Association Of Hospital Volume Research Articles

Association of hospital volume with survival but not with postoperative mortality in glioblastoma patients in Belgium.

Standard of care treatment for glioblastoma (GBM) involves surgical resection followed by chemoradiotherapy. However, variations in treatment decisions and outcomes exist across hospitals and physicians. In Belgium, where oncological care is dispersed, the impact of hospital volume on GBM outcomes remains unexplored. This nationwide study aims to analyse interhospital variability in 30-day postoperative mortality and 1-/2-year survival for GBM patients. Data collected from the Belgian Cancer Registry, identified GBM patients diagnosed between 2016 and 2019. Surgical resection and biopsy cases were identified, and hospital case load was determined. Associations between hospital volume and mortality and survival probabilities were analysed, considering patient characteristics. Statistical analysis included logistic regression for mortality and Cox proportional hazard models for survival. A total of 2269 GBM patients were identified (1665 underwent resection, 662 underwent only biopsy). Thirty-day mortality rates post-resection/post-biopsy were 5.1%/11.9% (target < 3%/<5%). Rates were higher in elderly patients and those with worse WHO-performance scores. No significant difference was found based on hospital case load. Survival probabilities at 1/2 years were 48.6% and 21.3% post-resection; 22.4% and 8.3% post-biopsy. Hazard ratio for all-cause death for low vs. high volume centres was 1.618 in first 0.7 year post-resection (p < 0.0001) and 1.411 in first 0.8 year post-biopsy (p = 0.0046). While 30-day postoperative mortality rates were above predefined targets, no association between hospital volume and mortality was found. However, survival probabilities demonstrated benefits from treatment in higher volume centres, particularly in the initial months post-surgery. These variations highlight the need for continuous improvement in neuro-oncological practice and should stimulate reflection on the neuro-oncological care organisation in Belgium.

Association of hospital volume and operative approach with clinical and financial outcomes of elective esophagectomy in the United States.

Literature regarding the impact of esophagectomy approach on hospitalizations costs and short-term outcomes is limited. Moreover, few have examined how institutional MIS experience affects costs. We thus examined utilization trends, costs, and short-term outcomes of open and minimally invasive (MIS) esophagectomy as well as assessing the relationship between institutional MIS volume and hospitalization costs. All adults undergoing elective esophagectomy were identified from the 2016-2020 Nationwide Readmissions Database. Multiple regression models were used to assess approach with costs, in-hospital mortality, and major complications. Additionally, annual hospital MIS esophagectomy volume was modeled as a restricted cubic spline against costs. Institutions performing > 16 cases/year corresponding with the inflection point were categorized as high-volume hospitals (HVH). We subsequently examined the association of HVH status with costs, in-hospital mortality, and major complications in patients undergoing minimally invasive esophagectomy. Of an estimated 29,116 patients meeting inclusion, 10,876 (37.4%) underwent MIS esophagectomy. MIS approaches were associated with $10,600 in increased incremental costs (95% CI 8,800-12,500), but lower odds of in-hospital mortality (AOR 0.76; 95% CI 0.61-0.96) or major complications (AOR 0.68; 95% CI 0.60, 0.77). Moreover, HVH status was associated with decreased adjusted costs, as well as lower odds of postoperative complications for patients undergoing MIS operations. In this nationwide study, MIS esophagectomy was associated with increased hospitalization costs, but improved short-term outcomes. In MIS operations, cost differences were mitigated by volume, as HVH status was linked with decreased costs in the setting of decreased odds of complications. Centralization of care to HVH centers should be considered as MIS approaches are increasingly utilized.

Association of Hospital Volume and Outcomes Following Off-Pump Coronary Artery Bypass Grafting.

