High-volume Centers Of Excellence Research Articles

Going the distance in acoustic neuroma resection: microsurgical outcomes at high-volume centers of excellence

High-volume hospitals are associated with improved surgical outcomes for acoustic neuromas (ANs). Due to the benign and slow-growing nature of ANs, many patients travel to geographically distant cities, states, or countries for their treatment. However, the impact of travel burden to high-volume centers, as well as its relative benefit are poorly understood. We compared post-operative outcomes between AN patients that underwent treatment at local, low-volume hospitals with those that traveled long distances to high-volume hospitals. The National Cancer Database was used to analyze AN patients that underwent surgery (2004-2015). Patients in the lowest quartile of travel distance and volume (Short-travel/Low-Volume: STLV) were compared to patients in the highest quartile of travel distance and volume (Long-travel/High-Volume: LTHV). Only STLV and LTHV cases were included for analysis. Of 13,370 cases, 2,408 met inclusion criteria. STLV patients (n = 1,305) traveled a median of 6 miles (Interquartile range [IQR] 3-9) to low-volume centers (median 2, IQR 1-3 annual cases) and LTHV patients (n = 1,103) traveled a median of 143 miles [IQR 103-230, maximum 4,797] to high-volume centers (median 34, IQR 28-42 annual cases). LTHV patients had lower Charlson/Deyo scores (p = 0.001), mostly received care at academic centers (81.7% vs. 39.4%, p < 0.001), and were less likely to be minorities (7.0% vs. 24.2%, p < 0.001) or underinsured (4.2% vs. 13.8%, p < 0.001). There was no difference in average tumor size. On multivariable analysis, LTHV predicted increased likelihood of gross total resection (odds ratio [OR] 5.6, 95% confidence interval [CI] 3.8-8.4, p < 0.001), longer duration between diagnosis and surgery (OR 1.3, 95% CI 1.0-1.6, p = 0.040), decreased length of hospital stay (OR 0.5, 95% CI 0.4-0.7, p < 0.001), and greater overall survival (Hazard Ratio [HR] 0.6, 95% CI 0.4-0.95, p = 0.029). There was no significant difference in 30-day readmission on adjusted analysis. Although traveling farther to high-volume centers was associated with greater time between diagnosis and treatment for AN patients, they experienced superior postoperative outcomes compared to patients who received treatment locally at low-volume centers. Enabling access and travel to high-volume centers may improve AN patient outcomes.

Trading the Proximal Risk for the Distal Payout in Annular Enlargement With Aortic Valve Replacement

Trading the Proximal Risk for the Distal Payout in Annular Enlargement With Aortic Valve Replacement

P102 LOW PROPORTION OF TOTAL ABDOMINAL COLECTOMIES IN PEDIATRIC ULCERATIVE COLITIS OCCUR AT HIGH VOLUME CENTERS IN THE U.S.

The volume-outcome relationship for surgical procedures is well established in the U.S. healthcare system. Studies of adult ulcerative colitis (UC) demonstrate that high volume centers consistently produce better surgical outcomes with fewer complications than low volume centers. Recently, published guidelines from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommend that pediatric UC surgeries be completed at high volume centers performing ≥10 pediatric colorectal surgeries annually. We aimed to evaluate the annual pediatric UC colectomy volume in hospitals across the U.S. and explore volume trends over time in high volume centers. We performed a cross-sectional analysis of pediatric (≤18 years) UC hospitalizations using the Kids’ Inpatient Database (KID), a nationally representative pediatric database that allows for valid nationwide estimates of pediatric inpatient hospitalization data. The KID includes approximately 7 million unique hospitalizations from up to 4,200 U.S. hospitals annually. We identified pediatric hospitalizations with a primary UC (International Classification of Diseases, Ninth Revision (ICD-9): 556.X) diagnosis and procedural code for total abdominal colectomy (TAC) (ICD-9: 45.8X) on a triennial basis between 1997 and 2012. We identified unique hospitals on an annual basis using a hospital ID-year combination. We defined high volume centers as performing ≥10 pediatric UC colectomies annually in accordance with ESPGHAN guidelines. A total of 517 unique hospital-year combinations accounted for 945 colectomies from 1997 to 2012. Weighted, this accounted for an estimated 1,610 pediatric UC colectomies (mean 268 colectomies per year). For hospitals performing 1 or more colectomies per year, the median annual hospital colectomy volume was 2 (IQR = 1,4). Less than 20% of colectomies were performed at high volume centers while 26.5% of colectomies occurred at centers performing ≤2 colectomies per year. High volume centers were more likely to be located in the Northeast and Midwest as compared to the South or West (p<0.01). No other patient or hospital characteristics were associated with having surgery at a high or low volume center (Table 1). Over the 15-year study period, there was a trend towards fewer colectomies being performed at high volume centers, though this trend appears to be reversing in more recent years (Figure 1). An alarmingly low proportion of colectomies in children with UC are performed at high volume centers. Hence the surgical care delivered to the vast majority of pediatric UC patients in the U.S. is not consistent with current guidelines. National efforts to re-direct care to high volume centers of excellence may lead to improved outcomes for pediatric UC patients. aLow Volume: < 10 colectomies annually; High volume: ≥ 10 colectomies annually. bRaw data is taken from the actual database. National Estimate reflects KID weighting of raw data to produce a national estimate. cData missing from 2012. Figure 1: Annual percentage estimates and standard errors of colectomies at high volume centers in the 1997-2012 KID database. Smoothing line demonstrates a decreasing proportion of colectomies in pediatric UC hospitalizations occurring at high volume centers over the 15-year study period with a modest increase in recent years.

