Annual Procedure Volume Research Articles

Total Ankle Arthroplasty and Ankle Arthrodesis Utilization: An American Board of Orthopaedic Surgery (ABOS) Part II Database Study

Category:Ankle, Ankle ArthritisIntroduction/Purpose:Total ankle arthroplasty (TAA) utilization has increased over the last 20 years, while ankle arthrodesis (AAD) utilization has remained constant. However, annual hospital procedure volume for TAA and AAD remains low, with 50% of hospitals performing a median of =5 cases per year. Practicing in a low-volume setting may have implications for technical performance and patient outcomes, especially amongst early-career surgeons. The purpose of this study was to examine trends in utilization of TAA and AAD in ABOS part-II candidates while considering the influence of fellowship training status on treatment of end-stage ankle arthritis.Methods:The American Board of Orthopedic Surgery (ABOS) Part II database was queried to identify all candidates who performed =1 TAA or AAD from exam years 2009-2018. Candidates were categorized by exam year and by self-reported fellowship training status. Descriptive statistical methods were used to report procedure volumes. Trends in utilization of TAA and AAD were examined using log-modified regression analyses.Results:From 2009-2018, there was no significant change in the utilization of TAA or AAD amongst all candidates (p=0.92, p=0.20) (Table 1). Candidates reporting a foot and ankle (FA) fellowship trended towards increased utilization of TAA relative to AAD versus non-FA fellowship candidates, but this failed to reach statistical significance (p=0.06). The utilization of arthroscopic AAD increased over time (p<0.01) amongst all candidates. There was no difference in the rates of utilization of open versus arthroscopic AAD amongst FA trained candidates. High-volume (=5 TAA) candidates represented 10.5% of all candidates performing TAA, and accounted for 34.2% of all TAAs performed over the study period.Conclusion:Utilization of TAA and AAD did not change over the study period, and the number of these procedures performed by early-career surgeons remains low. The majority of both procedures are performed by FA trained surgeons with relatively low practice volumes. There was a trend toward increased TAA utilization relative to AAD utilization in FA trained surgeons, but this did not reach statistical significance. The findings in this study may have implications for technical performance impacting patient outcomes and may guide potential changes in training curricula.

P1028Impact of atrial fibrillation ablation procedural volume on complication and recurrence rate across European centers. An ESC EORP registry: atrial fibrillation long-term

Abstract Background Catheter ablation has emerged as an effective therapy in patients with symptomatic and drug refractory atrial fibrillation (AF). Despite high success rates of the method, there is still heterogeneity of outcomes and complication rate across Europe. The impact of the annual procedural volume per center on success and complication rate of AF ablation, based on real-life data, has not been addressed till now. Purpose The aim of the study was to investigate if center AF ablation volume might be associated with one-year success or complication rate after the procedure. Methods Data for this analysis were extracted from the European AF Ablation Long-Term Study, a prospective registry designed to describe the clinical epidemiology of patients undergoing AF ablation. Based on 25th and 75th percentiles of AF ablation numbers performed, the participating centers were classified into high volume (HV) (≥250 procedures/year), medium volume (MV) (&lt;250 and ≥58/year) and low volume (LV) (&lt;58/year). One-year success was defined as patient survival free from any atrial arrhythmia, from the end of the 3-month blanking period to 12 months following the ablation procedure. Results A total of 91 centers in 26 European countries enrolled 3368 patients. There was a significantly higher reporting of cardiovascular complications in LV centers (5.2%), especially pericarditis (0.6%) and cardiac perforation (1.4%), while the HV and MV centers reported cardiovascular complications in 3.0 and 4.3% of cases, respectively (p=0.039). Additionally, stroke incidence after ablation was significantly higher in LV centers (0.5% of cases vs 0% in HV and MV centers, p=0.008). Kaplan-Meier survival analysis based on adjusted data of all complications demonstrated, however, that there was not a significant difference in complication rate according to volume's center (p=0.402, Figure A). One-year success after AF ablation ranged from 77.8% in HV vs 70.5% in LV vs 77.3% in MV centers (p&lt;0.001). Nonetheless, adjusted recurrence rate was not significantly different among centers (p=0.363, Figure B), a result driven by differences both in ablation technical characteristics and risk/severity of cases ablated in different volume centers. Conclusions Despite the notion that “the higher, the better”, our results suggest that AF ablation is a safe procedure with high success rates in all European centers, independent of the AF ablation procedural volume. Differences in patients and procedural characteristics may justify the equality of complication and recurrence rate among centers, since expertise level counterbalances the risk of each case.

