Surgery?

Specialization and high volume are reported to be related to a better outcome after abdominal aortic aneurysm repair. The aim of this study was to compare, in patients undergoing abdominal aortic aneurysm repair, the outcomes of those whose surgery was done by general surgeons with the outcomes of those whose surgery was done by specialist vascular surgeons.

All patients undergoing abdominal aortic aneurysm repair at the Basel University Hospital (referral center) from January 1990 to December 2000 were included. Patients with endovascular treatment were excluded.

Operations in group A ( n = 189), between January 1990 and May 1995, were done by general surgeons. Operations in group B ( n = 291), between June 1995 and December 2000, were done by vascular surgeons.

In-hospital mortality and local and systemic complications were assessed.

In-hospital mortality rates were significantly lower for group B (with specialist surgeons) than for group A, both overall (group B, 11.7%; group A, 21.7%; p = .003) and for emergency interventions (group B, 28.1%; group A, 41.9%; p = .042). The reduction in mortality for elective surgery in group B was not statistically significant (group B, 1.1%; group A, 4.9%; p = .054). There were significantly fewer pulmonary complications in group B compared with group A ( p = .000).

We conclude that in patients undergoing abdominal aortic aneurysm repair, those whose surgery is done by a specialized team have a significantly better outcome than those whose surgery is done by general surgeons.

When Does Regionalization of Expensive Medical Care save Money?

Regionalization of expensive, high-technology medical care is often proposed as a way to reduce medical costs. Most empirical estimates of the cost implications of regionalization suffer from methodological shortcomings. Here, we discuss all the factors that must be taken into account to produce an accurate assessment of how regionalization changes costs. These factors include the following: (1) The extent of resource sharing among different services; (2) The extent of unused capacity; (3) Whether regionalized facilities have high, low or average costs; (4) Costs of a regionalized system, including transporting patients to the regionalized facilities, coordinating care between the referring and regionalized providers, and out-of network care; (5) The effect of regionalization on the volume of care; and (6) whether a short- or long-term view is taken.

Beyond Volume: Hospital-Based Healthcare Technology for Better Outcomes in Cerebrovascular Surgical Patients Diagnosed With Ischemic Stroke: A Population-Based Nationwide Cohort Study From 2002 to 2013

We examined whether the level of hospital-based healthcare technology was related to the 30-day postoperative mortality rates, after adjusting for hospital volume, of ischemic stroke patients who underwent a cerebrovascular surgical procedure. Using the National Health Insurance Service-Cohort Sample Database, we reviewed records from 2002 to 2013 for data on patients with ischemic stroke who underwent cerebrovascular surgical procedures. Statistical analysis was performed using Cox proportional hazard models to test our hypothesis. A total of 798 subjects were included in our study. After adjusting for hospital volume of cerebrovascular surgical procedures as well as all for other potential confounders, the hazard ratio (HR) of 30-day mortality in low healthcare technology hospitals as compared to high healthcare technology hospitals was 2.583 (P < 0.001). We also found that, although the HR of 30-day mortality in low healthcare technology hospitals with high volume as compared to high healthcare technology hospitals with high volume was the highest (10.014, P < 0.0001), cerebrovascular surgical procedure patients treated in low healthcare technology hospitals had the highest 30-day mortality rate, irrespective of hospital volume. Although results of our study provide scientific evidence for a hospital volume/30-day mortality rate relationship in ischemic stroke patients who underwent cerebrovascular surgical procedures, our results also suggest that the level of hospital-based healthcare technology is associated with mortality rates independent of hospital volume. Given these results, further research into what components of hospital-based healthcare technology significantly impact mortality is warranted.

Intermediate-fidelity simulator for self-training in mitral valve surgery

Current training in mitral valve (MV) surgery is affected by many factors, among which are the complexity of surgical procedures and complex three-dimensional anatomy of the MV. An MV repair simulator is proposed in this study as a low-cost, reusable and portable tool to guide trainees at all levels to effectively construct it with the aim of improving their surgical skills in major techniques of MV surgery in an intermediate-fidelity concept. The simulator is a self-made portable box that is supplied with a self-made silicone MV substitute to simulate the flexible property of MV components. The building process is detailed in this study. Surgical procedures were simulated to test the surgical handling.

Improving Survival of Pancreatic Cancer. What Have We Learnt?