Off-pump coronary artery bypass grafting (OPCAB) has been used to mitigate the negative systemic effects of cardiopulmonary bypass. Recent consortium and single-institution studies suggest an association between operator experience and long-term survival. We thus aimed to ascertain the relationship between institutional OPCAB volume and outcomes using a contemporary nationwide all-payer database. Adult admissions for elective isolated OPCAB were identified from the 2016-2019 Nationwide Readmissions Database. The primary outcome was major adverse events (MAE), defined as a composite of mortality, reoperation, prolonged mechanical ventilation, acute kidney injury requiring dialysis, or perioperative stroke during the index hospitalisation. Secondary outcomes included temporal trends, postoperative length of stay (pLOS), hospitalisation costs, non-home discharge, and 30-day readmission rate. High-volume hospitals (HVH) were defined to have annual caseloads >35 based on cubic spline analysis. Of an estimated 41,154 patients, 59.9% were treated at HVH. The proportion of coronary artery bypass grafting operations that were OPCAB significantly decreased from 21.1% in 2016 to 18.3% in 2019. After adjustment, HVH status was associated with lower adjusted odds of MAE (adjusted odds ratio [AOR] 0.78, 95% confidence interval [CI] 0.70-0.88), compared to others. HVH were also associated with shorter pLOS (β -0.10, 95% -0.13, -0.07), reduced costs (β -US$4,900, - US$6,300, - US$3,600), non-home discharge (AOR 0.54, 95% CI 0.45-0.64), and 30-day readmission (AOR 0.86, 95% CI 0.77-0.96). Our results suggest that OPCAB requires a distinct set of surgical expertise and institutional aptitude. As a result, centralisation of care to centres of excellence should be considered.

Association of hospital volume with conversion to open from minimally invasive colectomy in patients with diverticulitis: A national analysis.

Despite the known advantages of minimally invasive surgery (MIS) for diverticular disease, the impact of conversions to open (CtO) colectomy remains understudied. The present study used a nationally representative database to characterize risk factors and outcomes associated with CtO in patients with diverticular disease. All elective adult hospitalizations entailing colectomy for diverticulitis were identified in the 2017-2019 Nationwide Readmissions Database. Annual institutional caseloads of MIS and open colectomy were independently tabulated. Restricted cubic splines were utilized to non-linearly estimate the risk-adjusted association between hospital volumes and CtO. Additional regression models were developed to evaluate the association of CtO with outcomes of interest. Of an estimated 110,281 patients with diverticulitis who met study criteria, 39.3% underwent planned open colectomy, 53.3% completed MIS, and 7.4% had a CtO. Following adjustment, an inverse relationship between hospital MIS volume and risk of CtO was observed. In contrast, increasing hospital open volume was positively associated with greater risk of CtO. On multivariable analysis, CtO was associated with lower odds of mortality (AOR 0.3, p = 0.001) when compared to open approach, and similar risk of mortality when compared to completed MIS (AOR 0.7, p = 0.436). In the present study, institutional MIS volume exhibited inverse correlation with adjusted rates of CtO, independent of open colectomy volume. CtO was associated with decreased rates of mortality compared to planned open approach but equivalence risk relative to completed MIS. Our findings highlight the importance of MIS experience and suggest that MIS may be safely pursued as the initial surgical approach among diverticulitis patients.

Association of hospital volume and long-term survival after esophagectomy: A systematic review and meta-analysis.

It remains controversial whether esophageal cancer patients may benefit from esophagectomy in specialized high-volume hospitals. Here, the effect of hospital volume on overall survival (OS) of esophageal cancer patients post esophagectomy was assessed. PubMed, Embase, and Cochrane Library were systematically searched for relevant published articles between January 1990 and May 2022. The primary outcome was OS after esophagectomy in high- vs. low-volume hospitals. Random effect models were applied for all meta-analyses. Subgroup analysis were performed based on volume grouping, sample size, study country, year of publication, follow-up or study quality. Sensitivity analyses were conducted using the leave-one-out method. The Newcastle-Ottawa Scale was used to assess the study quality. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidance, and was registered (identifier: INPLASY202270023). A total of twenty-four studies with 113,014 patients were finally included in the meta-analysis. A significant improvement in OS after esophagectomy was observed in high-volume hospitals as compared to that in their low-volume counterparts (HR: 0.77; 95% CI: 0.71-0.84, P < 0.01). Next, we conducted subgroup analysis based on volume grouping category, consistent results were found that high-volume hospitals significantly improved OS after esophagectomy than their low-volume counterparts. Subgroup analysis and sensitivity analyses further confirmed that all the results were robust. Esophageal cancer should be centralized in high-volume hospitals.