Association of revisions or conversions after sleeve gastrectomy with annual bariatric center procedural volume in the state of New York.

Although bariatric center procedural volume has been associated with early perioperative safety, data on the effect of such volume and long-term outcomes after sleeve gastrectomy (SG) are limited. This study aims to examine the relationship between annual bariatric center SG volume and the incidence of revisions or conversions (RC) after SG. The New York Statewide Planning and Research Cooperative System database was used to identify all patients who underwent SG between 2006 and 2012. Subsequent RC events were captured up to 2016. Bariatric centers having annual SG volume less than 45, between 45 and 65, and greater than 65 were defined as low (LV), medium (MV), and high volume (HV), respectively. Multivariable Cox proportional hazard regression analysis was performed to compare the risk of having RC among centers with different yearly sleeve volumes. We identified 8389 patients who underwent SG. The overall estimated cumulative incidence of RC was 0.5% (95% CI 0.3-0.6%) at 1year, 6.2% (95% CI 5.4-7.0%) at 5years, and 15.3% (95% CI 12.6-18.0%) at 8years after SG. The estimated cumulative incidence of RC for LV, MV, and HV at 8years after SG was 16.7% (95% CI 11.1-22.3%), 15.5% (95% CI 11.2-19.8%), and 13.7% (95% CI 9.4-17.9%), respectively. HV centers have lower risk of RC compared to LV (hazard ratio 0.65; 95% CI 0.48-0.88) and MV (hazard ratio 0.75; 95% CI 0.57-0.98). LV and MV centers have comparable risk of RC (hazard ratio 1.15; 95% CI 0.87-1.51). Patients having the initial SG performed in LV were the least likely to have RC in the same institution (46.1% of LV, 13.2% of MV and 22.3% of HV; p < 0.0001). Patients undergoing SG at LV centers experience the highest risk of subsequent RC. This effect persists after adjusting for patient-level factors. These data underline the relationship between volume threshold and long-term effect.

Association Between Annual Surgeon Total Thyroidectomy Volume and Transient and Permanent Complications

Although the association between annual surgeon total thyroidectomy volume and clinical outcomes is well established, published methods typically group surgeons into volume categories. The volume-outcomes association is likely continuous, but little is known about the point at which the annual surgeon procedure volumes begin to be associated with a decrease in complication rates. To model the volume-outcomes association as a continuous function and identify the point at which increasing surgeon volume begins yielding better outcomes. A retrospective cohort study was conducted in 2018 to 2019 on 10 546 patients from 2 Kaiser Permanente regions (Northern and Southern California), who underwent total thyroidectomy from January 1, 2008, through December 31, 2015, and were followed up through December 31, 2017. The association between annual surgeon procedure volume and outcomes was modeled with analyses that accounted for an association of unknown form and surgeon-specific effects, after adjusting for sociodemographics, prior-year utilization, and multiple comorbidities. Data were analyzed from October 2018 to April 2019. Total thyroidectomy. Presence or absence of transient and permanent hypoparathyroidism and vocal cord paralysis (VCP) in relation to surgeon volume of total thyroidectomies. Of 10 546 patients in this study, 8500 (81.0%) were male and 4877 (46.2%) aged 45 to 64 years. Surgeons with annual volumes of 1 to 9 total thyroidectomies operated on 2912 patients (27.7%), those with an annual volume of 10 to 19 operated on 3404 (32.6%), and those with an annual volume of 20 or more operated on the remaining 4232 (40.6%). During 2008-2015, a mean of 53.5 (range, 46-198) thyroidectomies were performed each year by surgeons with an annual volume of 40 or more procedures. A generalized additive model showed that the occurrence rates of VCP and hypoparathyroidism began to decrease at annual surgeon procedure volumes of 18.2 (95% CI, 15.0-21.5) and 18.1 (95% CI, 13.8-21.3) procedures per year, respectively. The model revealed a subsequent increase in complication rates for transient VCP. With the use of a refined model, statistically significant decreases were noted in the occurrence rates of complications as annual surgeon volumes increased. Among all 10 546 patients who underwent total thyroidectomy, 632 (6.0%) experienced transient hypoparathyroidism and 170 (1.6%) experienced permanent hypoparathyroidism, whereas 440 (4.2%) experienced transient VCP and 182 (1.7%) experienced permanent VCP. Absolute decreases in complication rates when all surgeons had modeled minimum annual procedure volumes greater than 40 were low, ranging from 0.6% for permanent VCP and hypoparathyroidism to 1.5% for transient hypoparathyroidism. In this study, occurrence rates of transient and permanent hypoparathyroidism and VCP appeared to decrease as the annual surgeon procedure volume increased, but the absolute decrease may be modest if the affected health system already has low complication rates. Shifting patients to higher-volume surgeons to realize these reductions may be of variable attractiveness in systems with low baseline complication rates.

