Effect of Hospital Volume on In-hospital Morbidity and Mortality Following Pancreatic Surgery in Germany.
01 Apr 2017-Annals of Surgery (Ovid Technologies (Wolters Kluwer Health))-Vol. 267, Iss: 3, pp 411-417
TL;DR: In Germany, patients who are undergoing major pancreatic resections have improved outcomes if they are admitted to higher volume hospitals, and centralization of surgical care to the minimum volume and mortality risk of the medium volume quintile could prevent at least 94 deaths per year.
Abstract: Objective:We aimed to determine the effect of hospital volume on in-hospital mortality, and failure to rescue following major pancreatic resections using hospital discharge data of every inpatient case in Germany.Summary Background Data:Several studies have found strong volume–outcome relationships
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TL;DR: The safety and efficacy of pancreatic cancer surgery have improved considerably in the past decade, enabling perioperative mortality of around 3% and 5-year survival approaching 30–40% after resection and chemotherapy.
Abstract: Pancreatic cancer is likely to become the second most frequent cause of cancer-associated mortality within the next decade. Surgical resection with adjuvant systemic chemotherapy currently provides the only chance of long-term survival. However, only 10-20% of patients with pancreatic cancer are diagnosed with localized, surgically resectable disease. The majority of patients present with metastatic disease and are not candidates for surgery, while surgery remains underused even in those with resectable disease owing to historical concerns regarding safety and efficacy. However, advances made over the past decade in the safety and efficacy of surgery have resulted in perioperative mortality of around 3% and 5-year survival approaching 30% after resection and adjuvant chemotherapy. Furthermore, owing to advances in both surgical techniques and systemic chemotherapy, the indications for resection have been extended to include locally advanced tumours. Many aspects of pancreatic cancer surgery, such as the management of postoperative morbidities, sequencing of resection and systemic therapy, and use of neoadjuvant therapy followed by resection for tumours previously considered unresectable, are rapidly evolving. In this Review, we summarize the current status of and new developments in pancreatic cancer surgery, while highlighting the most important research questions for attempts to further optimize outcomes.
467 citations
TL;DR: Investigation of variations in resection for PaC in Europe and USA and determinants for its utilisation found rates of PaC resection remain low in European and USA with great international variations.
Abstract: Objective Resection can potentially cure resectable pancreatic cancer (PaC) and significantly prolong survival in some patients. This large-scale international study aimed to investigate variations in resection for PaC in Europe and USA and determinants for its utilisation. Design Data from six European population-based cancer registries and the US Surveillance, Epidemiology, and End Results Program database during 2003–2016 were analysed. Age-standardised resection rates for overall and stage I–II PaCs were computed. Associations between resection and demographic and clinical parameters were assessed using multivariable logistic regression models. Results A total of 153 698 records were analysed. In population-based registries in 2012–2014, resection rates ranged from 13.2% (Estonia) to 21.2% (Slovenia) overall and from 34.8% (Norway) to 68.7% (Denmark) for stage I–II tumours, with great international variations. During 2003–2014, resection rates only increased in USA, the Netherlands and Denmark. Resection was significantly less frequently performed with more advanced tumour stage (ORs for stage III and IV versus stage I–II tumours: 0.05–0.18 and 0.01–0.06 across countries) and increasing age (ORs for patients 70–79 and ≥80 versus those Conclusion Rates of PaC resection remain low in Europe and USA with great international variations. Further studies are warranted to explore reasons for these variations.
155 citations
TL;DR: This review summarizes the current literature and provides an overview of how new therapies or new therapeutic strategies will guide multidisciplinary disease management, future clinical trials, and, hopefully, will increase overall survival.
Abstract: Pancreatic cancer is one of the most lethal solid organ tumors. Due to the rising incidence, late diagnosis, and limited treatment options, it is expected to be the second leading cause of cancer deaths in high income countries in the next decade. The multidisciplinary treatment of this disease depends on the stage of cancer at diagnosis (resectable, borderline, locally advanced, and metastatic disease), and combines surgery, chemotherapy, chemoradiotherapy, and supportive care. The landscape of multidisciplinary pancreatic cancer treatment is changing rapidly, especially in locally advanced disease, and the number of treatment options in metastatic disease, including personalized medicine, innovative targets, immunotherapy, therapeutic vaccines, adoptive T-cell transfer, or stemness inhibitors, will probably expand in the near future. This review summarizes the current literature and provides an overview of how new therapies or new therapeutic strategies (neoadjuvant therapies, conversion surgery) will guide multidisciplinary disease management, future clinical trials, and, hopefully, will increase overall survival.
