Average Case Volume Research Articles

Beyond 250: A Comprehensive Strategy to Maximize the Operative Experience for Junior Residents

Among surgical educators, duty-hour restrictions led to concern regarding the adequacy of operative experience during residency, especially for junior residents. The American Board of Surgery recently instituted guidelines mandating "a minimum of 250 operations by the end of the PGY-2 year". A series of programmatic and institutional changes were implemented at our institution to augment the junior resident operative experience and to exceed compliance with this mandate. Operative data from Accreditation Council for Graduate Medical Education case logs for categorical and nondesignated preliminary interns from our large academic surgical residency were identified for 5 consecutive academic years, 2011 until 2016. American Board of Surgery In-Training Examination (ABSITE) scores were collected anonymously. The program systematically instituted the following changes: night float minimization, identification of new surgical opportunities, augmenting use of midlevel care providers, identification of rotations with suboptimal operative experiences, maximizing rotations with involvement of junior residents in the operating room, and systematic review of junior case logs. After implementation, average total cases for residents completing postgraduate year (PGY)-2 increased from 176 to 330 (p < 0.001). Specifically, there was an 18% increase for interns (p = 0.059) and a 118% increase for PGY-2 residents (p < 0.001). There were statistically significant increases in skin and soft tissue cases, vascular cases, endoscopy, and complex laparoscopic cases. Average case volumes for senior residents did not change. Night float time was significantly decreased (5.7 vs 3.4 wk; p = 0.04). ABSITE scores were not significantly changed during this time. Before implementation of these interventions, our program would have had 0% compliance with the 250 junior resident case rule. Within 12 months of implementation, total case volumes for residents completing PGY-2 increased by 88%-exceeding minimum standards. Overall, 100% programmatic compliance was achieved. Our program's experience exemplifies how mandates from the American Board of Surgery can lead to programmatic changes that improve the experience of surgical house officers.

High Center Average Case Volume Associated With Improved Survival for Patients With Hepatocellular Carcinoma

The association between higher surgical case volume and improved survival outcomes is well documented for several cancer types. However, it is yet unknown whether patients treated at centers that see more cases of hepatocellular carcinoma (HCC) per year have improved overall survival (OS). This is a retrospective analysis of data from the Commission on Cancer’s National Cancer Database (NCDB) from 2004-2014. 154,408 patients with liver cancer were identified (International Classification of Diseases for Oncology 3rd edition disease topography code C22). Of these, 135,442 patients had histopathologic type HCC (malignant behavior code 8170/1). 53,829 patients were excluded from the analysis on the basis of stage IV disease (N=24,200) and incomplete staging information (N=29,629). This left 81,647 patients for analysis. Annual case volume was calculated by taking the total number of cases treated per center over the 10 year period and dividing by 10. Subsequently, annual case volume was separated into quartiles for analysis. Univariate and multivariate analyses were performed using Cox regression analysis to determine factors associated with improved OS. Factors with a P<.2 on univariate analysis were retained in the multivariate model (data not shown). Bonferroni correction was applied, and as 15 factors were tested for significant association, p-values were considered significant if <.003. Kaplan-Meier curves and log-rank tests were also used to calculate and compare OS estimates. A total of 81,647 patients with non-metastatic HCC were treated at a total 1218 centers. The median [range] HCC case volume per year averaged over the 10 year study period was 48.6 [0.1-205.5]. Centers in the 1st, 2nd, 3rd and 4th quartiles by volume treated between 0.1-11.35, >11.35-48.6, >48.6-60, and >60-205.5 patients per year, respectively. Median survival for patients treated in 1st, 2nd, 3rd and 4thquartile centers by annual case volume were 7.3, 12.8, 24.6 and 28.7 months, respectively; 2-year OS were 24.4%, 35.2%, 50.7% and 54.3%, respectively (Log Rank p<.001). In a multivariate model that included sex, age, race, Charlson Comorbidity Score, alpha-fetoprotein, creatinine, bilirubin, international normalized ratio, tumor size, tumor stage, community vs academic institution, insurance type, median household income and initial treatment modality, institutional annual HCC case volume remained significantly associated with improved OS when analyzed as a continuous variable (unit hazard ratio 0.997 [95% confidence interval 0.9965-0.9976]; p<.001). Higher annual HCC case volume at the treating institution is significantly associated with improved OS for patients with HCC. Although the selection bias of patients who present to high volume centers cannot be excluded, improved OS may be related to access to multidisciplinary evaluation, option of varied treatment modalities, and increased subspecialty expertise.