Pancreatic adenocarcinoma still ranks high among cancer-related deaths worldwide. In spite of substantial strides in preoperative staging, surgery, perioperative care, and adjuvant treatment, the survival still remains dismal. A number of patient-, disease-, and surgeon-related factors play a role in deciding the eventual outcome of the patient. The aim of this commentary is to review the current knowledge of various factors and the recent advances that impact the survival of patients with pancreatic adenocarcinoma. A search of scientific literature using Embase and MEDLINE, for the years 1985-2015, was carried out for search terms "pancreatic cancer" and "survival." Further search was based on the various specific prognostic factors that contribute towards survival of patients with pancreatic cancer found in the literature. Most of the studies used for this review include those that deal with pancreatic head cancers, some include patients with pancreatic cancers in all locations while very few included patients with tumors of body and tail only. In spite of significant developments in pre- and perioperative management, increased rates of margin-negative resections, and use of adjuvant treatment, the survival rates of pancreatic cancer patients remains poor. A paradigm shift with more effective adjuvant regimen and genetic interventions may help change the outcomes of patients with pancreatic cancer.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part III: impact and sustainability

BACKGROUND

The Guwahati Comprehensive Cleft Care Center (GCCCC) utilizes a high-volume, subspecialized institution to provide safe, quality, and comprehensive and cost-effective surgical care to a highly vulnerable patient population.

METHODS

The GCCCC utilized a diagonal model of surgical care delivery, with vertical inputs of mission-based care transitioning to investments in infrastructure and human capital to create a sustainable, local care delivery system. Over the first 2.5 years of service (May 2011-November 2013), the GCCCC made significant advances in numerous areas. Progress was meticulously documented to evaluate performance and provide transparency to stakeholders including donors, government officials, medical oversight bodies, employees, and patients.

RESULTS

During this time period, the GCCCC provided free operations to 7,034 patients, with improved safety, outcomes, and multidisciplinary services while dramatically decreasing costs and increasing investments in the local community. The center has become a regional referral cleft center, and governments of surrounding states have contracted the GCCCC to provide care for their citizens with cleft lip and cleft palate. Additional regional and global impact is anticipated through continued investments into education and training, comprehensive services, and research and outcomes.

CONCLUSION

The success of this public private partnership demonstrates the value of this model of surgical care in the developing world, and offers a blueprint for reproduction. The GCCCC experience has been consistent with previous studies demonstrating a positive volume-outcomes relationship, and provides evidence for the value of the specialty hospital model for surgical delivery in the developing world.

Comparison of Inhospital Outcomes of Surgical Aortic Valve Replacement in Hospitals With and Without Availability of a Transcatheter Aortic Valve Implantation Program (from a Nationally Representative Database)

We hypothesized that the availability of a transcatheter aortic valve implantation (TAVI) program in hospitals impacts the overall management of patients with aortic valve disease and hence may also improve postprocedural outcomes of conventional surgical aortic valve replacement (SAVR). The aim of the present study was to compare the inhospital outcomes of SAVR in centers with versus without availability of a TAVI program in an unrestricted large nationwide patient population >50 years of age. SAVRs performed on patients aged >50 years were identified from the Nationwide Inpatient Sample (NIS) for the years 2011 and 2012 using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. SAVR cases were divided into 2 categories: those performed at hospitals with a TAVI program (SAVR-TAVI) and those without (SAVR-non-TAVI). A total of 9,674 SAVR procedures were identified: 4,526 (46.79%) in the SAVR-TAVI group and 5,148 (53.21%) in SAVR-non-TAVI group. The mean age of the study population was 70.2 ± 0.1 years with majority (53%) of the patients aged >70 years. The mean Charlson's co-morbidity score for patients in SAVR-TAVI group was greater (greater percentage of patients were aged >80 years, had hypertension, congestive heart failure, renal failure, and peripheral arterial disease) than that of patients in SAVR-non-TAVI group (1.6 vs 1.4, p <0.001). The propensity score matching analysis showed a statistically significant lower inhospital mortality (1.25% vs 1.72%, p = 0.001) and complications rate (35.6% vs 37.3%, p = 0.004) in SAVR-TAVI group compared to SAVR-non-TAVI group. The mean length of hospital stay was similar in the 2 groups the cost of hospitalization was higher in the SAVR-TAVI group ($43,894 ± 483 vs $41,032 ± 473, p <0.0001). Having a TAVI program was a significant predictor of reduced mortality and complications rate after SAVR in multivariate analysis. In conclusion, this largest direct comparative analysis demonstrates that SAVRs performed in centers with a TAVI program are associated with significantly lower mortality and complications rates compared to those performed in centers without a TAVI program.

Low-Fidelity Simulation of Mitral Valve Surgery: Simple and Effective Trainer

OBJECTIVES

Training in mitral valve (MV) surgery is difficult because of its complex 3-dimentional anatomy and sophisticated surgical techniques. The goal of this study was to create an effective and simple simulator to enable the trainee in performing MV repair and replacement techniques in a low-fidelity environment.

METHODS

The MV surgery simulator is a self-shaped sponge integrated into a portable box that can be used for an unrestricted number of procedures. The building process is detailed in this study. MV procedures were performed in which the surgical handling was tested. The total cost was calculated in euros.

