Does volume help predict outcome in surgical disease?

Cranial Tumor Surgical Outcomes at a High-Volume Academic Referral Center

OBJECTIVE

To determine adverse event rates for adult cranial neuro-oncologic surgeries performed at a high-volume quaternary academic center and assess the impact of resident participation on perioperative complication rates.

PATIENTS AND METHODS

All adult patients undergoing neurosurgical intervention for an intracranial neoplastic lesion between January 1, 2009, and December 31, 2013, were included. Cases were categorized as biopsy, extra-axial/skull base, intra-axial, or transsphenoidal. Complications were categorized as neurologic, medical, wound, mortality, or none and compared for patients managed by a chief resident vs a consultant neurosurgeon.

RESULTS

A total of 6277 neurosurgical procedures for intracranial neoplasms were performed. After excluding radiosurgical procedures and pediatric patients, 4151 adult patients who underwent 4423 procedures were available for analysis. Complications were infrequent, with overall rates of 9.8% (435 of 4423 procedures), 1.7% (73 of 4423), and 1.4% (63 of 4423) for neurologic, medical, and wound complications, respectively. The rate of perioperative mortality was 0.3% (14 of 4423 procedures). Case performance and management by a chief resident did not negatively impact outcome.

CONCLUSION

In our large-volume brain tumor practice, rates of complications were low, and management of cases by chief residents in a semiautonomous manner did not negatively impact surgical outcomes.

Patient Outcomes as a Function of Shoulder Surgeon Volume: A Systematic Review

PURPOSE

To examine surgical complications, length of stay, surgical time, cost, revision rates, clinical outcomes, current surgical trends. and minimum number of cases in relationship to surgeon volume for shoulder arthroplasty and rotator cuff repair.

METHODS

We performed a systematic review of studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that met inclusion criteria from January 1990 to January 2016 were included. Inclusion criteria included Level IV evidence or greater, contained specific surgeon volume, and were written in or translated into English. Exclusion criteria included non-English manuscripts, abstracts, and review papers. A written protocol was used to extract relevant data and evaluate study results. Data extracted included volume-specific data pertaining to length of stay, operating time, complications, and cost.

RESULTS

A total of 10 studies were included. Seven studies evaluated arthroplasty with 88,740 shoulders, and 3 studies evaluated rotator cuff repair with 63,535 shoulders. Variation was seen in how studies defined low- versus high-volume surgeon. For arthroplasty, <5 cases per year met the criteria for a low-volume surgeon and were associated with increased length of stay, longer operating room time, increased in-hospital complications, and increased cost. Mortality was not significantly increased. In rotator cuff surgery, <12 surgeries per year met the criteria for low volume and were associated with increased length of stay, increased operating room time, and increase in reoperation rate.

CONCLUSIONS

Our systematic review demonstrates increased surgical complications, length of stay, surgical time, and surgical cost in shoulder arthroplasty and rotator cuff repair when performed by a low-volume shoulder surgeon, which is defined by those performing <5 arthroplasties and/or <12 rotator cuff repairs per year.

LEVEL OF EVIDENCE

Level III, systematic review of Level II and III studies.

Improving quality through process change: a scoping review of process improvement tools in cancer surgery

BACKGROUND

Surgery is a cornerstone of treatment for malignancy. However, significant variation has been reported in patterns and quality of cancer care for important health outcomes, including perioperative mortality. Surgical process improvement tools (SPITs) have been developed that focus on enhancing the processes of care at the point of care, as a means of quality improvement. This study describes SPITs and develops a conceptual framework by synthesizing the available literature on these novel quality improvement tools.

METHODS

A scoping review was conducted based on instruments developed for quality improvement in surgery. The search was executed on electronically indexed sources (MEDLINE, EMBASE, and the Cochrane library) from January 1990 to March 2011. Data were extracted, tabulated and reported thematically using a narrative synthesis approach. These results were used to develop a conceptual framework that describes and classifies SPITs.

RESULTS

232 articles were reviewed for data extraction and analysis. SPITs identified were classified into 3 groups: clinical mapping tools, structure communication tools and error reduction instruments. The dominant instrument reported were clinical mapping tools, including: clinical pathways (113, 48%), fast track (46, 20%) and enhanced recovery after surgery protocols (36, 15%). Outcomes reported included: length of stay (174, 75%), readmission rates (116, 50%), morbidity (116, 50%), mortality (104, 45%), and economic (60, 26%). Many gaps in the literature were recognized.

CONCLUSION

We have developed a conceptual framework of SPITs and identified gaps in current knowledge. These results will guide the design and development of new quality instruments in surgery.

Does surgical volume affect outcome after primary and revision knee arthroplasty? A systematic review of the literature

BACKGROUND

In 2009 there were 72,980 primary and 4565 revision knee arthroplasties performed in England and Wales [1]. Given the large number of procedures done annually any factors that may influence outcome and benefit the patient must be considered seriously.

