Center Case Volume Research Articles

Cancer center case volume is associated with differences in the effectiveness of neoadjuvant chemotherapy for advanced-stage epithelial ovarian cancer

Cancer center case volume is associated with differences in the effectiveness of neoadjuvant chemotherapy for advanced-stage epithelial ovarian cancer

Analysis of Surgeon and Center Case Volume and Stroke or Death after Transcarotid Artery Revascularization.

It has been suggested that the annual hospital volume of cases may affect the number of adverse events after carotid endarterectomy (CEA). We aim to study the associations between hospital as well as surgeon volume and the risk of stroke or death after transcarotid artery revascularization (TCAR). Retrospective review of the Vascular Quality Initiative data of patients undergoing TCAR from 2016 to 2021. Surgeon and center volume were calculated based on the mean number of cases (MNC) performed yearly by each surgeon and center. The primary outcome was a composite endpoint of in-hospital stroke or death. A total of 22,624 cases were included. Surgeon volume was divided into 3 quantiles: low (MNC = 4), medium (MNC = 10), and high (MNC = 26). Center volume was also divided into low (MNC = 14), medium (MNC = 32), and high (MNC = 64). After adjusting for potential confounders, and when compared with high-volume centers, low and medium center volumes were not associated with any increased odds of in-hospital stroke and death, stroke, death, or stroke with transient ischemic attack (TIA). Compared with high-volume surgeons, low surgeons' volume was associated with a higher odd of stroke (odds ratio 1.5, 95% CI 1.1 to 2.04, p = 0.008), and stroke and TIA (OR 1.5, 95% CI 1.2 to 1.9, p = 0.002). However, medium surgeon volume was not associated with higher odds of stroke and death, stroke, and stroke with TIA. Neither low nor medium surgeon volume was associated with a difference in mortality compared with high surgeon volume. In this retrospective study, center volume was not associated with any differences in outcomes among patients undergoing TCAR. On the other hand, surgeons with low volume were associated with a higher risk of stroke, death, or MI and stroke or TIA when compared with high surgeon volume. There was no difference in outcomes between medium and high surgeon volume.

Oxygenation management during veno-arterial ECMO support for cardiogenic shock: a multicentric retrospective cohort study.

Hyperoxemia is common and associated with poor outcome during veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for cardiogenic shock. However, little is known about practical daily management of oxygenation. Then, we aim to describe sweep gas oxygen fraction (FSO2), postoxygenator oxygen partial pressure (PPOSTO2), inspired oxygen fraction (FIO2), and right radial arterial oxygen partial pressure (PaO2) between day 1 and day 7 of peripheral VA ECMO support. We also aim to evaluate the association between oxygenation parameters and outcome. In this retrospective multicentric study, each participating center had to report data on the last 10 eligible patients for whom the ICU stay was terminated. Patients with extracorporeal cardiopulmonary resuscitation were excluded. Primary endpoint was individual mean FSO2 during the seven first days of ECMO support (FSO2mean (day 1-7)). Between August 2019 and March 2022, 139 patients were enrolled in 14 ECMO centers in France, and one in Switzerland. Among them, the median value for FSO2mean (day 1-7) was 70 [57; 79] % but varied according to center case volume. Compared to high volume centers, centers with less than 30 VA-ECMO runs per year were more likely to maintain FSO2 ≥ 70% (OR 5.04, CI 95% [1.39; 20.4], p = 0.017). Median value for right radial PaO2mean (day 1-7) was 114 [92; 145] mmHg, and decreased from 125 [86; 207] mmHg at day 1, to 97 [81; 133] mmHg at day 3 (p < 0.01). Severe hyperoxemia (i.e. right radial PaO2 ≥ 300 mmHg) occurred in 16 patients (12%). PPOSTO2, a surrogate of the lower body oxygenation, was measured in only 39 patients (28%) among four centers. The median value of PPOSTO2mean (day 1-7) value was 198 [169; 231] mmHg. By multivariate analysis, age (OR 1.07, CI95% [1.03-1.11], p < 0.001), FSO2mean (day 1-3)(OR 1.03 [1.00-1.06], p = 0.039), and right radial PaO2mean (day 1-3) (OR 1.03, CI95% [1.00-1.02], p = 0.023) were associated with in-ICU mortality. In a multicentric cohort of cardiogenic shock supported by VA ECMO, the median value for FSO2mean (day 1-7) was 70 [57; 79] %. PPOSTO2 monitoring was infrequent and revealed significant hyperoxemia. Higher FSO2mean (day 1-3) and right radial PaO2mean (day 1-3) were independently associated with in-ICU mortality.

