Annual Hospital Volume Research Articles

Variation in the management of cT1 renal cancer by surgical hospital volume: A nationwide study.

To analyse variation in clinical management of cT1 renal cell carcinoma (RCC) in the Netherlands related to surgical hospital volume (HV). Patients diagnosed with cT1 RCC during 2014-2020 were identified in the Netherlands Cancer Registry. Patient and tumour characteristics were retrieved. Hospitals performing kidney cancer surgery were categorised by annual HV as low (HV < 25), medium (HV = 25-49) and high (HV > 50). Trends over time in nephron-sparing strategies for cT1a and cT1b were evaluated. Patient, tumour and treatment characteristics of (partial) nephrectomies were compared by HV. Variation in applied treatment was studied by HV. Between 2014 and 2020, 10 964 patients were diagnosed with cT1 RCC. Over time, a clear increase in nephron-sparing management was observed. The majority of cT1a underwent a partial nephrectomy (PN), although less PNs were applied over time (from 48% in 2014 to 41% in 2020). Active surveillance (AS) was increasingly applied (from 18% to 32%). For cT1a, 85% received nephron-sparing management in all HV categories, either with AS, PN or focal therapy (FT). For T1b, radical nephrectomy (RN) remained the most common treatment (from 57% to 50%). Patients in high-volume hospitals underwent more often PN (35%) for T1b compared with medium HV (28%) and low HV (19%). HV is related to variation in the management of cT1 RCC in the Netherlands. The EAU guidelines have recommended PN as preferred treatmentfor cT1 RCC. In most patients with cT1a, nephron-sparing management was applied in all HV categories, although differences in applied strategy were found and PN was more frequently used in high HV. For T1b, high HV was associated with less appliance of RN, whereas PN was increasingly used. Therefore, closer guideline adherence was found in high-volume hospitals.

High surgical volume is associated with improved survival in head and neck cancer

ObjectivesExamine the relationship between hospital volume and overall mortality in a surgical cohort of head and neck squamous cell carcinoma (HNSCC) patients. Materials & methodsA retrospective review of the NCDB was completed for adults with previously untreated HNSCC diagnosed between 2004 and 2016. Mean annual hospital volume was calculated using the number of head and neck cancer cases treated at a given facility divided by the number of years the facility reported to the NCDB. Facilities were separated into three categories based on their volume percentile, informed by inflection points from a natural cubic spline: Hospital Group 1 (<50%); Hospital Group 2 (50–90%); Hospital Group 3 (90%+). Cox proportional hazard models were used to examine the association between volume percentiles (continuous or categorical) with patient overall survival, adjusting for important patient and facility variables known to impact survival. ResultsRisk of death decreased by 2.97% for every 10% increase in facility percentile after adjusting for other risk factors. Patients treated at facilities in Hospital Group 1 had a 23.1% increase in risk of mortality (HR 1.231 [95% CI 1.12–1.35]) relative those at facilities in Hospital Group 3. No significant difference in mortality risk was found between Hospital Group 2 versus Hospital Group 3 (HR 1.031 [95% CI 0.97–1.10]). ConclusionsSurvival of HNSCC patients is significantly improved when treated at facilities >50th percentile in annual hospital volume. This may support the regionalization of care to high volume head and neck centers with comprehensive facilities and supportive services to maximize patient outcomes.

Is hospital volume related to quality of hip fracture care? Analysis of 43,538 patients and 68 hospitals from the Dutch Hip Fracture Audit