The Association of Hospital Volume and Utilization of Palliative Surgery in Metastatic Foregut Cancers

Rasic, Gordana; Beaulieu-Jones, Brendin Ryan MD; Papageorge, Marianna MD; de Geus, Susanna WL MD, PhD; Ng, Sing Chau MS; Devaiah, Anand K MD, FACS; Tseng, Jennifer F MD, MPH, FACS; Sachs, Teviah E MD, MPH, FACS Author Information

Association of hospital volume with postoperative outcomes in Crohn's disease.

Most patients diagnosed with Crohn's disease (CD) require surgery during their lifetime. While the literature has shown that certain cancer patients have superior postoperative outcomes at high-volume hospitals, there remains a paucity of data on the hospital volume-outcome relationship in CD. Given the complexities in both medical and surgical management, this study aims to determine whether patients with CD have superior postoperative outcomes at high-volume hospitals. A retrospective analysis of patients undergoing abdominal surgery for CD in New York hospitals between 2012 and 2018 was performed using data from the Statewide Planning and Research Cooperation System. Outcomes included postoperative mortality, 30-day readmission and postoperative complications. Using a penalized B-spline plot, high-volume centres were defined as those performing more than 160 abdominal surgeries for CD each year. A total of 13,221 surgeries were performed across 176 hospital centres in New York State. Of these, 73.9% of procedures occurred at low-volume centres. High-volume hospitals had lower in-hospital mortality (0.5% vs. 1.5%; p< 0.001) and 30-day readmission rates (8.3% vs. 10.4%; p< 0.001) than low-volume centres. Major postoperative complications and reoperation rates did not differ by hospital volume. On multivariate analysis, patients at high-volume hospitals had lower odds of in-hospital mortality (OR 0.54, 95% CI 0.38-0.75) and 30-day readmission (OR 0.79, 95%CI 0.64-0.98). Hospital volume remained an independent predictor of 30-day readmission for emergent admissions (OR 0.72, 95% CI 0.61-0.85) and in-hospital mortality for nonemergent admissions (OR 0.39, 95% CI 0.19-0.82). Patients undergoing abdominal surgery for CD have lower odds of postoperative mortality and 30-day readmission when the operation occurs at a high-volume hospital. These findings suggest that surgical patients with CD may benefit from care at specialized centres.

Association of Hospital Volume with Perioperative Mortality of Endovascular Repair of Complex Aortic Aneurysms: A Nationwide Cohort Study

A review of the Dutch Surgical Aneurysm Audit between January 2016 and January 2020. Of 694 patients who underwent complex aortic aneurysm repair with fenestrated (n = 539) or branched (n = 155) endografts, the postoperative complication rates were 30% and 49%, respectively. The highest volume hospitals treated significantly more complex patients. Perioperative mortality of complex endovascular aneurysm repair was significantly higher in hospitals with an annual volume of fewer than 9 cases (9%) compared with hospitals with an annual volume of 13 or more cases (3%). This nationwide registry shows that high-volume complex endovascular aneurysm repair centers demonstrate lower mortality rates.

Association of Hospital Volume with Perioperative Mortality of Endovascular Repair of Complex Aortic Aneurysms: A Nationwide Cohort Study.

We evaluate nationwide perioperative outcomes of complex EVAR and assess the volume-outcome association of complex EVAR. Endovascular treatment with fenestrated (FEVAR) or branched (BEVAR) endografts is progressively used for excluding complex aortic aneurysms (complex AAs). It is unclear if a volume-outcome association exists in endovascular treatment of complex AAs (complex EVAR). All patients prospectively registered in the Dutch Surgical Aneurysm Audit who underwent complex EVAR (FEVAR or BEVAR) between January 2016 and January 2020 were included. The effect of annual hospital volume on perioperative mortality was examined using multivariable logistic regression analyses. Patients were stratified into quartiles based on annual hospital volume to determine hospital volume categories. We included 694 patients (539 FEVAR patients, 155 BEVAR patients). Perioperative mortality following FEVAR was 4.5% and 5.2% following BEVAR. Postoperative complication rates were 30.1% and 48.7%, respectively. The first quartile hospitals performed <9 procedures/yr; second, third, and fourth quartile hospitals performed 9-12, 13-22, and ≥23 procedures/yr. The highest volume hospitals treated the significantly more complex patients. Perioperative mortality of complex EVAR was 9.1% in hospitals with a volume of < 9, and 2.5% in hospitals with a volume of ≥13 (P = 0.008). After adjustment for confounders, an annual volume of ≥13 was associated with less perioperative mortality compared to hospitals with a volume of < 9. Data from this nationwide mandatory quality registry shows a significant effect of hospital volume on perioperative mortality following complex EVAR, with high volume complex EVAR centers demonstrating lower mortality rates.