Impact of social media “challenges” on poison center case volume for intentional ingestions among school-aged children: an observational study

Introduction Mental health problems among youth have escalated over the past decade, with increased rates of self-harm, including suicide attempts by ingestion. Social media use has been linked to youth mental health, including “challenges” urging youth to ingest substances for recreational and other purposes. We hypothesized that social media challenges for particular substances would temporally correspond with increased ingestions of these substances. Methods We identified peak Google Trends search times for social media ingestion challenges involving diphenhydramine, laundry pods, nutmeg, and cinnamon, and used data from America’s Poison Centers National Poison Data System to plot reported ingestions 3 months before and after peak searches in school-aged children. Results There were 2,169 individuals in the analysis. Diphenhydramine was the most frequently reported ingestion for misuse/abuse and suicidal purposes (n = 266 and 1,609, respectively). For all ingestions together, 45 percent (n = 979) had a moderate health effect, and 6.35 percent (n = 137) had a major health effect. Time of peak searches corresponded with increased ingestions for each substance. Discussion We found a temporal relationship between peak Google Trends searches for ingestion challenges and ingestions of that substance reported to United States poison centers. Compared to misuse/abuse ingestions, most suicidal ingestions peaked 1–2 months later, suggesting a public health opportunity for intervention. Limitations This retrospective observational study does not establish causal effect. All data are a result of self-reporting of the exposures, which may lead to a reporting bias. Google Trends is not the only search engine and likely underestimates the true incidence of social media posts. Conclusions Additional research is needed on the relationship between social media and youth mental health, particularly around “challenges” that place youths’ health at risk. There may be opportunities for intervention to decrease medical and mental health sequelae of these challenges.

Center case volume is associated with Society of Thoracic Surgeons–defined failure to rescue in cardiac surgery

ObjectiveOur understanding of the impact of a center's case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR. MethodsPatients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. After we excluded patients with missing Society of Thoracic Surgeons Predicted Risk of Mortality scores, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared with all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year. ResultsA total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2%) developed an FTR complication, and 735 (13.8% of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th percentile cutoffs of 136 and 284 cases, respectively. Increasing center-level case volume was associated with significantly greater center-level major complication rates but lower mortality and FTR rates (all P values < .01). Observed-to-expected FTR was significantly associated with case volume (P = .040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (odds ratio, 0.87 per quartile; confidence interval, 0.799-0.946, P = .001). ConclusionsIncreasing center case volume is significantly associated with improved FTR rates. Assessment of low-volume centers' FTR performance represents an opportunity for quality improvement.

Pediatric penetrating thoracic trauma: Examining the impact of trauma center designation and penetrating trauma volume on outcomes

IntroductionWe analyzed the impact of treating center designation and case volume of penetrating trauma on outcomes after pediatric penetrating thoracic injuries (PTI). MethodsPTI patients <18 years were identified from the National Trauma Data Bank (2013–2016). Centers were categorized by type (Pediatric or Adult) and designation status (Level I, Level II, and other). Performance was calculated as the difference between observed and expected mortality and standardized using the total penetrating trauma volume per center. Expected mortality was calculated using the Trauma Mortality Prediction Model. Pearson correlation and linear mixed-effects models evaluated the association between variables and performance. ResultsWe identified 4,134 PTI patients treated at 596 trauma centers: 879 (21%) at Adult Level I, 608 (15%) at Adult Level II, 531 (13%) at Pediatric Level I, 320 (8%) at Pediatric Level II, and 1,796 (43%) at other centers. Primary injury mechanisms were firearm-related (58%) and cut/piercing (42%). Overall mortality was 16% and median predicted mortality was 3.6% (IQR: 1.5% - 11.2%). Among patients with thoracic firearm-related injuries, centers with lower penetrating case volume and total trauma care demonstrated significantly worse outcomes. Multivariable analysis revealed Adult Level I centers had superior outcomes compared with all other non-Level I centers. There was no difference in mortality between Pediatric and Adult Level I centers. DiscussionAdult Level I trauma center designation and annual case volume of penetrating thoracic trauma are associated with improved mortality after pediatric firearm-related thoracic injuries. Further study is needed to identify factors in higher volume centers that improve outcomes. Level of evidenceLevel III.