124 citations
TL;DR: Based on complete national hospital discharge data, the results confirmed volume–outcome relationships for many complex surgical procedures, as well as for some emergency conditions and low-risk procedures.
Abstract: Objectives To explore the existence and strength of a relationship between hospital volume and mortality, to estimate minimum volume thresholds and to assess the potential benefit of centralisation of services. Design Observational population-based study using complete German hospital discharge data (Diagnosis-Related Group Statistics (DRG Statistics)). Setting All acute care hospitals in Germany. Participants All adult patients hospitalised for 1 out of 25 common or medically important types of inpatient treatment from 2009 to 2014. Main outcome measure Risk-adjusted inhospital mortality. Results Lower inhospital mortality in association with higher hospital volume was observed in 20 out of the 25 studied types of treatment when volume was categorised in quintiles and persisted in 17 types of treatment when volume was analysed as a continuous variable. Such a relationship was found in some of the studied emergency conditions and low-risk procedures. It was more consistently present regarding complex surgical procedures. For example, about 22 000 patients receiving open repair of abdominal aortic aneurysm were analysed. In very high-volume hospitals, risk-adjusted mortality was 4.7% (95% CI 4.1 to 5.4) compared with 7.8% (7.1 to 8.7) in very low volume hospitals. The minimum volume above which risk of death would fall below the average mortality was estimated as 18 cases per year. If all hospitals providing this service would perform at least 18 cases per year, one death among 104 (76 to 166) patients could potentially be prevented. Conclusions Based on complete national hospital discharge data, the results confirmed volume–outcome relationships for many complex surgical procedures, as well as for some emergency conditions and low-risk procedures. Following these findings, the study identified areas where centralisation would provide a benefit for patients undergoing the specific type of treatment in German hospitals and quantified the possible impact of centralisation efforts.
122 citations
TL;DR: Patients selected to receive MIPD for cancer have equivalent short-term and oncologic outcomes, when compared with patients who undergo OPD, according to the National Cancer Database.
Abstract: Objective:To compare short-term and oncologic outcomes of patients with cancer who underwent open pancreaticoduodenectomy (OPD) versus minimally invasive pancreaticoduodenectomy (MIPD) using the National Cancer Database.Summary Background Data:MIPD, including laparoscopic and robotic approaches, has
110 citations
Cites result from "Effect of Hospital Volume on In-hos..."
...Such findings corroborate with findings from recent studies that showed that PD volume was inversely correlated with failure to rescue rates.(21,22) Finally, because we included patients who underwent surgery from 2010 to 2014 in our mortality analysis, as opposed to only 2010 to 2011, it is possible that the lack of increased mortality with MIPD in our cohort was related to overall increased experience with the technique in most recent years, with surgeons overcoming their learning curve and the surgical technique becoming more standardized....
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References
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TL;DR: For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume, and patients can often improve their chances of survival substantially, even at high-volume hospitals.
Abstract: BACKGROUND Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain. METHODS Using information from the national Medicare claims data base for 1998 through 1999, we examined mortality among all 474,108 patients who underwent one of eight cardiovascular procedures or cancer resections. Using nested regression models, we examined the relations between operative mortality and surgeon volume and hospital volume (each in terms of total procedures performed per year), with adjustment for characteristics of the patients and other characteristics of the providers. RESULTS Surgeon volume was inversely related to operative mortality for all eight procedures (P=0.003 for lung resection, P<0.001 for all other procedures). The adjusted odds ratio for operative death (for patients with a low-volume surgeon vs. those with a high-volume surgeon) varied widely according to the procedure--from 1.24 for lung resection to 3.61 for pancreatic resection. Surgeon volume accounted for a large proportion of the apparent effect of the hospital volume, to an extent that varied according to the procedure: it accounted for 100 percent of the effect for aortic-valve replacement, 57 percent for elective repair of an abdominal aortic aneurysm, 55 percent for pancreatic resection, 49 percent for coronary-artery bypass grafting, 46 percent for esophagectomy, 39 percent for cystectomy, and 24 percent for lung resection. For most procedures, the mortality rate was higher among patients of low-volume surgeons than among those of high-volume surgeons, regardless of the surgical volume of the hospital in which they practiced. CONCLUSIONS For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently.
1,758 citations
TL;DR: Although increased market concentration and hospital volume have contributed to declining mortality with some high-risk cancer operations, declines in mortality with other procedures are largely attributable to other factors.