PSU6 IMPACT OF PROCEDURE VOLUME ON 30-DAY ALL-CAUSE READMISSIONS IN LAPAROSCOPIC AND ROBOTIC BARIATRIC SURGERY

To examine the impact of procedure volume on 30-day all-cause readmissions among patients undergoing laparoscopic or robotic bariatric surgery. We extracted hospital discharge records from the Premier Healthcare Database for patients aged≥18 undergoing elective laparoscopic or robotic bariatric surgery (Roux-en-Y gastric bypass, sleeve gastrectomy) between 1-1-2015 and 12-31-2017 (first admission=index). For each patient, we used the month of index and 12 months prior to measure their hospital’s annual procedure volume of the specific procedure/approach that they underwent (Roux-en-Y/laparoscopic, Roux-en-Y/robotic, sleeve/laparoscopic, sleeve/robotic); we then used multivariable generalized estimating equations to quantify the association between the annual procedure volume (categorized in quartiles [Q1-Q4] from low-to-high volume) and 30-day all-cause readmission to the same hospital in which the bariatric surgery was performed, accounting for hospital-level clustering and adjusting for patients’ demographics, body mass index, comorbidities, and provider/hospital characteristics. The study included 30,301 Roux-en-Y/laparoscopic, 2,751 Roux-en-Y/robotic, 66,788 sleeve/laparoscopic, and 6,227 sleeve/robotic patients from 294 hospitals. In analyses of the laparoscopic approach, higher annual procedure volume was significantly associated with lower adjusted risk of 30-day all-cause readmission (Roux-en-Y/laparoscopic: Q1=6.5%, Q2=5.9%, Q3=4.8%, Q4=4.6%, P=0.002; sleeve/laparoscopic: Q1=3.3%, Q2=2.8%, Q3=2.9%, Q4=2.3%, P=0.006). In contrast, for the robotic approach, procedure volume was not significantly associated with adjusted risk of 30-day all-cause readmissions (Roux-en-Y/robotic: Q1=7.1 %, Q2=7.2%, Q3=7.0%, Q4=5.6%, P=0.836; sleeve/robotic: Q1=2.8%, Q2=2.5%, Q3=2.9%, Q4=3.9%, P=0.335). Among patients undergoing elective bariatric surgery, higher hospital procedure volume was significantly associated with lower adjusted risks of 30-day all-cause readmission for laparoscopic procedures but not robotic procedures. The robotic approach is a relatively new and less common technique in bariatric surgery; readmission data may reflect the fact that robotics is in early experience with hospitals and surgeons still advancing on their learning curves. More research is needed to understand the hospital and surgeon-specific factors which influence outcomes in robotic bariatric surgery.

Relation of Hospital Volume With In-Hospital and 90-Day Outcomes After Transcatheter Mitral Valve Repair Using MitraClip

MitraClip therapy has shown increasing use since it was commercially adopted among US hospitals in October 2013. However, the relation of institutional MitraClip volume with outcomes is unclear. This study sought to examine the association between hospital volume and outcomes after transcatheter mitral valve repair using the MitraClip device. Using the Nationwide Readmissions Database, we identified all patients who underwent a MitraClip procedure and categorized hospitals into tertiles based on their annual procedure volume: low (≤3 procedures/year), medium (4 to 13/year), and high (≥14/year) volume centers. Multivariable logistic and Cox regression analyses were performed to examine the impact of institutional MitraClip volume on in-hospital and 90-day outcomes, respectively. From 2014 to 2015, a total of 3,420 procedures were performed at 266 hospitals with a median annual procedural volume of 5 per hospital. Low (n = 81), medium (n = 86), and high (n = 99) volume hospitals performed 147 (4.3%), 403 (11.8%), and 2,870 (83.9%) MitraClip procedures, respectively. The low versus high hospital volume was independently associated with increased in-hospital mortality (7.8% vs 3.0%; adjusted odds ratio [aOR] 2.64; p = 0.04), acute myocardial infarction (10.2% vs 2.2%; aOR 2.93; p = 0.02), and acute respiratory failure (19.3% vs 7.7%; aOR 2.24; p = 0.02) during index admission as well as 90-day all-cause readmissions (37.8% vs 26.6%; adjusted hazard ratio 1.54; p = 0.03), and 90-day infective endocarditis (2.4% vs 0.3%; adjusted hazard ratio 10.06; p = 0.003). In conclusion, low hospital MitraClip volume is an independent determinant of worse outcomes including in-hospital mortality and 90-day readmissions.