Impact of Hospital Volume on Outcomes of Septal Myectomy for Hypertrophic Cardiomyopathy

BackgroundLeft ventricular outflow tract obstruction is common among symptomatic patients with hypertrophic cardiomyopathy, yet septal reduction by surgical myectomy (septal myectomy [SM]) is performed infrequently in many centers. This study examined the possible relationship between institutional case volume and early outcomes of SM. MethodsThe Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for patients with hypertrophic cardiomyopathy who underwent SM from January 2012 to December 2019. The study defined center case volume categories as <1, 1 to 4.99, 5 to 9.99, and ≥10 cases performed on average per year. ResultsThe study population included 5935 patients at 481 centers with 933 surgeons. The range of average center volume was <1 to 138 cases per year. Overall early mortality was 2.6%, ventricular septal defect (VSD) occurred in 1.9%, and complete heart block occurred in 9.0%. Concomitant mitral valve (MV) repair was performed in 28.7%, and MV replacement was performed in 17.1%. In multivariable analysis, the lowest annual case volume (average <1 case/y) was consistently associated with greater early mortality (odds ratio [OR], 5.4; CI, 3.0-9.9; P < .001), greater risk of VSD (OR, 9.3; CI ,4.2-20.4; P < .001), increased incidence of complete heart block (OR, 2.0; CI, 1.5-2.7; P < .001), and a higher likelihood of MV replacement (OR, 9.4; CI, 7.5-11.8; P < .001). ConclusionsVolume of SM cases varies widely among institutions reporting to the Society of Thoracic Surgeons Adult Cardiac Surgery Database. There appears to be an important association between surgical experience, as reflected by institutional case volume, and early outcomes, including mortality, as well as the occurrence of VSD, heart block, and MV replacement.

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.

Abstract 13689: The Center-Volume Effect on Congenital Heart Surgery Revised: Is It Time to Consider Regionalization of Care?

Introduction: Regionalization of congenital heart surgery (CHS) has been debated in the U.S. and other countries. Previous reports demonstrated a variable effect of a center’s volume on in-hospital postoperative mortality. However, the volume-outcome relationship for CHS remains incompletely understood without considering outcomes beyond hospital discharge. Hypothesis: We sought to determine, whether procedure-specific center volume predicts postoperative mortality for infants undergoing three complex benchmark procedures (Norwood procedure, arterial switch operation and complete atrioventricular canal repair) and used ventricular septal defect (VSD) closure as a simple benchmark procedure comparison. Methods: We used data from the Pediatric Cardiac Care Consortium, a multi-center U.S.-based clinical registry of CHS, enriched with post-discharge death data after linkage with the National Death Index. We used generalized estimating equations to assess the association between procedure-specific volume and mortality from the time of CHS and up to three years after CHS. Models were adjusted for patient age and weight at CHS, presence of a chromosomal abnormality, and surgical era and accounted for clustering at the center-level. Results: Analysis included 6,656 infants operated at 42 centers between 1982 and 2003. We found an absolute reduction in post-operative risk of death ranging from 6-12% for every additional surgery performed in the same center for Norwood, ASO, and CAVC repair and at all time points examined (Table). There was no statistically significant association between VSD center volume and mortality at any time point. Conclusions: In-hospital and longer-term survival after infantile CHS is improved with increased center case volume for complex CHS. These findings support the regionalization of complex CHS in the U.S.. Decision-makers should consider feasibility of such regionalization to improve outcomes after complex CHS.

Association of Treatment Facility Characteristics With Overall Survival After Mohs Micrographic Surgery for T1a-T2a Invasive Melanoma