Abstract: BACKGROUND There were numerous efforts in the United States during the previous decade to concentrate selected surgical procedures in high-volume hospitals. It remains unknown whether referral patterns for high-risk surgery have changed as a result and how operative mortality has been affected. METHODS We used national Medicare data to study patients undergoing one of eight different cancer and cardiovascular operations from 1999 through 2008. For each procedure, we examined trends in hospital volume and market concentration, defined as the proportion of Medicare patients undergoing surgery in the top decile of hospitals by volume per year. We used regression-based techniques to assess the effects of volume and market concentration on mortality over time, adjusting for case mix. RESULTS Median hospital volumes of four cancer resections (lung, esophagus, pancreas, and bladder) and of repair of abdominal aortic aneurysm (AAA) rose substantially. Depending on the procedure, higher hospital volumes were attributable to an increasing number of cases nationwide, an increasing market concentration, or both. Hospital volumes rose slightly for aortic-valve replacement but fell for coronary-artery bypass grafting and carotid endarterectomy. Operative mortality declined for all eight procedures, ranging from a relative decline of 8% for carotid endarterectomy (1.3% mortality in 1999 and 1.2% in 2008) to 36% for AAA repair (4.4% in 1999 and 2.8% in 2008). Higher hospital volumes explained a large portion of the decline in mortality for pancreatectomy (67% of the decline), cystectomy (37%), and esophagectomy (32%), but not for the other procedures. CONCLUSIONS Operative mortality with high-risk surgery fell substantially during the previous decade. Although increased market concentration and hospital volume have contributed to declining mortality with some high-risk cancer operations, declines in mortality with other procedures are largely attributable to other factors. (Funded by the National Institute on Aging.).
1,179 citations
"Effect of Hospital Volume on In-hos..." refers background in this paper
...In the past, studies on US databases have described increasing regionalization of high-risk surgery including pancreatic resections as a result of volume-based referral initiatives.(12,21) There is evidence that in the United States increased market concentration and hospital volumes have contributed to declining mortality of pancreatectomy....
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...There is evidence that in the United States increased market concentration and hospital volumes have contributed to declining mortality of pancreatectomy.(12) An impressive improvement of outcomes based on centralization of pancreatic surgery has been reported from the Netherlands resulting in significant decrease of nationwide mortality rates following pancreatoduodenectomy from 9....
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TL;DR: This large observational study demonstrates an improvement in operative mortality for patients undergoing pancreatic resections for neoplastic disease from 1998 to 2003, and a greater proportion of pancreatectomies were performed at high-volume centers in 2003.
Abstract: Objective:To analyze in-hospital mortality after pancreatectomy using a large national database.Summary and Background Data:Pancreatic resections, including pancreaticoduodenectomy, distal pancreatectomy, and total pancreatectomy, remain the only potentially curative interventions for pancreatic can
442 citations
TL;DR: Despite recent improvements in surgical safety, the strong inverse relationship between hospital volume and mortality persists in the modern era.
Abstract: Objective:To determine whether the relationship between hospital volume and mortality has changed over time.Background:It is generally accepted that hospital volume is associated with mortality in high-risk procedures. However, as surgical safety has improved over the last decade, recent evidence ha
370 citations
TL;DR: Although hospital volume may be an important predictor of operative mortality, it is not associated with resource use as reflected by length of stay or readmission rates.
Abstract: ObjectiveAimed at reducing surgical deaths, several recent initiatives have attempted to establish volume-based referral strategies in high-risk surgery. Although payers are leading the most visible of these efforts, it is unknown whether volume standards will also reduce resource use.MethodsWe stud
312 citations
"Effect of Hospital Volume on In-hos..." refers background or result in this paper
...Aiming to compare results in the context of the current literature volume categories were established as previously described elsewhere.(19) After ranking hospitals according to increasing total hospital volume, five volume categories were established by the selections of whole number cutoff points for annual volume that most closely sorted the patients into five groups of equal size (quintiles) within each year of observation....
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...Emphasis on procedure volume as a quality indicator may create incentives for hospitals and surgeons to operate more often.(19) Therefore, policy makers should anticipate potential benefits as well as unintended side effects of volume-based referral strategies....
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...After ranking hospitals according to increasing total hospital volume, five volume categories were established by the selections of whole number cutoff points for annual volume that most closely sorted the patients into five groups of equal size (quintiles) within each year of observation.(19) Additionally, hospital volume was analyzed as a continuous variable....
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