PurposeEvidence for a hospital volume–outcome relationship in hip fracture surgery is inconclusive. This study aimed to analyze the association between hospital volume as a continuous parameter and several processes and outcomes of hip fracture care.MethodsAdult patients registered in the nationwide Dutch Hip Fracture Audit (DHFA) between 2018 and 2020 were included. The association between annual hospital volume and turnaround times (time on the emergency ward, surgery < 48 h and length of stay), orthogeriatric co-treatment and case-mix adjusted in-hospital and 30 days mortality was evaluated with generalized linear mixed models with random effects for hospital and treatment year. We used a fifth-degree polynomial to allow for nonlinear effects of hospital volume. P-values were adjusted for multiple comparisons using the Bonferoni method.ResultsIn total, 43,258 patients from 68 hospitals were included. The median annual hospital volume was 202 patients [range 1–546]. Baseline characteristics did not differ with hospital volume. Provision of orthogeriatric co-treatment improved with higher volumes but decreased at > 367 patients per year (p < 0.01). Hospital volume was not significantly associated with mortality outcomes. No evident clinical relation between hospital volume and turnaround times was found.ConclusionThis is the first study analyzing the effect of hospital volume on hip fracture care, treating volume as a continuous parameter. Mortality and turnaround times showed no clinically relevant association with hospital volume. The provision of orthogeriatric co-treatment, however, increased with increasing volumes up to 367 patients per year, but decreased above this threshold. Future research on the effect of volume on complications and functional outcomes is indicated.

A Survey of IPEG-Middle East Chapter members to ascertain their perceptions of, and changes to, the Nissen's wrap design and the outcomes

BackgroundNissen's description of fundoplication has proven seminal in our understanding of anti-GERD surgeries. This survey aimed to ascertain the perceptions of, and changes to, the Nissen's wrap design among the IPEG-ME surgeons and their outcomes.MethodsDuring the months of February and March 2021, all IPEG-ME members were contacted via WhatsApp and asked to complete an anonymous online survey. Google Forms was used as the platform for the survey. Responses were collected over a four-week period.ResultsFrom a total of 99 IPEG-ME members, 51 practicing pediatric surgeons from eight countries reported seven separate conceptions for the original Nissen wrap design. With more surgeon years of experience, not hospital annual volume, the percentage of surgeons who choose to preserve the short gastric vessels at laparoscopic Nissen fundoplication increased from 10 to 25%. Moreover, transmigration and reoperation rates were cut in half, while dysphagia rates doubled as surgeon years of experience increased from under 10 to over 30.ConclusionOwing to haziness, specialized surgeons may have expressed non-identical thoughts of the original description of a commonly employed procedure. Wrap transmigration and reoperation rates were cut in half, while dysphagia rates doubled as surgeon years of experience increased from under 10 to over 30. It seems reasonable to standardize the wrap design based on the components' justifications rather than surgeons’ preferences.

A Population-Based Study Using Belgian Cancer Registry Data Supports Centralization of Esophageal Cancer Surgery in Belgium.

Esophageal cancer surgery outcomes benefit from higher hospital volumes. Despite the evidence, organization of national health care often is complex and depends on various factors. The volume-outcome results of this population-based study supported national health policy measures regarding concentration of esophageal resections in Belgium. The Belgian Cancer Registry (BCR) database was linked to administrative data on cancer treatment. All Belgian patients with newly diagnosed esophageal cancer in 2008-2018 undergoing resection were allocated to the hospital at which surgery was performed. The study assessed hospital volume association with 90-day mortality and 5-year overall survival, classifying average annual hospital volume of resections as low (LV, <6), medium (MV, 6-19), or high (HV, ≥20) and as a continuous covariate in the regression models. The study included 4156 patients who had surgery in 79hospitals (2 HV hospitals [37% of all surgeries], 12 MV hospitals [30% of all surgeries], and 65 LV hospitals [33% of all surgeries]). Adjusted 90-day mortality in HV hospitals was lower than in LV hospitals (odds ratio [OR], 0.37; 95% CI, 0.21-0.65; p = 0.001). Case-mix adjusted 5-year survival was superior in HV versus LV (hazard ratio [HR], 0.43; 95% CI, 0.31-0.60; p < 0.001). The continuous model demonstrated a lower 90-day mortality (OR, 0.40; 95% CI, 0.23-0.71; p = 0.002) and a superior 5-year survival (HR, 0.45; 95% CI, 0.33-0.63; p < 0.001) in hospitals with volumes of 40 or more resections annually. Population-based data from the BCR confirmed a strong volume-outcome association for esophageal resections. Improved 5-year survival in centers with annual volumes of 20 or more resections was driven mainly by the achievement of superior 90-day mortality. These findings supported centralization of esophageal resections in Belgium.