P102 LOW PROPORTION OF TOTAL ABDOMINAL COLECTOMIES IN PEDIATRIC ULCERATIVE COLITIS OCCUR AT HIGH VOLUME CENTERS IN THE U.S.

The volume-outcome relationship for surgical procedures is well established in the U.S. healthcare system. Studies of adult ulcerative colitis (UC) demonstrate that high volume centers consistently produce better surgical outcomes with fewer complications than low volume centers. Recently, published guidelines from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommend that pediatric UC surgeries be completed at high volume centers performing ≥10 pediatric colorectal surgeries annually. We aimed to evaluate the annual pediatric UC colectomy volume in hospitals across the U.S. and explore volume trends over time in high volume centers. We performed a cross-sectional analysis of pediatric (≤18 years) UC hospitalizations using the Kids’ Inpatient Database (KID), a nationally representative pediatric database that allows for valid nationwide estimates of pediatric inpatient hospitalization data. The KID includes approximately 7 million unique hospitalizations from up to 4,200 U.S. hospitals annually. We identified pediatric hospitalizations with a primary UC (International Classification of Diseases, Ninth Revision (ICD-9): 556.X) diagnosis and procedural code for total abdominal colectomy (TAC) (ICD-9: 45.8X) on a triennial basis between 1997 and 2012. We identified unique hospitals on an annual basis using a hospital ID-year combination. We defined high volume centers as performing ≥10 pediatric UC colectomies annually in accordance with ESPGHAN guidelines. A total of 517 unique hospital-year combinations accounted for 945 colectomies from 1997 to 2012. Weighted, this accounted for an estimated 1,610 pediatric UC colectomies (mean 268 colectomies per year). For hospitals performing 1 or more colectomies per year, the median annual hospital colectomy volume was 2 (IQR = 1,4). Less than 20% of colectomies were performed at high volume centers while 26.5% of colectomies occurred at centers performing ≤2 colectomies per year. High volume centers were more likely to be located in the Northeast and Midwest as compared to the South or West (p<0.01). No other patient or hospital characteristics were associated with having surgery at a high or low volume center (Table 1). Over the 15-year study period, there was a trend towards fewer colectomies being performed at high volume centers, though this trend appears to be reversing in more recent years (Figure 1). An alarmingly low proportion of colectomies in children with UC are performed at high volume centers. Hence the surgical care delivered to the vast majority of pediatric UC patients in the U.S. is not consistent with current guidelines. National efforts to re-direct care to high volume centers of excellence may lead to improved outcomes for pediatric UC patients.

The effect of distance on short-term outcomes in a regionalized, publicly funded bariatric surgery model.

While high-volume Centers of Excellence (COE) for bariatric surgery may have improved clinical outcomes, their disparate distribution results in longer travel distances for patients. The purpose of this study was to investigate effect of distance from COE on outcomes and readmission. This was a retrospective study of alladults,aged 18 years or older, receiving bariatric surgery from April 2009 to March 2012 in the province of Ontario. Main outcomes included 30-day complication rates and readmission. Multivariable logistic regression was used to examine the impact of distance from patients' primary residence to their bariatric COE on patient outcomes and readmissions. Five thousand and seven patients were identified, two-thirds residing within 100km of a COE with a mean distance of 117.2km. The majority of patients did not reside within a Local Integrated Health Network (LHIN) that contained a COE, while 18.3% of patients lived in rural areas. Using multivariable adjustment, for every 10km increase from the COE where surgery was performed, the Odds Ratio (OR) for complications was 1.00 [95% Confidence Interval (CI) 0.99-1.01; P = 0.747]. Additionally, both residing in a LHIN without a COE, OR 1.10 (95% CI 0.87-1.40; P = 0.434), and rural status, OR 0.97 (95% CI 0.77-1.23; P = 0.821) showed no increase in risk of complication. Similarly, further distances did not influence rate of readmission, OR 0.99 (95% CI 0.98-1.00; P = 0.077) nor did rural status OR 1.31 (95% CI 0.97-1.76; P = 0.076). The COE model, where a few centers in high population areas service a large geographic region, is adequate in ensuring patients that livefurther away receive appropriate short-term care.

Improved outcomes for patients with cerebrovascular malformations at high-volume centers: the impact of surgeon and hospital volume in the United States, 2000-2009.