Association Between Institutional Factors and Long-Term Survival Following Transjugular Intrahepatic Portosystemic Shunt.

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure designed to treat portal hypertension. Hospital teaching status is an institutional factor found to be predictive of outcomes following several complex procedures; however, its impact on outcomes following TIPS is unknown. The aim of this study was to determine the association between hospital teaching status and long‐term survival in patients with cirrhosis receiving TIPS. We performed a retrospective population‐based cohort study using linked administrative health data from Ontario, Canada. Adult patients with cirrhosis who received TIPS between January 1, 1998, and December 31, 2016, with follow‐up until December 31, 2017, were included. Hospital teaching status was defined based on hospital participation in the instruction of medical students and/or resident physicians. Liver transplant‐free (LTF) survival was evaluated using Kaplan‐Meier analysis, and overall survival was assessed using competing risks regression analysis, which accounted for hospital clustering. A total of 857 unique patients were included (mean age 57.1 years; 69.1% male). The TIPS procedures were performed in teaching hospitals (84.3%) as well as nonteaching hospitals (15.7%). Median LTF survival was more than twice as long for procedures performed in teaching hospitals compared to nonteaching hospitals (2.2 years versus 0.9 year, respectively; P < 0.001). After adjusting for confounders and clustering, hospital teaching status was not independently associated with mortality (nonteaching subdistribution hazard ratio [sHR], 1.32; 95% confidence interval [CI], 0.97‐1.81; P = 0.08); however, annual hospital procedure volume was (per unit increase sHR, 0.96; 95% CI, 0.93‐0.99; P = 0.003). Conclusion: Hospital procedure volume is associated with long‐term survival following TIPS. These results further support the centralization of TIPS to high‐volume hospitals to improve long‐term outcomes in this population.

Percutaneous Vertebral Augmentation for Vertebral Compression Fractures: National Trends in the Medicare Population (2005-2015).

Retrospective analysis of Medicare data OBJECTIVE.: To analyze trends of vertebral augmentation in the elderly Medicare population in the context of evolving evidence and varied medical society opinions. Percutaneous vertebral augmentation offers a minimally invasive therapy for vertebral compression fractures. Numerous trials have been published on this topic with mixed results. The impact of these studies and societal recommendations on physician practice patterns is not well understood. The Centers for Medicare and Medicaid Services annual Medicare Physician Supplier Procedure Summary database was examined for kyphoplasty and vertebroplasty procedures from 2005 through 2015. Top provider specialties were determined based on annual procedural volume, and grouped into the three broad categories of radiology, surgery, and anesthesia/pain medicine. Data entries were independently analyzed by provider type, site of service, submitted charges, and reimbursement rates for interventions during the study period. Between 2005 and 2015 total annual claims for vertebral augmentation procedures in the Medicare population increased from 108.11% (37,133-77,276) peaking in 2008 and declining by 15.56% in 2009. Radiology is the largest provider of vertebral augmentation by specialty with declining market shares from 71% in 2005 to 43% in 2015. The frequency of vertebroplasty declined by 61.7% (35,409-13,478) from 2005 to 2015 with reduction in Medicare reimbursement. Annual volume of kyphoplasty grew by 18.3% (48,725-57,646) with significant increase in reimbursement for office-based procedures ($728.50/yr, P < 0.001, R = 0.69). The annual volume of vertebral augmentation declined in 2009 following two negative trials on vertebroplasty. Although these publications had a persistent negative impact on practice of vertebroplasty, the overall frequency of vertebral augmentation in the Medicare population has not changed significantly between 2005 and 2015. Instead, there has been a significant shift in provider practice patterns in favor of kyphoplasty in increasingly outpatient and office-based settings. 3.

