Elsevier

Surgery

Volume 125, Issue 3, March 1999, Pages 250-256
Surgery

Surgical Outcomes Research
Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy,☆☆,

https://doi.org/10.1016/S0039-6060(99)70234-5Get rights and content

Abstract

Background: Reports of better results at national referral centers than at low-volume community hospitals have prompted calls for regionalizing pancreaticoduodenectomy (the Whipple procedure). We examined the relationship between hospital volume and mortality with this procedure across all US hospitals. Methods: Using information from the Medicare claims database, we performed a national cohort study of 7229 Medicare patients more than 65 years old undergoing pancreaticoduodenectomy between 1992 and 1995. We divided the study population into approximate quartiles according to the hospital's average annual volume of pancreaticoduodenectomies in Medicare patients: very low (<1/y), low (1-2/y), medium (2-5/y), and high (5+/y). Using multivariate logistic regression to account for potentially confounding patient characteristics, we examined the association between institutional volume and in-hospital mortality, our primary outcome measure. Results: More than 50% of Medicare patients undergoing pancreaticoduodenectomy received care at hospitals performing fewer than 2 such procedures per year. In-hospital mortality rates at these low- and very-low-volume hospitals were 3- to 4-fold higher than at high-volume hospitals (12% and 16%, respectively, vs 4%, P < .001). Within the high-volume quartile, the 10 hospitals with the nation's highest volumes had lower mortality rates than the remaining high-volume centers (2.1% vs 6.2%, P < .01). The strong association between institutional volume and mortality could not be attributed to patient case-mix differences or referral bias. Conclusions: Although volume-outcome relationships have been reported for many complex surgical procedures, hospital experience is particularly important with pancreaticoduodenectomy. Patients considering this procedure should be given the option of care at a high-volume referral center. (Surgery 1999;125:250-6.)

Section snippets

Subjects and databases

As part of our work on the Dartmouth Atlas of Health Care in the United States ,14 by use of the Health Care Financing Administration's 100% MEDPAR file, we studied patients undergoing pancreaticoduodenectomy. This file contains diagnosis and procedure codes from hospital discharge abstracts for all Medicare hospitalizations (except those of the 8% of Medicare patients enrolled in risk-bearing health maintenance organizations during this time period). We included all patients more than 65 years

Volume and patient characteristics

Of 7229 Medicare patients undergoing pancreaticoduodenectomy between 1992 and 1995, 3833 patients (53%) received care at low- or very-low-volume institutions (those performing fewer than 2 per year in Medicare patients) (Table I). Of these, 1988 patients (28%) underwent surgery at 1203 hospitals performing fewer than 1 pancreaticoduodenectomy annually. Conversely, 1541 patients (21%) underwent pancreaticoduodenectomy at 40 hospitals performing at least 5 per year in Medicare patients, including

Discussion

Inverse relationships between hospital volume and mortality with high-risk surgical procedures have long been recognized.7, 8, 9, 10 What distinguishes the findings of our analysis of pancreaticoduodenectomy is the magnitude of the volume-outcome effect. Between 1992 and 1995, more than 50% of Medicare patients undergoing pancreaticoduodenectomy received care at hospitals performing fewer than 2 such procedures per year. In-hospital mortality rates at these low- and very-low-volume hospitals

References (30)

  • EL Hannan et al.

    Coronary artery bypass surgery: the relationship between inhospital mortality rate and surgical volume after controlling for clinical risk factors

    Med Care

    (1991)
  • RG Hughes et al.

    Effects of surgeon volume and hospital volume on quality of care in hospitals

    Med Care

    (1987)
  • PJ Imperato et al.

    The effects of regionalization on clinical outcomes for a high risk surgical procedure: a study of the Whipple procedure in New York state

    Am J Med Qual

    (1996)
  • MD Lieberman et al.

    Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy

    Ann Surg

    (1995)
  • TA Gordon et al.

    The effects of regionalization on cost and outcome for one general high-risk surgical procedure

    Ann Surg

    (1995)
  • Cited by (440)

    • Somatostatin analogues for the prevention of pancreatic fistula after open pancreatoduodenectomy: A nationwide analysis

      2022, Pancreatology
      Citation Excerpt :

      The most common major complication after pancreatoduodenectomy is leakage of the pancreato-enteric anastomosis which can result in postoperative pancreatic fistula (POPF) development, delayed gastric emptying, postpancreatectomy hemorrhage, and death [1]. Although mortality after pancreatoduodenectomy has decreased to approximately 2% in high-volume centers, the morbidity after these procedures still remains between 30 and 50% mainly due to POPF, of which the incidence varies between 10 and 30% [2–5]. Well-known risk factors of POPF are soft texture of the pancreas without pre-existing fibrosis, small pancreatic duct size, tension on the anastomosis, poor anastomotic perfusion and surgeon's experience with the procedure [6].

    View all citing articles on Scopus

    Supported in part by a grant from the Robert Wood Johnson Foundation.

    ☆☆

    The views expressed herein do not necessarily reflect the views of the Health Care Financing Administration, the Department of Veterans Affairs, or the United States government.

    Reprint requests: John D. Birkmeyer, MD, VA Outcomes Group (111B), Department of Veterans Affairs Medical Center, White River Junction, VT 05009.

    View full text