Impact of Mediating and Confounding Variables on the Volume-Outcome Association in the Treatment of Pancreatic Cancer.

High-volume centers (HVC), academic centers (AC), and longer travel distances (TD) have been associated with improved outcomes for patients undergoing surgery for pancreatic adenocarcinoma (PAC). Effects of mediating variables on these associations remain undefined. The purpose of this study is to examine the direct effects of hospital volume, facility type, and travel distance on overall survival (OS) in patients undergoing surgery for PAC and characterize the indirect effects of patient-, disease-, and treatment-related mediating variables. Using the National Cancer Database, patients with non-metastatic PAC who underwent resection were stratified by annual hospital volume (< 11, 11-19, and ≥ 20cases/year), facility type (AC versus non-AC), and TD (≥ 40 versus < 40 miles). Associations with survival were evaluated using multiple regression models. Effects of mediating variables were assessed using mediation analysis. In total, 19,636 patients were included. Treatment at HVC or AC was associated with lower risk of death [hazard ratio (HR) 0.90, confidence interval (CI) 0.88-0.92; HR 0.89, CI 0.86-0.91, respectively]. TD did not impact OS. Patient-, disease-, and treatment-related variables explained 25.5% and 41.8% of the survival benefit attained from treatment at HVC and AC, reducing the survival benefit directly attributable to each variable to 4.9% and 6.4%, respectively. Treatment of PAC at HVC and AC was associated with improved OS, but the magnitude of this benefit was less when mediating variables were considered. From a healthcare utilization and cost-resource perspective, further research is needed to identify patients who would benefit most from selective referral to HVC or AC.

The Effect of Surgeon and Hospital Volume on Total Hip Arthroplasty Patient-Reported Outcome Measures: An American Joint Replacement Registry Study.

Some studies have shown lower morbidity and mortality rates with increased surgeon and hospital volumes after total hip arthroplasty (THA). This study sought to determine the relationship between surgeon and hospital volumes and patient-reported outcome measures after THA using American Joint Replacement Registry data. Using American Joint Replacement Registry data from 2012 to 2020, 4,447 primary, elective THAs with both preoperative and 1-year postoperative Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) scores were analyzed. This study was powered to detect the minimum clinically important difference (MCID). The main exposure variables were median annual surgeon and hospital volumes. Tertiles were formed based on the median annual number of THAs conducted: low-volume (1 to 42), medium-volume (42 to 96), and high-volume (≥96) surgeons and low-volume (1 to 201), medium-volume (201 to 392), and high-volume (≥392) hospitals. Mean preoperative and 1-year postoperative HOOS-JR scores were compared. Preoperative HOOS-JR scores were significantly higher at high-volume hospitals than low-volume and medium-volume hospitals (49.66 ± 15.19 vs. 47.68 ± 15.09 and 48.34 ± 15.22, P < 0.001), although these differences were less than the MCID. At the 1-year follow-up, no difference was noted with no resultant MCID. Preoperative and 1-year HOOS-JR scores did not markedly vary with surgeon volume. In multivariate regression, low-volume and medium-volume surgeons and hospitals had similar odds of MCID achievement in HOOS-JR scores compared with high-volume surgeons and hospitals, respectively. Using the HOOS-JR score as a validated patient-reported outcome measure, higher surgeon or hospital THA volume did not correlate with higher postoperative HOOS-JR scores or greater chances of MCID achievement in HOOS-JR scores compared with medium and lower volume surgeons and hospitals.

Bariatric surgery volume by hospital and long-term survival: population-based NordOSCo data.