Influence of individual surgeon volume on early postoperative outcomes after rectal cancer resection

Background/Aim. Surgeon-specific experience as measured by procedure volume can have a significant impact on survival of patients with rectal cancer (RC). The aim of this study was to determine whether an individual surgeon-specific volume of procedure influences early postoperative outcomes as well as to determine the strength of different groups of annual surgeon volume (ASV), as a predictor of outcomes in patients after RC resection up to 30 days postoperatively. Methods. This retrospective observational single center study involved a cohort of 546 patients of both sexes, operated for a 10-year period due to RC. Patients were divided into three groups, according to the annual volume of RC procedures of a surgeon who operated them. Seven outcomes were analyzed: the incidence of colorectal anastomotic dehiscence (CRAD), operative time, intraoperative blood loss, hospital stay, in-hospital death, the status of the circumferential resection margin (CRM) and the total mesorectal excision (TME) with number of lymph nodes, as well as some risk factors (several independent, dependent and ?confusing? variables) of importance for the outcome, to explain the difference. The strength of each group of surgeons and their effect on early outcome of treatment were determined. Results. The majority of surgeons (77.7%) belonged to the low and medium ASV, which performed a slightly higher number of surgeries (281) than the high volume group. The high-volume surgeon group was associated with significantly better results in four outcomes (CRAD, operating time, CRM, TME and number of lymph nodes). Conclusion. In our surgical institution, the high volume surgeon remains an important predictor of success of the RC surgery.

A population-based cohort examining factors affecting all-cause morbidity and cost after pediatric appendectomy: Does annual adult procedure volume matter?

The purpose of this study was to examine factors affecting morbidity and cost after pediatric appendectomy and particularly the role of adult surgical volume. This was population-based study including all pediatric patients who underwent appendectomy for appendicitis in Canada (excluding Quebec) from 2008 to 2015. All-cause morbidity was the main outcome of interest. Cost of the index admission (in 2014 Canadian dollars) was a secondary outcome. Hierarchal linear and logistic regressions were used to model the outcomes. Overall, 41,512 patients were identified. After adjustment, younger patients (OR = 0.98/year, 95%CI 0.97-0.99, p < 0.001), patients with comorbidities (OR = 2.20, 95%CI 1.96-2.46, p < 0.001), and those with perforated appendicitis (OR = 5.95, 95%CI 5.44-6.50, p < 0.001) were more susceptible to morbidity. Annual pediatric appendectomy volume was a significant predictor of reduced morbidity (OR = 0.85/20 cases, 95%CI 0.76-0.93, p < 0.001) as was the use of laparoscopy (OR = 0.81, 95%CI 0.72-0.91, p = 0.001). Conversely, annual adult appendectomy volume conferred no benefit nor did pediatric surgery specialty training. Outcomes after pediatric appendectomy are influenced by pediatric case volume, regardless of specialty training, but extra adult surgical volume confers no benefit.

The Learning Curve and Annual Procedure Volume Standards for Optimum Outcomes of Transcatheter Aortic Valve Replacement: Findings From an International Registry

ObjectivesThe authors aimed to determine the procedural learning curve and minimum annual institutional volumes associated with optimum clinical outcomes for transcatheter aortic valve replacement (TAVR). BackgroundTranscatheter aortic valve replacement (TAVR) is a complex procedure requiring significant training and experience for successful outcome. Despite increasing use of TAVR across institutions, limited information is available for its learning curve characteristics and minimum annual volumes required to optimize clinical outcomes. MethodsThe study collected data for patients at 16 centers participating in the international TAVR registry since initiation of the respective TAVR program. All cases were chronologically ordered into initial (1 to 75), early (76 to 150), intermediate (151 to 225), high (226 to 300), and very high (>300) experience operators for TAVR learning curve characterization. In addition, participating institutions were stratified by annual TAVR case volume into low-volume (<50), moderate-volume (50 to 100), and high-volume (>100) groups for comparative analysis. Procedural and 30-day clinical outcomes were collected and multivariate regression analysis performed for 30-day mortality and the early safety endpoint. ResultsA total of 3,403 patients comprised the study population. On multivariate analysis, all-cause mortality was significantly higher for initial (odds ratio [OR]: 3.83; 95% confidence interval [CI]: 1.93 to 7.60), early (OR: 2.41; 95% CI: 1.51 to 5.03), and intermediate (OR: 2.53; 95% CI: 1.19 to 5.40) experience groups compared with the very high experience operators. In addition, the early safety endpoint was significantly worse for all experience groups compared with the very high experience operators. Low annual volume (<50) TAVR institutions had significantly higher all-cause 30-day mortality (OR: 2.70; 95% CI: 1.44 to 5.07) and worse early safety endpoint (OR: 1.60; 95% CI: 1.17 to 2.17) compared with the moderate- and high-volume groups. There was no difference in patient outcomes between intermediate and high annual volume groups. ConclusionsTAVR procedures display important learning curve characteristics with both greater procedural safety and a lower mortality when performed by experienced operators. In addition, TAVR performed at low annual volume (<50 procedures) institutions is associated with decreased procedural safety and higher patient mortality. These findings have important implications for operator training and patient care at centers performing TAVR.