Early-stage melanoma, among the most common cancers in the US, is typically treated with wide local excision. However, recent advances in immunohistochemistry have led to an increasing number of these cases being excised via Mohs micrographic surgery (MMS). Although studies of resections for other cancers have reported that facility-level factors are associated with patient outcomes, it is not yet established how these factors may affect outcomes for patients treated with Mohs micrographic surgery. To evaluate the association of treatment center academic affiliation and case volume with long-term patient survival after MMS for T1a-T2a invasive melanoma. In a retrospective cohort study, 4062 adults with nonmetastatic, T1a-T2a melanoma diagnosed from 2004 to 2014 and treated with MMS in the National Cancer Database (NCDB) were identified. The NCDB includes all reportable cases from Commission on Cancer-accredited facilities and is estimated to capture approximately 50% of all incident melanomas in the US. Multivariable survival analyses were conducted using Cox proportional hazards models. Data analysis was conducted from February 27 to August 18, 2020. Treatment facility characteristics. Overall survival. The study population included 4062 patients (2213 [54.5%] men; median [SD] age, 60 [16.3] years) treated at 462 centers. Sixty-two centers were top decile-volume facilities (TDVFs), which treated 1757 patients (61.9%). Most TDVFs were academic institutions (37 of 62 [59.7%]). On multivariable analysis, treatment at an academic center was associated with a nearly 30% reduction in hazard of death (hazard ratio, 0.730; 95% CI, 0.596-0.895). In a separate analysis, treatment at TDVFs was also associated with improved survival (hazard ratio, 0.795; 95% CI, 0.648-0.977). In this cohort study, treatment of patients with T1a-T2a invasive melanoma excised with MMS at academic and top decile-volume (≥8 cases per year) facilities was associated with improved long-term survival compared with those excised by MMS at nonacademic and low-volume facilities. Identification and protocolization of the practices of these facilities may help to reduce survival differences between centers.

Effect of institutional case volume on mid-term mortality after coronary artery bypass grafting surgery.

The impact of center case volume on mid-term postoperative outcome after coronary artery bypass grafting surgery (CABG) is still controversial and requires investigation. The aim of this study was to compare mid-term survival after CABG according to the institutional annual CABG case volume. Adult patients (≥ 18years) who underwent CABG from 2009 to 2016 were identified by searching National Health Insurance database of Korea for CABG procedure codes. Hospitals were classified into three groups based on annual case volume; low-volume centers (< 20 cases/year), medium-volume centers (20-50 cases/year), and high-volume centers (> 50 cases/year). A total of 22,575 CABG were performed in 95 centers during the study period, and 14,697 (65.1%) cases performed at 15 high-volume centers, 5,262 (23.3%) cases at 26 medium-volume centers, and 2,616 (11.6%) cases at 54 low-volume centers. The overall 1-year mortality rate was the lowest in high-volume centers (6.5%), followed by medium-volume centers (10.6%) and low-volume centers (15.2%). Logistic regression identified medium-volume centers (adjusted OR 1.30 [95% CI 1.15-1.49], P < 0.01) and low-volume centers (adjusted OR 1.75 [95% CI 1.51-2.03], P < 0.01) as risk factors for 1-year mortality after CABG compared to high-volume centers. In the Cox proportional hazard model, low- and medium-volume centers were significantly risk factors for poor survival (adjusted HR 1.41 [95% CI 1.31-1.54], P < 0.01 and HR 1.26 [95% CI 1.17-1.35], P < 0.01 for low- and medium-volume centers, respectively). Higher institutional case volume of CABG was associated with lower mid-term mortality.

Relationship between treatment center case volume and survival for localized Ewing sarcoma: The role of radiotherapy timing.

In the treatment of localized Ewing sarcoma (EWS), delays in local therapy are known to adversely impact overall survival (OS). However, the role of treatment center volume in EWS outcomes, and the interaction between center volume and local therapy timing with definitive radiotherapy, remains unknown. Using the National Cancer Database, we demonstrate that treatment at the lowest EWS volume centers is associated with reduced OS, explained partly by higher rates of delayed local therapy. Treatment at the highest volume centers results in improved OS, but appears independent of radiotherapy timing. Future efforts to improve care for EWS patients across treatment centers are imperative.

The Impact of Center Volume on Trends in Contemporary Open Abdominal Aortic Aneurysm Repair