OBJECTIVES

To find out whether a relationship exists between hospital and surgical volume and patient outcomes for primary and revision knee arthroplasty. A systematic review of the literature was performed to evaluate the current evidence using the PRISMA criteria [2].

DATA SOURCES

A computerised literature search was performed on the electronic databases PubMed, Medline, Embase and CINAHL between 1973 and 2011.

STUDY ELIGIBILITY CRITERIA

All abstracts, in the English language, pertaining to either surgical or hospital volume and outcome after primary and revision knee arthroplasty between 1973 and 2011 were considered. Outcomes of interest included morbidity, mortality, clinical and economic outcomes.

CONCLUSIONS

Both the orthopaedic and surgical specialties literature demonstrates a clear and consistent relationship between both surgeon and hospital volume with outcome, higher volume being associated with improved patient outcomes. In view of the literature consideration should be given to whether all orthopaedic operations should be carried out by all surgeons in all hospitals.

Does surgeon workload per day affect outcomes after pulmonary lobectomies?

BACKGROUND

Our aim was to evaluate whether the workload of a surgeon, including number of operations, operative time, or number of rooms per day, influenced patient morbidity or mortality after pulmonary lobectomy.

METHODS

The records of all patients who underwent pulmonary lobectomy at our institution during 2 years (2007-2009) by 6 surgeons were retrospectively reviewed. Surgeon workload per day and individual patient variables were evaluated. Both univariate and multivariate analyses were performed to identify risk factors for patient morbidity and mortality.

RESULTS

We analyzed 481 patients (269 men, 112 women) whose median age was 68 years (range, 20 to 94 years). Operative mortality occurred in 6 patients (1.25%), and morbidity occurred in 198 patients (41%). On univariate analysis, the total number of hours a surgeon operated per day was a significant predictor of complications (odds ratio, 1.032; p=0. 048) and length of stay (average increase of 0.17 days for each additional hour; p=0.004). There were multiple patient variables that were significant predictors of outcome. On multivariate analysis, which adjusted for patient variables, the total number of hours a surgeon operated per day remained a significant predictor of complications (odds ratio, 1.036; p=0.03) and increased length of stay (average increase of 0.16 days for each additional hour; p=0.006). On multivariate analysis, patient variables of age, forced expiratory volume In 1 second, and renal failure were significant predictors of outcome.

CONCLUSIONS

The total number of hours a surgeon operates per day is independently associated with an increased risk of complications when performing pulmonary lobectomies. This could be related to surgeon fatigue associated with longer operative days. However, other patient variables are also associated with outcome. The relationship among these factors needs to be better understood with larger-scale models on a multiinstitutional level.

Pancreatic resection in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study

BACKGROUND

Pancreatectomy is a high-risk, technically demanding operation associated with substantial perioperative morbidity and mortality. This study aims to describe the 30-day morbidity and mortality for pancreatectomy and to compare outcomes between private-sector and Veterans Affairs hospitals using multiinstitutional data.

STUDY DESIGN

This is a retrospective review of patients who underwent pancreatic resection for neoplasia at private-sector (PS) and Veterans Affairs (VA) hospitals participating in the National Surgical Quality Improvement Program Patient Safety in Surgery Study in fiscal years 2002 to 2004. The variables reviewed were demographics, preoperative medical conditions, intraoperative variables, and outcomes. Using logistic regression to control for differences in patient comorbidities, 30-day mortality and morbidity rates between PS and VA hospitals were compared.

RESULTS

A total of 1,069 patients underwent pancreatectomy for neoplasia at 97 participating hospitals. Six hundred ninety-two patients were treated at PS hospitals and 377 at VA hospitals. The average number of patients treated at each hospital was 11.0, with a range of 1 to 83 during the 3-year study period. There were 842 patients who underwent pancreaticoduodenectomy (CPT 4815x) and 227 who underwent distal/subtotal pancreatectomy (CPT 4814x). Significant differences were observed between PS patients and VA patients with regard to comorbidities and patient demographics. The 30-day unadjusted morbidity rate was 33.8% overall, 42.2% at VA hospitals versus 29.1% at PS hospitals (p < 0.0001). Unadjusted and adjusted odds ratio (OR) for postoperative morbidity comparing VA with PS hospitals was 1.781 (95% CI, 1.369-2.318) and 1.581 (95% CI, 1.064-2.307). The 30-day unadjusted operative mortality rate was 3.8% overall, 6.4% at VA hospitals and 2.5% at PS hospitals (p = 0.0015). Unadjusted and adjusted OR for postoperative mortality was 2.909 (95% CI, 1.525-5.549) and 2.533 (95% CI, 1.020-6.290), respectively. Similar outcomes were observed when looking at pancreaticoduodenectomy (CPT 4815x) when analyzed independent of other types of pancreatic resections.

CONCLUSION

Pancreatectomies are high-risk operations with substantial perioperative morbidity and mortality. Risk-adjusted outcomes for patients treated at PS hospitals were found to be superior to those for patients treated at VA hospitals in the study.