Adoption Patterns of Bronchoscopic Lung Volume Reduction Procedures in Germany and Predicted Procedure Volumes for Other European Countries

Background: Bronchoscopic lung volume reduction (BLVR) using valves and coils has been approved for use since 2003 and 2010, respectively. Objective(s): To study adoption patterns of BLVR in an early-adopting country, and to estimate potential treatment volumes in other European countries. Methods: Therapy- and age-specific volumes for endobronchial valve and coil procedures were obtained from German federal statistics for 2007–2016. Therapy-specific and total BLVR procedure volumes and growth were computed, and patterns in treatment age and device utilization analyzed. Patient volumes for other European countries were predicted using mean German patient volumes of the last 3 data years and age-specific population and emphysema incidences. Results: Over the study period, annual BLVR procedure volumes grew from 91 to 2,053 (+2,256%), reaching a peak of 2,556 procedures in 2013. Coil procedures constituted 36% of the total volume in 2016. Treatment age was stable over time, with highest procedure counts in age group 60–64 years for valves and 65–69 years for coils. A limited increase in device use per procedure was observed. For ­Germany, 1,655 newly treated BLVR patients were estimated per year, approximating about 5% of the annual newly diagnosed severe emphysema cases. Predicted volume estimates for other European countries ranged from 1 for Liechtenstein to 1,226 for France. Conclusions: Analysis of ­German procedure data show pronounced BLVR therapy uptake in the early years of adoption, with the more recently introduced coil therapy used in about one-third of patients. Estimated patient volumes to date constitute only a small fraction of the severe emphysema population.

Volume–outcome relationship in transcatheter aortic valve implantations in Germany 2008–2014: a secondary data analysis of electronic health records

ObjectivesWe examine the volume–outcome relationship in isolated transcatheter aortic valve implantations (TAVI). Our interest was whether the volume–outcome relationship for TAVI exists on the centre level, whether it occurs equally...

Early intake of solid food after Roux-en-Y gastric bypass and complications. A cohort study from the Scandinavian Obesity Surgery Registry

BackgroundRoux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. There are few studies investigating how early return to solid food affects complications. ObjectiveThe aim of this study was to explore how oral intake was resumed in RYGB patients and how the postoperative food regimen affects outcomes, such as complications and length of stay. SettingRetrospective nationwide registry study. MethodsThe Scandinavian Obesity Surgery Registry included prospective data from RYGB patients operated in 2009 to 2014. A questionnaire assessed the postoperative reintroduction of solid food applied at each bariatric center. The postoperative regimen was established in 23,589 patients. Outcomes were recorded at 30-day follow-up according to the standard Scandinavian Obesity Surgery Registry routine. ResultsNine percent of patients (n = 2074) returned to solid food within the first week after surgery. Most commonly solid food was resumed in week 4 (37%, n = 8659). Median length of stay was 2 days for all. Of all, 2.8% suffered from a severe complication (>Clavien-Dindo 3a). After adjusting for the annual volume of procedures at hospitals, there was no correlation that the timing of solid food affected complication rates. The odds ratio for a severe complication was significantly lower for intermediate- (odds ratio .64 95% confidence interval .48–.85) or high- (odds ratio .52 95% confidence interval .42–.66) volume centers. The rate of leaks and small bowel obstructions were evenly distributed between the different postoperative food regimens. ConclusionEarly return to solid food after RYGB did not affect the risk of severe complications. Patients operated at centers with an annual volume of >100 procedures have a lower risk of severe complications.

Utilization and Short-Term Outcomes of Primary Total Hip and Knee Arthroplasty in the United States and Canada: An Analysis of New York and Ontario Administrative Data.