Increased hospital volume is associated with reduced mortality after thoracoabdominal aortic aneurysm repair

ObjectiveContemporary data on outcomes in open thoracoabdominal aortic aneurysm (TAAA) repair are limited to reports from major aortic referral centers showing excellent outcomes. This study aimed to characterize the national experience of open TAAA repair using national outcomes data, with a primary focus on the association of hospital volume with mortality and morbidity. MethodsThe Nationwide Inpatient Sample was queried from 1998 to 2011, and all patients with a diagnosis of TAAA who underwent open operative repair were included. These patients were further stratified into tertiles based on the operative volume of the institution that performed the operation: low volume (LV), <3 cases/y; medium volume (MV), 3 to 11 cases/y; and high volume (HV), ≥12 cases/y. Baseline demographics as well as perioperative outcomes were compared between these groups. Multivariable logistic regression was performed to determine predictors of operative mortality and morbidity. Subgroup analyses were performed for patients presenting for elective surgery and for those presenting for urgent and emergent surgery. ResultsOverall operative mortality was 21% for the entire cohort. Operative mortality was higher at LV (26%) and MV (21%) centers compared with HV centers (15%; P < .001). This difference was similar in both elective surgery (LV, 18%; MV, 14%; HV, 12%; P < .001) and urgent and emergent surgery (LV, 34%; MV, 30%; HV, 19%; P < .001). Furthermore, rates of blood transfusion and acute renal failure were significantly lower in the HV group. Multivariable analysis revealed that compared with the HV group, patients operated on at LV centers (odds ratio [OR], 1.9, 95% confidence interval [CI], 1.7-2.1; P < .001) and MV centers (OR, 1.5; 95% CI, 1.4-1.7; P < .001) had at least 1.5 times the odds of in-hospital mortality. The HV group also had significantly lower odds of dying in the subgroup analyses of both elective surgery and urgent and emergent surgery. Increasing TAAA volume was associated with increased use of distal aortic perfusion (OR, 1.03; 95% CI, 1.02-1.03; P < .001). ConclusionsPatients with TAAA in the United States operated on at HV centers have significantly lower mortality and morbidity compared with patients operated on at lower volume centers. Consideration of referral to HV centers may be warranted, but further research is required to justify this conclusion.

92 The Association of Hospital Volume with Patient Safety Indicators and Mortality in Burn Patients

92 The Association of Hospital Volume with Patient Safety Indicators and Mortality in Burn Patients

Association of Hospital Volume With Laryngectomy Outcomes in Patients With Larynx Cancer