It is unclear whether annual hospital volume of bariatric surgery influences the long-term survival of individuals who undergo surgery for severe obesity. The hypothesis that higher annual hospital volume of bariatric surgery is associated with better long-term survival was evaluated. This retrospective population-based study included patients who underwent bariatric surgery in Sweden and Finland between 1989 and 2020. Annual hospital volume was analysed for risk of all-cause mortality. Multivariable Cox regression provided HRs with 95 per cent confidence intervals adjusted for age, sex, co-morbidity, country, and type of bariatric procedure. Weight loss surgery was performed in 77 870 patients with a 0.5 per cent risk of postoperative death (mortality rate (MR) per 100 000 people 592.7, 95 per cent c.i. 575.0 to 610.9). Higher annual hospital volume of bariatric surgery was associated with a lower risk of all-cause mortality. The adjusted HRs were slightly more reduced for each quartile of annual hospital volume compared with the lowest quartile (MR per 100 000 people for lowest quartile 815.1, 95 per cent c.i. 781.7 to 849.9; for quartile II: HR 0.88, 95 per cent c.i. 0.81 to 0.96 (MR per 100 000 people 545.0, 512.0 to 580.1); for quartile III: HR 0.87, 0.78 to 0.97 (MR per 100 000 people 428.8, 395.5 to 465.0); for quartile IV: HR 0.82, 0.73 to 0.93 (MR per 100 000 people 356.0, 324.1 to 391.1)). In analyses restricted to laparoscopic surgery, volume and mortality were related only in the crude model (HR 0.86, 0.75 to 0.98), but not in the multivariable model (HR 0.97, 0.84 to 1.13) that compared highest and lowest quartiles. If there was a survival benefit associated with hospital volume, it may have been due to a faster uptake of laparoscopic surgery in the busier hospitals.

The impact of hospital volume on survival in patients with locally advanced colonic cancer.

High hospital volume has been shown associated with improved survival in patients with several cancers. The aim of this nationwide cohort study was to investigate whether hospital volume affects survival in patients with locally advanced colonic cancer. All patients with non-metastatic locally advanced colonic cancer diagnosed between 2007 and 2017 in Sweden were included. Tertiles of annual hospital volume of locally advanced colonic cancer were analysed and 5-year overall and colonic cancer-specific survival were calculated with the Kaplan-Meier method. HRs comparing all-cause and colonic cancer-specific mortality rates were estimated using Cox models adjusted for potential confounders (age, sex, year of diagnosis, co-morbidity, elective/emergency resection, and university hospital) and mediators (preoperative multidisciplinary team assessment, neoadjuvant chemotherapy, radical resection, and surgical experience). A total of 5241 patients were included with a mean follow-up of 2.7-2.8 years for low- and high-volume hospitals. The number of patients older than 79 years were 569 (32.3 per cent), 495 (29.9 per cent), and 482 (26.4 per cent) for low-, medium- and high-volume hospitals respectively. The 3-year overall survival was 68 per cent, 60 per cent and 58 per cent for high-, medium- and low-volume hospitals, respectively (P < 0.001 from log rank test). High volume hospitals were associated with reduced all-cause and colon cancer-specific mortality after adjustments for potential confounders (HR 0.76, 95 per cent CI 0.62 to 0.93 and HR 0.73, 95 per cent CI 0.59 to 0.91, respectively). The effect remained after inclusion of potential mediators. High hospital volume is associated with reduced mortality in patients with locally advanced colonic cancer.

Volume-outcome relationship in intra-abdominal robotic-assisted surgery: a systematic review.

As robotic-assisted surgery (RAS) expands to smaller centres, platforms are shared between specialities. Healthcare providers must consider case volume and mix required to maintain quality and cost-effectiveness. This can be informed, in-part, by the volume-outcome relationship. We perform a systematic review to describe the volume-outcome relationship in intra-abdominal robotic-assisted surgery to report on suggested minimum volumes standards. A literature search of Medline, NICE Evidence Search, Health Technology Assessment Database and Cochrane Library using the terms: "robot*", "surgery", "volume" and "outcome" was performed. The included procedures were gynecological: hysterectomy, urological: partial and radical nephrectomy, cystectomy, prostatectomy, and general surgical: colectomy, esophagectomy. Hospital and surgeon volume measures and all reported outcomes were analysed. 41 studies, including 983,149 procedures, met the inclusion criteria. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale and the retrieved data was synthesised in a narrative review.Significant volume-outcome relationships were described in relation to key outcome measures, including operative time, complications, positive margins, lymph node yield and cost. Annual surgeon and hospital volume thresholds were described. We concluded thatin centres with an annual volume of fewer than 10 cases of a given procedure, having multiple surgeons performing these procedures led to worse outcomes and, therefore, opportunities should be sought to perform other complimentary robotic procedures or undertake joint cases.