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are common and effective surgical procedures. This study sought to compare utilization and short-term outcomes of primary TKA and THA in adjacent regions of Canada and the United States. The study was designed as a retrospective cohort study of patients who underwent primary TKA or THA, comparing administrative data from New York and Ontario in 2012-2013. Demographic features of the TKA and THA patients, per capita utilization rates, and short-term outcomes were compared between the jurisdictions. A higher percentage of New York hospitals performed TKA compared to Ontario hospitals (75.7% versus 42.1%; P < 0.001), and the mean annual procedural volume for TKAs was lower in New York hospitals (mean 179 versus 327 in Ontario hospitals; P < 0.001). After direct standardization, utilization was significantly lower in New York compared to Ontario, both for TKA (16.1 TKAs versus 21.4 TKAs per 10,000 population per year; P < 0.001) and for THA (10.5 THAs versus 11.5 THAs per 10,000 population per year; P < 0.001). For those who underwent TKA, the length of stay in Ontario hospitals was significantly longer (mean 3.7 days versus 3.4 days in New York hospitals; P < 0.001). A smaller percentage of New York patients were discharged directly home (46.2% versus 90.9% of Ontario patients; P < 0.001), but 30-day and 90-day readmission rates were higher in New York compared to Ontario (30-day rates, 4.6% versus 3.9% [P < 0.001]; 90-day rates, 8.4% versus 6.7% [P < 0.001]). For the THA cohorts, the results with regard to length of stay, discharge disposition, and readmission rates were similar to those for TKA. Ontario has higher utilization of total joint arthroplasty than New York but has a smaller percentage of hospitals performing these procedures. Patients are more likely to be discharged home and less likely to be readmitted in Ontario. Our results suggest areas where each jurisdiction could improve.

Risk-Benefit Assessment of Carotid Revascularization.

Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes.To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure.The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event.There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.

Editor's Choice – High Annual Hospital Volume is Associated with Decreased in Hospital Mortality and Complication Rates Following Treatment of Abdominal Aortic Aneurysms: Secondary Data Analysis of the Nationwide German DRG Statistics from 2005 to 2013

The aim of this study was to analyse the association between annual hospital procedural volume and post-operative outcomes following repair of abdominal aortic aneurysms (AAA) in Germany. Data were extracted from nationwide Diagnosis Related Group (DRG) statistics provided by the German Federal Statistical Office. Cases with a diagnosis of AAA (ICD-10GM I71.3, I71.4) and procedure codes for endovascular aortic repair (EVAR; OPS 5-38a.1*) or open aortic repair (OAR; OPS 5-38.45, 5-38.47) treated between 2005 and 2013 were included. Hospitals were empirically grouped to quartiles depending on the overall annual volume of AAA procedures. A multilevel multivariable regression model was applied to adjust for sex, medical risk, type of procedure, and type of admission. Primary outcome was in hospital mortality. Secondary outcomes were complications, use of blood products, and length of stay (LOS). The association between AAA volume and in hospital mortality was also estimated as a function of continuous volume. A total of 96,426 cases, of which 11,795 (12.6%) presented as ruptured (r)AAA, were treated in >700 hospitals (annual median: 501). The crude in hospital mortality was 3.3% after intact (i)AAA repair (OAR 5.3%; EVAR 1.7%). Volume was inversely associated with mortality after OAR and EVAR. Complication rates, LOS, and use of blood products were lower in high volume hospitals. After rAAA repair, crude mortality was 40.4% (OAR 43.2%; EVAR 27.4%). An inverse association between mortality and volume was shown for rAAA repair; the same accounts for the use of blood products. When considering volume as a continuous variate, an annual caseload of 75-100 elective cases was associated with the lowest mortality risk. In hospital mortality and complication rates following AAA repair are inversely associated with annual hospital volume. The use of blood products and the LOS are lower in high volume hospitals. A minimum annual case threshold for AAA procedures might improve post-operative results.