A volume-outcome association exists for larynx cancer surgery, but to date it has not been investigated for specific surgical procedures. To characterize the volume-outcome association specifically for laryngectomy surgery and to identify a minimum hospital volume threshold associated with improved outcomes. In this cross-sectional study, the Nationwide Inpatient Sample was used to identify 45 156 patients who underwent laryngectomy procedures for a malignant laryngeal or hypopharyngeal neoplasm between January 2001 and December 2011. The analysis was performed in 2018. Hospital laryngectomy volume was modeled as a categorical variable. Associations between hospital volume and in-hospital mortality, complications, length of hospitalization, and costs were examined using multivariate logistic regression analysis. Among 45 156 patients (mean age, 62.6 years; age range, 20-96 years; 80.2% male) at 5516 hospitals, higher-volume hospitals were more likely to be teaching hospitals in urban locations; were more likely to treat patients who had hypopharyngeal cancer, were of white race/ethnicity, were admitted electively, had no comorbidity, and had private insurance; and were more likely to perform flap reconstruction or concurrent neck dissection. After controlling for all other variables, hospitals treating more than 6 cases per year were associated with lower odds of surgical and medical complications, with a greater reduction in the odds of complications with increasing hospital volume. High-volume hospitals in the top-volume quintile (>28 cases per year) were associated with decreased odds of in-hospital mortality (odds ratio, 0.45; 95% CI, 0.23-0.88), postoperative surgical complications (odds ratio, 0.63; 95% CI, 0.50-0.79), and acute medical complications (odds ratio, 0.63; 95% CI, 0.48-0.81). A statistically meaningful negative association was observed between very high-volume hospital care and the mean incremental length of hospitalization (-3.7 days; 95% CI, -4.9 to -2.4 days) and hospital-related costs (-$4777; 95% CI, -$9463 to -$900). Laryngectomy outcomes appear to be associated with hospital volume, with reduced morbidity associated with a minimum hospital volume threshold and with reduced mortality, morbidity, length of hospitalization, and costs associated with higher hospital volume. These data support the concept of centralization of complex care at centers able to meet minimum volume thresholds to improve patient outcomes.

Treatment trends of localized renal cell carcinoma by hospital type: A NCDB analysis.

641 Background: Weighing operative, oncologic and comorbid risks guide treatment recommendations for localized kidney cancers. We hypothesize that individualized surgical decision making may also be influenced by surgical center and volume. Methods: The National Cancer Database (NCDB) was queried for patients 18-80 years old with pT1a-T2bN0M0 RCC, treated by partial (PN) or radical nephrectomy (RN), or ablation (ABL) from 2004-2014. After adjusting for clinicopathologic characteristics, we evaluated the association of hospital volume (vol) and center classification with receipt of PN. High vol was defined as the top 10% in treatment volume. Results: 142,090 patients met inclusion criteria, where 58% (n = 82,498) and 41% (n = 58,873) were treated by RN and PN, respectively, and 1% (n = 719) by ABL. The utilization of PN increased over time (2004: 24% vs 2014: 53%; p &lt; 0.001). Stratified by tumor stage, 60% (n = 47,484) of pT1a and 24% (n = 9,906) of pT1b tumors were treated by PN. On multivariate analysis, patients treated at a high-vol center (OR 1.89, 95% CI 1.57-2.28) had a greater likelihood of receiving a PN when compared to treatment elsewhere. Additionally, compared to a community cancer program, treatment at a comprehensive community cancer center (OR 1.39, 95%CI 1.23-1.57), academic/research (OR 1.67, 95%CI 1.47-1.90), or integrated network cancer program (OR 1.48, 95%CI 1.24-1.77) had a higher likelihood of receiving a PN. The median distance travelled was 9.8 and 18.1 miles, for treatment at non high vol and high vol centers, respectively. An inverse correlation was noted between increasing tumor stage and receipt of PN, compared to pT1a tumors (pT1b [OR 0.22, 95%CI 0.20-0.23], pT2a [OR 0.06, 95%CI 0.05-0.06], pT2b [OR 0.03, 95%CI 0.02-0.03]). Conclusions: In the NCDB, despite increased utilization of PN at higher vol centers, the majority of localized renal tumors are still treated with RN. Smaller tumor size, treatment at a higher vol centers, comprehensive community cancer centers, academic/research programs, or integrated network cancer programs increase the likelihood of receipt of PN. Evaluation of population based trends aid in understanding localized RCC surgical management and may help quality improvement efforts.

Association of Hospital Volume and Quality of Care With Survival for Ovarian Cancer.

