Trends in access, quality, and adherence to minimum volume standards for pancreatectomy

Abstract

Background: For two decades, the Leapfrog Group has advocated for minimum volume standards at hospitals that perform pancreatic resections. While these standards receive near-universal support from surgeons and policymakers, the extent to which they have changed national practice patterns is unclear. Methods: We used 100% Medicare claims to identify all patients undergoing pancreatic resections between 2005 and 2014. Because cases in the Medicare population only represent a proportion of the total surgical volume, we used data on primary payer status from the National Inpatient Sample to generate more complete estimates of the true volume at each hospital. We then analyzed national trends in hospital adoption of pancreatic surgery adoption, adherence to volume standards (≥20 cases/year), and risk-adjusted postoperative outcomes. Results: The total number of pancreatic resections in the United States increased by 56% (6,852 to 10,690) between 2005 and 2014. While the number of hospitals performing pancreatectomy decreased by 13% (794 to 694), those meeting the minimum volume standard increased 2-fold, from 79 (10% of hospitals) in 2005 to 157 (23% of hospitals) in 2014. The proportion of patients undergoing surgery in one of these hospitals also increased from 52% to 70%. However, 77% of hospitals performing pancreatectomy still do not meet minimum annual volume standards. Furthermore, the number of hospital referral regions offering pancreatectomy decreased by 10% and only 1 in 3 contain a hospital meeting the minimum volume standard. Though outcomes improved for all hospitals from 2005 to 2014, those meeting the minimum volume standards continue to have lower morality (3.5% v. 5.8%), fewer complications (41.4% v. 49.9%), and lower total episode payments ($31,538 v. $33,362, p<0.01 for each) than all other hospitals. Conclusion: Despite a nearly 2-fold increase in surgical volume, the proportion of U.S. hospitals meeting minimum volume standards for pancreatectomy remains low. Efforts to improve quality by further centralizing pancreatic surgery may limit access to certain patient populations.