Impact of institutional procedural volume on inhospital outcomes after cardiac resynchronization therapy device implantation: US national database 2003–2011

The relationship between hospital volume and outcomes for cardiac resynchronization therapy (CRT) implantations has not been well established. The purpose of this study was to examine outcomes after CRT device implantation stratified by hospital volume using a large national inpatient database. Using the National Inpatient Sample database, we identified all patients undergoing de novo CRT implants between 2003 and 2011. Hospitals were categorized according to tertiles of annual CRT procedural volume. Rates of inhospital adverse events including death, cardiac perforation, pneumothorax, and lead revision were examined. A multivariate logistic regression analysis was performed to compare outcomes across hospital volume categories. Between 2003 and 2011, 410,104 de novo CRT implantations were performed. More than half (50.9%) of hospitals performed ≤16 CRT implants/y. Overall complication rates were higher in the lower-volume centers (3.9%, 3.5%, and 3.2%; P=.001) when stratified by first, second, and third tertiles of CRT volume, respectively. The lowest tertile of CRT volume was independently associated with increased inhospital all-cause mortality (adjusted odds ratio [OR] 1.37; 95% confidence interval [CI] 1.10-1.70; P = .005), any complication (adjusted OR 1.21, 95% CI 1.07-1.37; P = .003), and lead revision (adjusted OR 1.27; 95% CI 1.03-1.58; P = .03). Lower CRT hospital volume was associated with worse outcomes, including inhospital death, overall complications, and lead revision. Establishment of standards defining minimum CRT volume thresholds to identify centers of excellence may result in improved outcomes.

Hospital volume and the risk of revision in Oxford unicompartmental knee arthroplasty in the Nordic countries -an observational study of 14,496 cases

BackgroundHigh procedure volume and dedication to unicompartmental knee arthroplasty (UKA) has been suggested to improve revision rates. This study aimed to quantify the annual hospital volume effect on revision risk in Oxfordu nicompartmental knee arthroplasty in the Nordic countries.Methods14,496 cases of cemented medial Oxford III UKA were identified in 126 hospitals in the four countries included in the Nordic Arthroplasty Register Association (NARA) database from 2000 to 2012. Hospitals were divided by quartiles into 4 annual procedure volume groups (≤11, 12-23, 24-43 and ≥44). The outcome was revision risk after 2 and 10 years calculated using Kaplan Meier method. Multivariate Cox regression analysis was used to assess the Hazard Ratio (HR) of any revision due to specific reasons with 95% confidence intervals (CI).ResultsThe implant survival was 80% at 10 years in the volume group ≤11 procedures per year compared to 83% in other volume groups. The HR adjusted for age category, sex, year of surgery and nation was 0.87 (95% CI: 0.76-0.99, p = 0.036) for the group 12-23 procedures per year, 0.78 (95% CI: 0.68-0.91, p = 0.002) for the group 24-43 procedures per year and 0.82 (95% CI: 0.70-0.94, p = 0.006) for the group ≥44 procedures per year compared to the low volume group. Log-rank test was p = 0.003. The risk of revision for unexplained pain was 40-50% higher in the low compared with other volume groups.ConclusionLow volume hospitals performing ≤11 Oxford III UKAs per year were associated with an increased risk of revision compared to higher volume hospitals, and unexplained pain as revision cause was more common in low volume hospitals.

Interventional nephrology: current status and clinical impact in Japan

BackgroundCurrent status and clinical significance of interventional nephrology has not been reported from Japan.MethodsQuestionnaires were mailed twice to the directors of all 534 Japanese certificated nephrology training institutions in 2014. The main questions were current performance, categorized annual procedure volume and managers of peritoneal dialysis (PD) access, vascular access (VA) surgery, endovascular intervention, and kidney biopsy. Frequencies of nephrologist involvement between high volume center and low volume center and association between the level of nephrologists’ involvement to each procedure and annual procedure volume were examined.Results332 (62.2%) institutions answered performance of all procedures and 328 (61.4%) institutions answered all procedure volume. Kidney biopsy, VA surgery, endovascular intervention and PD access surgery were performed by any doctors in 94.2, 96.3, 88.4, and 76.2% and each involvement of nephrologist was 93.9, 54.1, 53.1 and 47.6%, respectively. Cochran–Armitage analyses demonstrated significant increases in all 4 procedure volume with greater management by nephrologists (p < 0.01). Nephrologists involvement to VA surgery associated with procedure volume increase in not only VA surgery, but also PD catheter insertion (p < 0.01) and kidney biopsy (p < 0.05). And nephrologists involvement to PD catheter insertion also associated with surgical volume increase in both VA surgery (p < 0.01) and endovascular intervention (p < 0.05).ConclusionsMain manager of all 4 procedures was nephrologist in Japan. Each procedure volume increased as nephrologists become more involved. Acquisition of one specific procedure by nephrologist associated with increase not only in this specific procedure volume, but also the other procedure volume.