Mortality and 30-day readmission rate following leadless pacemaker implantation: insights from the Nationwide Readmissions Database

Abstract Background Clinical trials and registry data showed encouraging outcomes for leadless pacemaker (LP) implantation. However, reports of patient characteristics, trends, and clinical outcomes in a real-world population are limited. Purpose To provide real-world evidence of the rates, trends, and patient characteristics associated with in-hospital complications and 30-days readmission after LP implantations. Methods Using the all-payer, nationally representative Nationwide Readmissions Database between 2017 and 2019, we analyzed leadless or conventional pacemaker implantations. The national trends of in-hospital mortality, in-hospital complication rates and 30-day readmission rates after pacemaker implantation and their national trends were analyzed. Mixed-effects multivariable logistic regression analysis was performed to identify factors associated with in-hospital death and 30-days readmission in LP patients. Results A total of 137,732 admissions (age: 78 [70–85], 5,986 LP implantations) were analyzed (Figure 1). The in-hospital mortality, overall in-hospital complication rate, and 30-days readmission rates after LP implantations were 5.0%, 16%, and 16%, respectively. In LP recipients, the national estimate of in-hospital mortality declined from 10.9% in the second quarter of 2017 to 4.3% in the fourth quarter of 2019 (P&amp;lt;0.001) (Figure 2a). Furthermore, the national estimate of overall complication rate declined from 20.6% in the second quarter of 2017 to 13.0% in the fourth quarter of 2019 (P&amp;lt;0.001) (Figure 2b). Conversely, non-elective 30-day readmission rate did not show any increasing or decreasing trends in LP recipients (P=0.74) (Figure 2c). In LP recipients, female sex (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.04–1.93), history of heart failure (OR 2.02, 95% CI 1.46–2.79), and first quartile annual pacemaker implantation hospital volume (OR 2.49, 95% CI 1.56–3.97, fourth quartile annual pacemaker implantation hospital volume used as a reference standard) were factors associated with in-hospital death. Conclusions Analysis of the nationally representative claims database in the US showed in-hospital mortality, complication rates, and non-elective 30-day readmission rate of 5.0%, 16%, and 16% respectively, for LP implantation performed during hospitalization. Although in-hospital mortality and complication rates showed a decreasing trend over time, ongoing surveillance is needed for the safety of LP implantation. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Intramural research fund (21-6-9)for cardiovascular diseases of national cerebral and cardiovascular center.

Associations of Annual Hospital and Surgeon Volume with Patient Outcomes After Gastrectomy: A Systematic Review and Meta-analysis.

Procedural volume is an important determinant of outcomes in cancer surgery. There is a lack of a comprehensive and updated assessment of hospital and surgeon volumes in relation to short- and long-term outcomes after gastrectomy for cancer. The PubMed and Embase databases were searched on January 2021. We conducted meta-analyses and meta-regressions assuming a random effects model to assess the associations of procedural volumes with outcomes after gastrectomy. Effect sizes included hazard ratios (HRs), odds ratios (ORs), and standardized mean differences (SMDs). Heterogeneity was evaluated with the I2 statistic and explored by subgroup analyses. The risk of publication bias, risk of bias, and certainty of evidence were also assessed. We identified 53 primary publications on the effect of hospital (n=48) or surgeon (n=11) volume on 11 gastrectomy outcomes. Patients operated on in high-volume centers had better overall survival (HR 0.82, 95% confidence interval [CI] 0.75-0.90), lower short-term mortality (OR 0.66, 95% CI 0.58-0.75), more adequate lymphadenectomy (OR 2.14, 95% CI 1.76-2.59), and shorter length of stay (SMD -0.08, 95% CI -0.12 to -0.04). The meta-analysis showed no significant associations of hospital volume with surgical complications, R0 or negative margin resection, or disease-free survival (all p>0.05). A higher surgeon volume was associated with lower 30-day mortality (OR 0.94, 95% CI 0.90-0.97). The current study suggested with high confidence that gastric cancer patients operated on in high-volume centers had better overall survival. Centralization of gastrectomy in high-volume centers might lead to an overall improvement in other outcomes, but more studies, especially on surgeon volume, are needed.