RESULTS

The building of the MV simulator resulted in the development of a new low-cost tool for training in MV surgery. The usage of the sponge led to building the MV components with flexible properties and allowing the surgical procedures to be performed in unrestricted numbers. This involved MV replacement in both intra- and supra-annular fashion and MV repair according to the Carpentier classification.

CONCLUSION

Surgical skills in mitral surgery could be improved by usage of the low-fidelity simulator. The high cost of the training for residents and junior surgeons could be effectively reduced by using this low-cost, portable, reusable simulator and its accessories (ring and band).

Readmission destination and risk of mortality after major surgery: an observational cohort study

BACKGROUND

Hospital readmissions are common after major surgery, although it is unknown whether patients achieve improved outcomes when they are readmitted to, and receive care at, the index hospital where their surgical procedure was done. We examined the association between readmission destination and mortality risk in the USA in Medicare beneficiaries after a range of common operations.

METHODS

By use of claims data from Medicare beneficiaries in the USA between Jan 1, 2001, and Nov 15, 2011, we assessed patients who needed hospital readmission within 30 days after open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, coronary artery bypass surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. We used logistic regression models incorporating inverse probability weighting and instrumental variable analysis to measure associations between readmission destination (index vs non-index hospital) and risk of 90 day mortality for patients who underwent surgery who needed hospital readmission.

FINDINGS

9,440,503 patients underwent one of 12 major operations, and the number of patients readmitted or transferred back to the index hospital where their operation was done varied from 186,336 (65·8%) of 283,131 patients who were readmitted after coronary artery bypass grafting, to 142,142 (83·2%) of 170,789 patients who were readmitted after colectomy. Readmission was more likely to be to the index hospital than to a non-index hospital if the readmission was for a surgical complication (189,384 [23%] of 834,070 patients readmitted to index hospital vs 36,792 [13%] of 276,976 patients readmitted non-index hospital, p<0·0001). Readmission to the index hospital was associated with a 26% lower risk of 90 day mortality than was readmission to a non-index hospital, with inverse probability weighting used to control for selection bias (odds ratio [OR] 0·74, 95% CI 0·66-0·83). This effect was significant (p<0·0001) for all procedures in inverse probability-weighted models, and was largest for patients who were readmitted after pancreatectomy (OR 0·56, 95% CI 0·45-0·69) and aortobifemoral bypass (OR 0·69, 95% CI 0·61-0·77). By use of hospital-level variation among regional index hospital readmission rates as an instrument, instrumental variable analysis showed that the patients with the highest probability of returning to the index hospital had 8% lower risk of mortality (OR 0·92 95% CI 0·91-0·94) than did patients who were less likely to be readmitted to the index hospital.

INTERPRETATION

In the USA, patients who are readmitted to hospital after various major operations consistently achieve improved survival if they return to the hospital where their surgery took place. These findings might have important implications for cost-effectiveness-driven regional centralisation of surgical care.

FUNDING

None.

Embolisation for pulmonary arteriovenous malformation

BACKGROUND

Pulmonary arteriovenous malformations are abnormal direct connections between the pulmonary artery and pulmonary vein which result in a right-to-left shunt. They are associated with substantial morbidity and mortality mainly from the effects of paradoxical emboli. Potential complications include stroke, cerebral abscess, pulmonary haemorrhage and hypoxaemia. Embolisation is an endovascular intervention based on the occlusion of the feeding arteries the pulmonary arteriovenous malformations thus eliminating the abnormal right-to-left-shunting.

OBJECTIVES

To determine the efficacy and safety of embolisation in patients with pulmonary arteriovenous malformations including a comparison with surgical resection and different embolisation devices.

SEARCH METHODS

We searched the Cystic Fibrosis and Genetic Disorders Group's Trials Register; date of last search: 31 March 2014.We also searched the following databases: the Australian New Zealand Clinical Trials Registry; ClinicalTrials.gov; International Standard Randomised Controlled Trial Number Register; International Clinical Trials Registry Platform Search Portal (last searched 1 July 2014).We checked cross-references and searched references from review articles.

SELECTION CRITERIA

Trials in which individuals with pulmonary arteriovenous malformations were randomly allocated to embolisation compared to no treatment, surgical resection or embolisation using a different embolisation device.

DATA COLLECTION AND ANALYSIS

Studies identified for potential inclusion were independently assessed for eligibility by two authors, with excluded studies further checked by a third author. No trials were identified for inclusion in the review and hence no analysis was performed.

MAIN RESULTS

There were no randomised controlled trials included in the review; one ongoing trial has been identified which may be eligible for inclusion in the future.

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials for embolisation of pulmonary arteriovenous malformations. However, randomised controlled trials are not always feasible on ethical grounds. Accumulated data from observational studies suggest that embolisation reduces morbidity. A standardised approach to reporting with long-term follow-up through registry studies can help to strengthen the evidence for embolisation in the absence of randomised controlled trials.

