Abstract
Despite growing interest from various surgical societies and patient safety organizations, concerns remain that volume-based credentialing standards are arbitrary and may fail to recognize a surgeon's full scope of practice. To evaluate whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone. This proof-of-concept cohort study used the all-payer State Inpatient Databases from 6 geographically diverse states to identify all operations for surgeons who performed at least 1 pancreaticoduodenectomy from January 1, 2012, to December 31, 2014. Each surgeon's mean annual volume for pancreaticoduodenectomies and related complex hepatopancreatobiliary (HPB) procedures was calculated. Outcomes for surgeons above and below a threshold of 12 pancreaticoduodenectomies per year were evaluated. Whether related HPB procedure volume was also associated with better outcomes for surgeons not meeting the procedure-specific threshold was also evaluated. Data were analyzed from March 2 through 20, 2019. Thirty-day mortality and complications. The study cohort included 176 043 patients, of whom 92 064 were female (52.3%), with a mean (SD) age of 59 (17) years. Within 270 hospitals, only 54 of 1028 surgeons (5.3%) met the mean pancreaticoduodenectomy volume threshold from 2012 to 2014. In-hospital mortality after pancreaticoduodenectomy was lower for surgeons who performed 12 or more procedures per year (1.8% [95% CI, 1.1%- 2.4%] vs 4.7% [95% CI, 4.0%-5.4%]; odds ratio, 0.32; 95% CI, 0.21-0.50). However, in-hospital mortality varied 7-fold among surgeons who did not meet the threshold (1.2% [95% CI, 0.8%-1.6%] to 8.4% [95% CI, 7.9%-8.9%]). Increasing HPB case volume was associated with better outcomes for pancreaticoduodenectomy in this group. For example, surgeons performing 2 or fewer pancreaticoduodenectomies annually would need to perform an additional 27 related HPB procedures to match the in-hospital mortality rate of surgeons performing 12 or more pancreaticoduodenectomies. In this proof-of-concept cohort study, few surgeons met even modest annual volume thresholds for pancreaticoduodenectomy. The findings suggest that inclusion of related procedure volumes may safely expand the cohort of surgeons credentialed to perform certain procedures under volume-based standards.
Highlights
Hospital credentialing remains an important process to ensure that surgeons have the appropriate experience to safely perform certain surgical procedures.[1]
In-hospital mortality after pancreaticoduodenectomy was lower for surgeons who performed 12 or more procedures per year (1.8% [95% CI, 1.1%- 2.4%] vs 4.7% [95% CI, 4.0%-5.4%]; odds ratio, 0.32; 95% CI, 0.21-0.50)
The findings suggest that inclusion of related procedure volumes may safely expand the cohort of surgeons credentialed to perform certain procedures under volume-based standards
Summary
Hospital credentialing remains an important process to ensure that surgeons have the appropriate experience to safely perform certain surgical procedures.[1]. Despite the potential to improve patient safety, numerous concerns exist with implementing surgeon-specific volume credentialing standards. Others argue that the implementation of surgeon-specific volume standards may exacerbate disparities because care is restricted to even fewer surgeons and centers.[9] These standards may ignore surgeons’ full scope of practice, where cumulative experience with related procedures is associated with better outcomes for complex operations, such as esophagectomy.[10] The feasibility of using surgeons’ full scope of practice to credential low-volume surgeons remains unclear
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