Hospital factors and metastatic surgery in colorectal cancer patients, a population-based cohort study

BackgroundOnly a limited proportion of patients with metastatic colorectal cancer (mCRC) receives metastatic surgery (including local ablative therapy). The aim was to investigate whether hospital volume and hospital level were associated with the chance of metastatic surgery.MethodsThis national cohort retrieved from the CRCBaSe linkage included all Swedish adult patients diagnosed with synchronous mCRC in 2009–2016. The association between annual hospital volume of incident mCRC patients and the chance of metastatic surgery, and survival, were assessed using logistic regression and Cox regression models, respectively. Hospital level (university/non-university) was evaluated as a secondary exposure in a similar manner. Both uni- and multivariable (adjusted for sex, age, Charlson comorbidity index, year of diagnosis, cancer characteristics and socioeconomic factors) models were fitted.ResultsA total of 1,674 (17%) out of 9,968 mCRC patients had metastatic surgery. High hospital volume was not associated with increased odds of metastatic surgery after including hospital level in the model, whereas hospital level was (odds ratio (OR) (95% confidence interval (CI)): 1.94 (1.68–2.24)). All-cause mortality was lower in university versus non-university hospitals (hazard ratio (95% CI): 0.83 (0.78–0.88)).ConclusionsPatients with mCRC initially cared for by a university hospital experienced a greater chance to receive metastatic surgery and had superior overall survival. High hospital volume in itself was not associated with a greater chance to receive metastatic surgery nor a greater survival probability. Additional efforts should be imposed to provide more equal care for mCRC patients across Swedish hospitals.

Cost-volume analysis of deep inferior epigastric artery perforator flaps for breast reconstruction in the United States

BackgroundDeep inferior epigastric artery perforator flaps are increasingly utilized over other autologous methods of breast reconstruction. We evaluated the relationship between annual hospital volume and costs after breast reconstruction with the deep inferior epigastric artery perforator flap. MethodsAll female patients undergoing elective implant or autologous tissue breast reconstruction were identified using the 2016–2019 Nationwide Readmission Database. Annual hospital volume of deep inferior epigastric artery perforator reconstructions was tabulated and modeled using restricted cubic splines. Institutions were categorized into high- and low-volume based on the inflection point of the spline between annual caseload and costs. The association between high volume status and costs, complications, length of stay, and 30-day nonelective readmission was assessed using multivariable regression. ResultsOf an estimated 94,524 patients meeting inclusion criteria, 33,046 (34.6%) underwent deep inferior epigastric artery perforator flap reconstruction. Deep inferior epigastric artery perforator flap utilization increased from 31% in 2016 to 40% in 2019 (P < .001) among inpatient breast reconstructions. High-volume hospitals more frequently performed bilateral reconstructions (43.3 vs 37.7%, P = .021) but had similar rates of concurrent mastectomy (28.7 vs 30.6%, P = .46), relative to low-volume hospitals. The median cost of deep inferior epigastric artery perforator reconstruction was lower ($29,900 [interquartile range: 22,400–37,400] vs $31,600 [interquartile range: 22,500–44,900], P = .036) at high-volume hospitals compared to low-volume. On adjusted analysis, high-volume status was associated a $3,800 (95% confidence interval: -6,200 to -1,400) decrement in hospitalization costs, and reduced odds of perioperative complications (adjusted odd ratio: 0.68 95% confidence interval: 0.54–0.86). High-volume status was not associated with length of stay or likelihood of unplanned readmission. ConclusionThe present study demonstrated an inverse cost–volume relationship in deep inferior epigastric artery perforator flap breast reconstruction. In line with goals of value-based health care delivery, our findings may inform referral patterns to suitable centers for deep inferior epigastric artery perforator breast reconstruction.

The Relationship Between Physician and Center Case Volume on Outcomes of TransCarotid Artery Revascularization

It has been suggested that the annual hospital volume of cases may affect the number of adverse events following carotid endarterectomy (CEA). Transfemoral carotid stenting (TFCAS) was found to have an extended learning curve with an estimated minimum of 25 cases for the success of the stenting procedure. One prior study indicated that transcarotid artery revascularization (TCAR) is being performed with excellent stroke and mortality rates even in the early stages of the surgeons’ learning curve.