Are there identifiable risk factors and causes associated with unplanned readmissions following total knee arthroplasty?

We conducted a retrospective review of 3218 primary total knee arthroplasties (TKA) performed over two years at an urban academic hospital network using clinical and administrative data. Increased length of stay (LOS) was associated with readmission (P < 0.001). Readmission was not associated with age (P = 0.100), gender (P = 0.608), body mass index (P = 0.329), or staged bilateral procedures (P = 0.420). The most common readmitting diagnoses were post-operative infection (22.5%), hematoma (10.1%), pulmonary embolus (7.9%) and deep vein thrombosis (5.6%). Of readmissions, 53.9% were for surgical reasons and 46.1% were for medical reasons. Certain interventions described in previous literature may be more successful in minimizing unplanned readmissions by focusing on patients with extended LOS, elevated infection risk and low socioeconomic status.

Attitudes of early-career cardiologists in Japan about their cardiovascular training programs

Understanding the perspective of early-career cardiologists is important to design effective responses to the challenges in modern cardiovascular (CV) training programs. We conducted a web-based survey on a total of 272 early-career cardiologists (within 10 postgraduate years) who registered for the 2011 annual Japanese Circulation Society Meeting. Main outcome measures were satisfaction with their training, confidence in their clinical skills, and professional expectations, scaled from 0 to 10. The median training time was 6 years, with 2 years for internal medicine and 4 years for CV disease. Most received their training in university hospitals at some point during their career (79.5%) and were interested in a subspecialty training, such as interventional cardiology (38.6%), electrophysiology (15.1%), and advanced heart failure (10.3%); only 9.6% showed interest in general cardiology. The respondents felt comfortable in managing common CV conditions such as coronary artery disease (average score 6.3 ± 2.4 on an 11-point Likert scale) but less so in peripheral arterial disease (3.8 ± 2.8), arrhythmias (3.7 ± 2.3), and congenital heart disease (2.9 ± 2.2). Their satisfaction rate with their CV training positively correlated with their clinical proficiency level and was associated with volume of coronary angiograms, percutaneous coronary interventions, and echocardiograms completed. In conclusion, the current young cardiologists have a positive perception of and interest in procedure-based subspecialty training, and their training satisfaction was related to volume of cardiac procedures. Additional effort is needed in enforcing the training in underappreciated subspecialty areas.

Association of center volume with outcomes in critically ill children with acute asthma

BACKGROUND

Little is known about the relation between center volume and outcomes in children requiring intensive care unit (ICU) admission for acute asthma.

OBJECTIVE

To evaluate the association of center volume with the odds of receiving positive pressure ventilation and length of ICU stay.

METHODS

Patients 2 to 18 years of age with the primary diagnosis of asthma were included (2009-2012). Center volume was defined as the average number of mechanical ventilator cases per year for any diagnoses during the study period. In multivariable analysis, the odds of receiving positive pressure ventilation (invasive and noninvasive ventilation) and ICU length of stay were evaluated as a function of center volume.

RESULTS

Fifteen thousand eighty-three patients from 103 pediatric ICUs with the primary diagnosis of acute asthma met the inclusion criteria. Seven hundred fifty-two patients (5%) received conventional mechanical ventilation and 964 patients (6%) received noninvasive ventilation. In multivariable analysis, center volume was not associated with the odds of receiving any form of positive pressure ventilation in children with acute asthma, with the exception of high- to medium-volume centers. However, ICU length of stay varied with center volume and was noted to be longer in low-volume centers compared with medium- and high-volume centers.

CONCLUSION

In children with acute asthma, this study establishes a relation between center volume and ICU length of stay. However, this study fails to show any significant relation between center volume and the odds of receiving positive pressure ventilation; further analyses are needed to evaluate this relation in more detail.

Operative volume in colon surgery: a matched cohort analysis

Although previous studies have suggested that higher volumes of colectomies performed by surgeons and hospitals are associated with lower mortality, less is known about the relationship between volume and resource utilization. The research team tested the association between volume, costs, complications, length of stay, and mortality using data from the National Inpatient Sample. Results suggest higher volumes for both surgeons and hospitals were associated with lower costs, fewer complications, shorter length of stay, and lower mortality. Propensity score matching showed no significant difference in mortality by surgeon volume (7.38% vs 7.46%, P=.0.842), but significantly fewer complications (45.06% vs 49.10%, P=.008), shorter length of stay (11.8 vs 13.1 days, P<.0001), and lower costs ($33,142 vs $29,578, P<.0001) for high-volume surgeons. Although the major driver of complications and mortality is burden of disease and comorbid conditions, individual surgeon volume is an important determinant of length of stay and costs.