Recent literature has shown the growing complexity of open abdominal aortic aneurysm (AAA) repair over time. Limited data exist on the trends in open AAA repair in the context of operative volume. We evaluated data from the open AAA registry in the Vascular Quality Initiative from 2003 to 2019. Centers were separated by the average number of open AAA repairs submitted per year into four volume categories based on the 25th (<8 cases), 50th (>8-16 cases), 75th (>16-33 cases), and >75th (>33 cases) percentiles. Analysis of variance and χ2 analysis were used to compare continuous and categorical variables; Cox regression analysis was used to assess in-hospital and overall mortality. Between 2003 and 2019, 13,984 patients underwent open AAA repair. In the lower quartile centers, ruptures represented a greater proportion of the overall volume (20.0%, 18.0%, 16.5%, 14.1%; P < .001), whereas the proportion of transfers was highest in the top three quartiles (14.5%, 19.5%, 17.8%, 17.8%; P < .001). There was a higher proportion of endograft explantations (5.4%, 6.0%, 5.5%, 8.5%; P < .001) in the highest quartile centers. Supraceliac clamp was most prevalent in the second-quartile centers (8.6%, 12.4%, 8.4%, 9.8%; P < .001). Median renal ischemia time (33, 30, 29, 26 minutes; P < .001) and median procedure time (229, 227, 242, 211 minutes; P = .001) were lowest in the highest quartile group. Postoperative complications including congestive heart failure (5.8%, 5.6%, 4.1%, 2.9%; P < .001), reintubation (13.7%, 10.9%, 11.1%, 9.6%; P < .001), and dialysis (3.8%, 3.7%, 3.7%, 2.0%; P < .001) were most common in the lower volume quartiles. In-hospital reinterventions were more frequent (13.2%, 12.6%, 10.6%, 10.5%; P < .001) and in-hospital mortality was highest (12.3%, 8.8%, 7.8%, 5.3%; P < .001) at the lower volume centers. Multivariable analysis demonstrated that higher center volume was independently protective against in-hospital mortality (Fig 1; P < .001). Furthermore, patients undergoing explantation (P = .007) and transferred (P < .001) to higher volume centers had decreased operative mortality. Despite these findings, the proportion of cases being performed at the highest quartile centers decreased over time from 41.0% in 2003 to 16.9% in 2019 (P < .001; Fig 2). In contrast, center case volume was associated with increased mortality in the long term (P = .014). Higher center volume was independently associated with a lower in-hospital mortality after open AAA repair. Despite these findings, the proportion of open AAA repairs being performed at lower volume centers is increasing over time. Interestingly, higher center volume was associated with increased long-term mortality. Further discussions regarding the feasibility and benefits of regionalization of open AAA repair should be explored.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Relationship between Treatment Center Case Volume and Outcomes for Ewing Sarcoma Patients: The Role of Local Therapy Timing

Relationship between Treatment Center Case Volume and Outcomes for Ewing Sarcoma Patients: The Role of Local Therapy Timing

Survey of Contemporary Cardiac Surgery Intensive Care Unit Models in the United States

Intensive care unit (ICU) structure and intensive care physician staffing (IPS) models are thought to influence outcomes after cardiac surgery. Given limited information on staffing in the cardiothoracic ICU, The Society of Thoracic Surgeons Workforce on Critical Care undertook a survey to describe current IPS models. We hypothesized that variability would exist throughout the United States. A survey was sent to The Society of Thoracic Surgeons centers in the United States. Center case volume, ICU census, procedure profiles, and the primary specialties of consultants were queried. Definitions of IPS models were open (managed by cardiac surgeons), closed (all decisions made by dedicated intensivists 7 days a week), or semiopen (intensivist attends 5-7 days a week with surgeons cosharing management). Experience level of bedside providers and after-hours provider coverage were also assessed. Of the 965 centers contacted, 148 (15.3%) completed surveys. Approximately 41% of reporting centers used a dedicated cardiothoracic ICU for immediate postoperative management. The most common IPS model was open (47%), followed by semiopen (41%) and closed (12%). The primary specialties of intensivists varied, with pulmonary medicine/critical care being predominant (67%). Physician assistants were the most common after-hours provider (44%). More than one-third of responding centers described having no house staff, other than bedside nurses, for nighttime coverage. Cardiothoracic ICU models vary widely in the United States, with almost half being open, often with no in-house coverage. In-house nighttime coverage was (1) not driven by case complexity and (2) most commonly provided by a physician assistant. Clinical outcomes associated with different ISPS models require further evaluation.