Volume and Outcomes of Joint Arthroplasty

BackgroundJoint arthroplasties are among the most commonly performed elective surgeries in the United States. Surgical outcomes are known to improve with volume but it is unclear whether this has led to consolidation among elective surgeries. We examined trends in volumes per surgeon and hospital to assess whether the known volume-outcome relationship has led to consolidation in elective joint arthroplasty and to determine if there exist volume thresholds above which outcomes do not change. MethodsAmong Medicare beneficiaries who underwent either total knee or total hip arthroplasty from 2009 through 2015, we described volume trends and used mixed-effect models to relate annual surgeon and hospital volumes with 30-day complications or mortality. We tested for optimal volume cut points at both the hospital and surgeon level. ResultsAdjusted annual complication rates were inversely associated with volume for both procedures at both the surgeon level and hospital level, but there was minimal consolidation between 2009 and 2015. Complications no longer declined after volumes of each case exceeded 260 per year. The vast majority of cases (around 93% of hip and 88% of knee arthroplasties) were performed by surgeons operating at suboptimal volumes. ConclusionMore than 2 decades after the volume-outcome relationship was established for joint arthroplasty, many cases continue to be performed by low-volume surgeons, with far more cases performed by surgeons operating at suboptimal volumes. Further improvement could be expected through consolidation at both the hospital and surgeon level, with a target of at least 260 cases per surgeon annually for each operation. Payers seem best-equipped to drive consolidation.

MP03-17 PATIENT, PHYSICIAN, HOSPITAL FACTORS ASSOCIATED WITH READMISSION AFTER RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 May 2022MP03-17 PATIENT, PHYSICIAN, HOSPITAL FACTORS ASSOCIATED WITH READMISSION AFTER RADICAL CYSTECTOMY Kassem Faraj, Lanyu Mi, and Mark Tyson Kassem FarajKassem Faraj More articles by this author , Lanyu MiLanyu Mi More articles by this author , and Mark TysonMark Tyson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002515.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical Cystectomy (RC) is associated with significant morbidity and a result, high complication rates. Patient, or clinical factors, are the most commonly identified variables associated with hospital readmission. Other factors that may be important include hospital and physician characteristics, which have been suggested as contributing factors for readmission in other major surgeries. This study investigates the contribution of patient, physician and hospital factors on hospital readmission after RC. METHODS: This was a retrospective review of the Surveillance Epidemiology and End Results (SEER)-Medicare database focusing on bladder cancer patients who underwent RC between 2007-2016. These claims were identified using ICD-9/ICD-10 or HCPCS codes from MEDPAR or NCH claims, from which the annual hospital and physician volumes were calculated and classified as low, medium and high. Univariate and multivariable analyses were done for 90-day readmission as the outcome using a multilevel model to explore the association between readmission and characteristics of patient, hospital, and physician. Models with random intercepts were constructed to consider the variation from hospital and physician. The intraclass correlation coefficient (ICC) for hospital, physician and patient levels were also calculated. RESULTS: In 3530 patients, 1291 (36.6%) were readmitted within 90 days of the index surgery. On univariate analysis, continent urinary diversion (OR 1.533), greater NCI comorbidity score (OR 1.460 for NCI 2-4 vs <2; OR 1.754 for NCI >4 vs <2), robotic approach (OR 1.210), AJCC stage (stage III vs stage I, OR 0.777), hospital length of stay (OR 1.037), Northeast vs Western hospital location (OR 4.19), and any postoperative complication (OR 6.790) were significantly (p <0.05) associated with 90-day hospital readmission. On multilevel multivariable analysis, factors significantly (p <0.05) associated with 90-day readmission included continent urinary diversion (OR 1.462), robotic approach (OR 1.299), and any postoperative complication (OR 6.865). Neither hospital volume, physician volume, hospital region, teaching hospital status, nor NCI center designation were associated with hospital readmission. The main source of variation was determined to be at the patient (92.5%), followed by the physician (5.1%), and then hospital (2.4%) levels. CONCLUSIONS: Ninety-day hospital readmission at the time of RC is high, with around one-third of patients requiring a readmission. Patient-specific factors are the most important in impacting the odds of readmission, while hospital and physician factors contribute minimally to this outcome. Consequently, efforts to reduce readmission rates should focus on the patient level. Source of Funding: This study was supported by Grant Number P30 CA015083 from the National Cancer Institute (NCI) from the Robert D. and Patricia E. Kern Center for Health Care Delivery Science (M.D.T.), the Christian Haub Family Career Development Award for Cancer Research Honoring Dr Richard Emslander (M.D.T.), and the Eric and Gail Blodgett Foundation (M.D.T.). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the NIH © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e27 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kassem Faraj More articles by this author Lanyu Mi More articles by this author Mark Tyson More articles by this author Expand All Advertisement PDF DownloadLoading ...