To assess whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and survival for ovarian cancer. We used the National Cancer Database to perform a retrospective cohort study of women with ovarian cancer from 2004 to 2013. Hospitals were stratified by annual case volume into quintiles (2 or less, 2.01-5, 5.01-9, 9.01-19.9, 20 cases or greater) and by adherence to ovarian cancer quality metrics into quartiles. Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to the quality metrics. A total of 100,725 patients at 1,268 hospitals were identified. Higher volume hospitals were more likely to adhere to the quality metrics. Both 2- and 5-year survival increased with hospital volume and with adherence to the measured quality metrics. For example, 2-year survival increased from 64.4% (95% CI 62.5-66.4%) at low-volume to 77.4% (95% CI 77.0-77.8%) at high-volume centers and from 66.5% (95% CI 65.5-67.5%) at low-quality to 77.3% (95% CI 76.8-77.7%) at high-quality hospitals (P<.001 for both). For each hospital volume category, survival increased with increasing adherence to the quality metrics. For example, in the lowest volume hospitals (two or less cases annually), adjusted 2-year survival was 61.4% (95% CI 58.4-64.5%) at hospitals with the lowest adherence to quality metrics and rose to 65.8% (95% CI 61.2-70.8%) at the hospitals with highest adherence to the quality metrics (P<.001). However, lower volume hospitals with higher quality scores still had survival that was lower than higher volume hospitals. Although both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer, low-volume hospitals that provide high-quality care still have survival rates that are lower than high-volume centers.

Association of Hospital Volume With Racial and Ethnic Disparities in Locally Advanced Cervical Cancer Treatment.

To evaluate racial-ethnic disparities in guideline-based care in locally advanced cervical cancer and their relationship to hospital case volume. Using the National Cancer Database, we performed a retrospective cohort study of women diagnosed between 2004 and 2012 with locally advanced squamous or adenocarcinoma of the cervix undergoing definitive primary radiation therapy. The primary outcome was the race-ethnicity-based rates of adherence to the National Comprehensive Cancer Network guideline-based care. The secondary outcome was the effect of guideline-based care on overall survival. Multivariable models and propensity matching were used to compare the hospital risk-adjusted rates of guideline-based adherence and overall survival based on hospital case volume. The final cohort consisted of 16,195 patients. The rate of guideline-based care was 58.4% (95% confidence interval [CI] 57.4-59.4%) for non-Hispanic white, 53% (95% CI 51.4-54.9%) for non-Hispanic black, and 51.5% (95% CI 49.4-53.7%) for Hispanic women (P<.001). From 2004 to 2012, the rate of guideline-based care increased from 49.5% (95% CI 47.1-51.9%) to 59.1% (95% CI 56.9-61.2%) (Ptrend<.001). Based on a propensity score-matched analysis, patients receiving guideline-based care had a lower risk of mortality (adjusted hazard ratio 0.65, 95% CI 0.62-0.68). Compared with low-volume hospitals, the increase in adherence to guideline-based care in high-volume hospitals was 48-63% for non-Hispanic white, 47-53% for non-Hispanic black, and 41-54% for Hispanic women. Racial and ethnic disparities in the delivery of guideline-based care are the highest in high-volume hospitals. Guideline-based care in locally advanced cervical cancer is associated with improved survival.

Creating an online resource providing hospital cancer surgery volumes in California.

172 Background: Little evidence is available to help patients and providers, payers and policymakers find the highest-quality hospitals for cancer surgery. We initiated a groundbreaking effort in California ( www.calqualitycare.org ) to publicly report hospital cancer surgery volume data online. Methods: With financial support from the nonprofit California HealthCare Foundation, we assembled a multidisciplinary team to oversee the project and ensure sound methodology. We obtained existing hospital discharge summary data from the California Office of Statewide Health Planning and Development (OSHPD). We selected cancer surgeries eligible for display through comprehensive review of the literature addressing the association of hospital volume and mortality. We found eleven cancer sites with sufficient evidence of association including bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum, and stomach. Experts advised volume calculation and display of results. Leaders of low volume hospitals were interviewed to understand the reasons for low volume. Results: In 2014, about 60% of cancer surgeries in California were performed at hospitals in the top 20% of volume, but many hospitals performed low numbers of complex procedures, with the per hospital median number of surgeries for esophageal, pancreatic, stomach, liver, or bladder cancer surgeries at 4 or less. Low-volume hospitals included rural and urban hospitals, with small and large bed sizes, and teaching and non-teaching status. At least 670 Californians received cancer surgery at hospitals that performed only one or two surgeries for a particular cancer site; 72% of those patients lived within 50 miles of a top-20% volume hospital. Conclusions: This project demonstrates the potential for public information about hospital volumes to point patients towards high-volume and away from low-volume hospitals. Data regarding 2014 volumes are now available online.