Committee Opinion No 701: Choosing the Route of Hysterectomy for Benign Disease.

Hysterectomy is one of the most frequently performed surgical procedures in the United States. Selection of the route of hysterectomy for benign causes can be influenced by the size and shape of the vagina and uterus; accessibility to the uterus; extent of extrauterine disease; the need for concurrent procedures; surgeon training and experience; average case volume; available hospital technology, devices, and support; whether the case is emergent or scheduled; and preference of the informed patient. Vaginal and laparoscopic procedures are considered "minimally invasive" surgical approaches because they do not require a large abdominal incision and, thus, typically are associated with shortened hospitalization and postoperative recovery times compared with open abdominal hysterectomy. Minimally invasive approaches to hysterectomy should be performed, whenever feasible, based on their well-documented advantages over abdominal hysterectomy. The vaginal approach is preferred among the minimally invasive approaches. Laparoscopic hysterectomy is a preferable alternative to open abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible. Although minimally invasive approaches to hysterectomy are the preferred route, open abdominal hysterectomy remains an important surgical option for some patients. The obstetrician-gynecologist should discuss the options with patients and make clear recommendations on which route of hysterectomy will maximize benefits and minimize risks given the specific clinical situation. The relative advantages and disadvantages of the approaches to hysterectomy should be discussed in the context of the patient's values and preferences, and the patient and health care provider should together determine the best course of action after this discussion.

Committee Opinion No. 701 Summary: Choosing The Route Of Hysterectomy For Benign Disease.

Hysterectomy is one of the most frequently performed surgical procedures in the United States. Selection of the route of hysterectomy for benign causes can be influenced by the size and shape of the vagina and uterus; accessibility to the uterus; extent of extrauterine disease; the need for concurrent procedures; surgeon training and experience; average case volume; available hospital technology, devices, and support; whether the case is emergent or scheduled; and preference of the informed patient. Vaginal and laparoscopic procedures are considered "minimally invasive" surgical approaches because they do not require a large abdominal incision and, thus, typically are associated with shortened hospitalization and postoperative recovery times compared with open abdominal hysterectomy. Minimally invasive approaches to hysterectomy should be performed, whenever feasible, based on their well-documented advantages over abdominal hysterectomy. The vaginal approach is preferred among the minimally invasive approaches. Laparoscopic hysterectomy is a preferable alternative to open abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible. Although minimally invasive approaches to hysterectomy are the preferred route, open abdominal hysterectomy remains an important surgical option for some patients. The obstetrician-gynecologist should discuss the options with patients and make clear recommendations on which route of hysterectomy will maximize benefits and minimize risks given the specific clinical situation. The relative advantages and disadvantages of the approaches to hysterectomy should be discussed in the context of the patient's values and preferences, and the patient and health care provider should together determine the best course of action after this discussion.

Evolution of practice patterns in plastic surgery using Current Procedural Terminology mapping: a 9-year analysis of cases submitted by primary and recertification candidates to the American Board of Plastic Surgery.

Understanding plastic surgery practice patterns allows the specialty to detect subtle shifts in the market and develop proactive strategies to maintain market share. Current Procedural Terminology codes from American Board of Plastic Surgery recertification and primary certification candidates from 2003 to 2011 were examined. Statistical analyses identified significant changes (p < 0.05) in the percentage of surgeons performing each type of procedure and trends in average case volume per surgeon. The overall number of procedures decreased from 2003 to 2011. There was a statistically significant (p < 0.05) decrease in the percentage of recertification and primary certification candidates performing facial cosmetic and facial malignancy procedures. Both groups also experienced statistically significant decrease in facial plastic surgery case volume. The percentage of surgeons performing breast reconstruction remained stable for the recertification group and increased significantly for primary certification surgeons. Breast reconstruction volume increased significantly for both groups. Craniofacial surgery remained stable in the percentage of surgeons performing the cases and case volume. Hand surgery experienced a significant loss of recertification surgeons performing hand surgery; however, hand surgery case volume remained stable for both groups. From 2003 to 2011, plastic surgery lost market share in facial cosmetic, facial malignancy, and hand surgery and maintained market share in breast and craniofacial surgery. CPT mapping enables us to analyze these trends to better train plastic surgeons to adapt to changing pressures both from economic recovery and from competing specialties seeking to benefit from redistribution of case loads.