82MO Risk-adjusted mortality rates as a quality proxy outperform volume in lung cancer surgery: A new perspective on hospital centralization using national population-based data

Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery from unsafe hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume.

Annual hospital volume and colorectal cancer survival in a population-based nationwide cohort study in Finland

PurposeTo examine the annual hospital volume of surgery in relation to survival in colorectal cancer. Previous studies on hospital volume and survival following colorectal cancer surgery are conflicting. MethodsAll 49 032 patients who underwent resection for colorectal cancer in 1987–2016 in Finland were included, with complete follow-up until December 31, 2019. Primary outcome was 5-year mortality. Cox regression provided hazard ratios (HR) with 95% confidence intervals (CI) for quartiles of annual hospital volume for colorectal surgery, adjusted for calendar period, age, sex, comorbidity, stage, tumor location and oncological therapy. Additionally, colon and rectal cancer surgery were assessed separately. Sensitivity analysis of patients with confirmed curative intent was conducted. ResultsCompared to highest quartile (≥108 resections annually), lowest hospital volume (≤37 resections annually) was associated with slightly increased 5-year all-cause mortality (adjusted HR 1.07, 95% CI 1.02–1.12). A pre-planned subgroup-analysis suggested a slightly improved 5-year survival in high-volume institutions for rectal cancer, but not colon cancer surgery. Sensitivity analysis including only those operated with confirmed curative intent suggested no differences between hospital volume groups in colorectal, colon or rectal cancer for 5-year all-cause mortality. ConclusionHigher hospital volume is associated with slightly improved all-cause 5-year mortality in colorectal cancer surgery, but this effect may be limited to rectal cancer surgery only. Volume-outcome relationship in rectal cancer surgery should be investigated further using large datasets. These results do not support centralization of colon cancer surgery based on hospital volume only.

No association between hospital volume and short-term outcomes of some common surgeries: a retrospective cohort study based on a Japanese nationwide database.

Centralization of high-risk surgeries has become a widespread strategy. However, whether or not the hospital volume affects the outcomes of common surgeries remains unclear. This study explored the association between hospital volume and short-term outcomes of common surgeries, as represented by appendectomy, cholecystectomy, and pneumothorax surgery, by analyzing data from a Japanese nationwide database. All hospitals were categorized into four groups (very low-, low-, high-, and very high-volume) according to the annual hospital volume of all gastrointestinal surgeries or all respiratory surgeries in 2017. Patient demographic data and surgical outcomes were evaluated across hospital volume categories. We analyzed 2392 facilities which performed 771,182 gastrointestinal surgeries, and 992 facilities which performed 98,656 respiratory surgeries. Short-term outcomes of patients who underwent appendectomy (n = 50,568), cholecystectomy (n = 104,262), and pneumothorax surgery (n = 11,723) were evaluated. The incidences of postoperative complications, reoperation, and readmission were similar among the groups. Multivariable logistic regression analyses revealed hospital volume to have no association with these short-term outcomes. Analyses of a Japanese nationwide database revealed that the hospital volume was not associated with short-term outcomes of appendectomy, cholecystectomy, and pneumothorax surgery. These common surgical procedures may not require centralization into high-volume hospitals.