Treatment of primary nonmetastatic melanoma at high-volume academic facilities is associated with improved long-term patient survival

Previous studies of cancer care have demonstrated improved long-term patient outcomes for those treated at high-volume centers. The influence of treatment center characteristics on outcomes for primary nonmetastatic melanoma is not currently established. We aimed to investigate the association of cancer treatment center case volume and academic affiliation with long-term patient survival for cases of primary nonmetastatic melanoma. Cases of melanoma diagnosed in US adults from 2004 to 2014 and included in the National Cancer Database were identified. Hospitals were grouped by yearly case-volume quartile: bottom quartile, 2 middle quartiles, and top quartile. Facility case volume was significantly associated with long-term patient survival (P<.0001). The 5-year survival rates were 76.8%, 81.9%, and 86.4% for patients treated at institutions in the bottom, middle, and top quartiles of case volume, respectively. On multivariate analysis, treatment at centers in both middle quartiles (hazard ratio, 0.834; 95% confidence interval, 0.778-0.895) and in the top quartile (hazard ratio, 0.691; 95% confidence interval, 0.644-0.741) of case volume was associated with improved survival relative to that of patients treated at hospitals in the bottom quartile of case volume. Academic affiliation was associated with improved outcomes for top-quartile- but not middle-quartile-volume facilities. Disease-specific survival was not available. Treatment at a high-volume facility is associated with improved long-term patient survival for melanoma. High-volume academic centers have improved patient outcomes compared with other high-volume centers.

Center case volume and minimally invasive liver surgery: a study based on the Italian Group of minimally invasive liver surgery registry

Introduction: The outcome of liver surgery is associated with the hospital case volume. To analyze the impact of the center case volume on the minimally invasive liver surgery (MILS). Methods: All patients enrolled in the prospective registry of the Italian Group of MILS from November 2014 to August 2016 were considered. Only centers with an accrual ≥6 months were included. The center case volume was defined as the number of MILS performed per month. Results: 919 MILS performed by 37 centers were analyzed. Ten centers performed >2 MILS/month (n=600 patients), 7 performed 1-2 MILS/month (n=142), and 20 performed < 1 MILS/month (n=177). Centers performing < 1 MILS/month resected more benign tumors and tumors in anterolateral segments (28.2% vs. 20.9%, p=0.035; 87.0% vs. 72.6%, p< 0.001). Major hepatectomies increased with the case volume (3.4% if < 1 MILS/month, 7.7% if 1-2, 13.7% if >2, p< 0.001). The R1 resection rate was higher in centers performing >2 MILS/month (10.9% vs. 2.6%, p< 0.001). The conversion, overall morbidity, and severe morbidity rates were similar among groups. The overall and severe morbidity rates of major hepatectomies were higher in centers performing < 2 MILS/month (52.9% vs. 29.3%, p=0.060; 23.6% vs. 8.5%, p=0.092). Conclusions: The center case volume does not impact the outcome of minor hepatectomies; however, it impacts the outcome of minimally invasive major hepatectomies (morbidity rates increase as the MILS volume decreases). Low-volume centers can safely perform MILS of anterolateral segments with excellent outcomes. High-volume centers approach more complex resections with adequate safety.

The British Association of Urological Surgeons radical cystectomy audit 2014/2015: An update on current practice, and an analysis of the effect of centre and surgeon case volume

Objective: The Consultant Outcomes Publication has made it mandatory to submit surgeon-level data on radical cystectomy (RC) practice in England. The current analysis describes contemporary surgical practice and compares this by surgeon and centre case volume. Materials and methods: Between 1 January 2014 and 31 December 2015, data on 3742 RCs performed by 161 surgeons over 84 centres were recorded on the British Association of Urological Surgeons audit and data platform. Centre case volumes were grouped as high (&gt; 60), medium (30–60) and low (&lt; 30), while surgeon case volumes were grouped as high (&gt; 30), medium (8–30) and low (&lt; 8). All data averages were for the combined 2-year period. Results: The median number of RCs performed was 16/surgeon and 31/centre; 45.4% of cases were performed for muscle-invasive transitional cell carcinoma (TCC). The commonest performed urinary diversion was ileal conduit (85.2%), followed by orthotopic bladder substitution (5.7%). Open radical cystectomy (ORC) was performed in 67.8%, robotically-assisted cystectomy (RARC) in 20.6% and laparoscopic cystectomy (LRC) in 9.1% of cases. RARC was more likely to be performed by high-volume surgeons and centres. The majority of patients underwent a lymph node dissection (LND), with rates varying from 79.5% to 90.3%. Reported rates of high-grade complication were generally low across all groups, suggesting under-reporting. There was a trend towards higher reported transfusion rates as centre volumes decreased. The median length of stay (LOS) was 7–9 days for minimally invasive approaches compared to open surgery, which was 11–12 days. Mortality rates were low across all groups. Conclusions: Compliance with the data registry is high. ORC remains the most common approach. High-case volume surgeons and centres more commonly offer RARC. The majority of patients undergo LND. There is a trend towards higher reported rates of transfusion as centre volume decreases. LOS is shorter in RARC and LRC in comparison to ORC, but is otherwise similar across centres and surgeons. Level of evidence: 2b