The association of hospital volume with rectal cancer surgery outcomes

An association between hospital volume and postoperative mortality has been identified for several oncologic surgical procedures. Our objective was to analyze differences in surgical outcomes for patients with rectal cancer according to hospital volume in the state of California. A cross-sectional study from 2000 to 2005 was performed using the state of California Office of Statewide Health Planning and Development database. Hospitals were categorized into low (≤30)-, medium (31-60)-, and high (>60)-volume groups based on the total number of rectal cancer operations performed during the study period. Overall, 7,187 rectal cancer operations were performed. Of the 321 hospitals in the study cohort, 72 % (n = 232), 20 % (n = 65), and 8 % (n = 24) were low-, medium-, and high-volume hospitals, respectively. Postoperative mortality was significantly lower- in high-volume hospitals (0.9 %) when compared to medium- (1.1 %) and low-volume hospitals (2.1 %; p < 0.001). High-volume hospitals also performed more sphincter-preserving procedures (64 %) when compared to medium- (55 %) and low-volume hospitals (51 %; p < 0.001). These data indicate that hospital volume correlates with improved outcomes in rectal cancer surgery. Rectal cancer patients may benefit from lower mortality and increased sphincter preservation in higher-volume centers.

Prevalence and Variability of Internal Mammary Artery Graft Use in Contemporary Multivessel Coronary Artery Bypass Graft Surgery

Use of an internal mammary artery (IMA) is a well-recognized, nationally endorsed quality indicator for evaluating the process of operative care for coronary artery bypass graft surgery. An objective assessment of the current status of IMA use has not been systematically performed. This cross-sectional observational study analyzed data on 541 368 coronary artery bypass graft surgery procedures reported by 745 hospitals in the Society of Thoracic Surgeons National Cardiac Database from 2002 through 2005. We assessed the current status of IMA use, the association of hospital volume and IMA use, and disparities in IMA use by patient gender and race and by region of hospital location. Rates of using at least 1 IMA and bilateral IMA were 92.4% and 4.0%, with increasing trends over the years. Hospital volume was not significantly associated with IMA use. IMAs were used less frequently in women than men (for at least 1 IMA: odds ratio, 0.62; 95% confidence interval, 0.61 to 0.63; for bilateral IMA: odds ratio, 0.65; 95% confidence interval, 0.63 to 0.68) and less frequently in nonwhite patients than white patients (for at least 1 IMA: odds ratio, 0.84; 95% confidence interval, 0.81 to 0.87; for bilateral IMA: odds ratio, 0.79; 95% confidence interval, 0.75 to 0.83). There were significant differences in frequency of IMA use by hospital region. Frequency of IMA use in coronary artery bypass graft surgery is increasing; however, many patients still do not receive the benefits of IMA grafts, and some hospitals have a very low IMA use rate. Hospital volume is not associated with IMA use in coronary artery bypass graft surgery. Analysis of this critical performance measure reveals significant gender and race disparities.

Revision Total Knee Arthroplasty Complication Rates in Northern Illinois

A paucity of population-based data exist which describe the rapid growth of revision total knee arthroplasties, changes in patient characteristics, or the association of hospital volume with complication rates. We analyzed whether inpatient complications for 2986 revision knee arthroplasties done on patients admitted to 63 hospitals in northern Illinois from 1993-1999 were correlated with volume of revision total knee arthroplasties. Coded complication rates for hospitals with less than seven, seven to 14, or greater than 14 annual procedures were compared using logistic regression to control for clinical and demographic characteristics of patients, hospital teaching status, and the proportion of the hospitals' patients discharged to rehabilitation facilities. Revision total knee arthroplasties increased 59%, and the overall complication rate declined from 9.3% during 1993-1996 to 7.3% during 1997-1999 (p = .04). When compared with the lowest volume hospitals, medium-volume hospitals had higher complication rates, whereas the highest volume hospitals were not significantly different. The absence of volume-outcome effects may be related to the relatively high volume of primary knee arthroplasties done at almost all area hospitals, surgeon group coverage across multiple hospitals, and the small annual number of revision total knee arthroplasties done during these years.