Five-year outcomes after regionalizing pediatric cardiac surgery centers

Infant mortality after cardiac surgery is multifactorial, but can be related to center and surgeon case volume. One method to increase case volume is to consolidate or regionalize pediatric cardiac surgical care. We evaluated in-hospital and 5-year outcomes in three separate pediatric cardiac surgical programs before and after they formed one regional consortium. Infants (<1 year of age) undergoing complete biventricular surgery were divided into two groups: pre-regionalization (when operations were performed at three separate hospitals between, 1991 and 1998) and post-regionalization (when all operations were performed at one regional program at two surgical centers between, 2001 and 2010). Cases during 1999 and 2000 were excluded as the consortium at that time included only two of the three programs. Primary outcomes were hospital mortality, 5-year survival, cardiac re-operation, and number of events (deaths plus re-operations) during the 5-year follow-up for each group. The 671 infants in the pre-regionalization group did not differ significantly from the 782 infants in the post-regionalization group in age at surgery, weight, or sex. Hospital mortality was significantly greater than the state average before regionalization (9.8% vs. 7.1%; 95% CI of difference: 0.008, 0.052, P < 0.001), but significantly lower than the state average after regionalization (1.9% vs. 4.5%; 95% CI of difference 0.013, 0.043, P < 0.001). Regionalization also significantly improved the 5-year survival (90.2% vs 95.2%; P < 0.001) and freedom from re-operation (83.4% vs. 91.1%; P < 0.001). Multivariate analysis showed that regionalization was independently associated with mortality lower event rate (hazard ratio, 0.35; 95% CI, 0.23 to 0.53; P < 0.001). In our experience, regionalizing and consolidating pediatric cardiac surgical care improved both in-hospital and 5-year survival outcomes. Application of this strategy in other regions of the US may be feasible and beneficial.

Comparable perioperative outcomes and mid-term survival in prosthetic valve endocarditis and native valve endocarditis.

Cardiac surgery for prosthetic valve endocarditis (PVE) represents one of the highest risk surgeries with in-hospital mortality of 20%. Given the complex nature of the operation, the operative outcome is likely strongly susceptible to the surgeon's experience and centre case volume, as measurements often are not apparent in large observational studies. We sought to evaluate operative outcomes and mid-term survival of patients with PVE compared with those of native valve endocarditis (NVE) at a tertiary care hospital. We conducted a single-institutional retrospective review of 188 consecutive patients (146 NVE and 42 PVE) undergoing cardiac surgery for endocarditis between 2011 and 2016 at a tertiary care hospital in the USA. A logistic regression model was fit to evaluate patient characteristics and perioperative outcomes in PVE and NVE: operative mortality and composite events (death, stroke, prolonged intubation, renal failure and sepsis). The Kaplan-Meier analysis was used to estimate the mid-term survival. The Cox proportional hazard model was fit to assess the adjusted risk associated with mid-term survival. Operative mortality was 4.1% for NVE and 0% for PVE (P = 0.34). Composite events occurred in 30.6% and 38.1% of NVE and PVE, respectively (P = 0.45). Multivariable logistic regression for composite events showed that PVE was not associated with increased risk of adverse events [odds ratio 1.4, 95% confidence interval (CI) 0.6-3.4; P = 0.49]. The Kaplan-Meier analysis demonstrated no statistically significant difference in survival (P = 0.99). Finally, the Cox proportional hazard analysis for mid-term mortality demonstrated that PVE was not associated with increased risk for hazard of death: hazard ratio 0.4, 95% CI 0.2-1.1; P = 0.085. Surgery for PVE can yield a low mortality rate with mid-term survival comparable with those of NVE. The diagnosis of PVE alone should not deter surgeons from operating on this complex patient population, provided that surgical expertise and experienced multidisciplinary team equipped to handle complex clinical scenarios are available.