OBJECTIVE Treatment of cerebrovascular malformations has grown in complexity with the development of multimodal approaches, including microsurgery, endovascular treatments, and radiosurgery. In spite of this changing standard of care, the provision of care continues across a variety of settings. The authors sought to determine the risk of adverse outcome after treatment of patients with vascular malformations in the US. Patient, surgeon, and hospital characteristics, including volume, were tested as potential outcome predictors. METHODS The authors examined data collected between 2000 and 2009 in the Nationwide Inpatient Sample (NIS) database, assessing safety, quality, and cost-effectiveness. They performed multivariate analyses of trends in microsurgical, radiosurgical, and endovascular treatment by hospital and surgeon volume, using death, routine discharge percentage, length of stay (LOS), complications, and hospital charges as end points. They further computed the value of care, which was defined as the ratio of the functional outcome (routine discharge percentage) to cost of care to the payer (hospital charges). RESULTS The authors identified 8227 patients with vascular malformations who were treated at US hospitals. Hospitals and surgeons were classified by yearly case volume. Compared with low-volume hospitals (2 or fewer cases/year), high-volume hospitals (16 or more cases/year) had shorter LOS (3 vs 2 days, p = 0.005), higher total charges ($37,374 vs $19,986, p = 0.003), more frequent discharge to home (p < 0.001), and lower mortality rates (0.7% vs 1.16%, p = 0.010). High-volume surgeons (7 or more cases/year) likewise had superior outcomes compared with low-volume surgeons (1 or fewer cases/year), with shorter LOS (2 vs 3 days, p = 0.03), more frequent discharge to home (p < 0.001), and lower mortality rates (0.7% vs 1.10%, p = 0.005). Underlying these outcomes, the rates of intervention for surgery, angiography, embolization, and radiosurgery were likewise significantly different in high- versus low-volume practices. Based on these results the authors modeled how outcomes might change if care were consolidated at designated centers of excellence (COEs), and found that on an annual basis, care at high-volume hospital COEs would result in 18.5 fewer deaths, 1252.1 fewer hospital days, 182.7 more discharges home without additional services, 48.5 fewer medical complications, and 117.4 fewer perioperative complications. Surgeon-level rates for high-volume COEs demonstrated an even larger benefit over current standards, with 27.4 fewer deaths, 10,713.7 fewer hospital days, a $51.6-million reduction in charges, 370.9 additional routine discharges, and reduced complications in all categories (27.8 fewer surgical, 198.0 fewer medical, and 32.1 fewer perioperative) compared with care at non-COEs. CONCLUSIONS For patients with vascular malformations who were treated in the US between 2000 and 2009, treatment performed at high-volume centers was associated with significantly lower morbidity and, for high-volume surgeons, with lower mortality rates. These data suggest that treatment by high-volume institutions and surgeons will yield superior outcomes and superior value. The authors therefore advocate the creation of care paradigms that triage patients to high-volume institutions and surgeons, which can serve as cerebrovascular COEs.

39-Year-Old Man With Dysphagia

39-year-old manwithnonotablemedical history presented for evaluation of dysphagia. He reported a several-year history of intermittent but progressive difficulty swallowing both solids and liquids. He had been able to manage his symptoms by using water to flush foods, drinking carbonated beverages, and elevating the head of his bed. He did not experience choking or coughing with swallowing. Two weeks before presentation, he began to feel generally unwell, with worsening dysphagia and regurgitation of undigested food, chest discomfort, and decreased oralintake.Hedidnothavenausea,abdominal pain, diarrhea, constipation, melena, hematochezia, hematemesis, odynophagia, unexplained weight loss, night sweats, exertional chest pain, dyspnea, orthopnea, neck pain, recent trauma, or recent travel outside the United States. Onphysicalexamination,thepatient’sbody

Invited Commentary

Spinal cord injury leading to paraplegia remains a dreaded complication after surgical intervention for descending and thoracoabdominal aortic pathology, and it has a reported incidence as high as 6% to 7% in high-volume centers of excellence. Paraplegia is caused by a multitude of factors in the setting of open repair and includes loss of segmental spinal cord perfusion by intercostal arteries, ischemia during aortic cross clamping, and relative postoperative hypotension leading to decreased collateral flow.

P-0114 Advances in The Treatment of Resectable Pancreatic Cancer: Lessons Learned from two Decade

IntroductionPancreatic adenocarcinoma (PDC) is nowadays recognized as an aggressive malignancy, recent studies have provided a reason for optimism. A trend toward improved overall survival was reported. In addition, progress in surgical technique and perioperative care, in conjunction with the emergence of high volume centers of excellence, have reduced the mortality rate and the severity of complications after pancreatic resection. It is unclear whether progress in the field of pancreatic cancer over the past two decades has translated into a measurable improvement in survival in patients who present with resectable disease outside of a clinical trial. The intent of this investigational design was to focus specifically on changes in oncologic outcome after pancreatic resection for PDC between decades. The end point of the study was to evaluate long-term survival. MethodsFrom 1990 to 2009, 544 patients with histologically proven PDC were resected at the Department of Surgery of the University of Verona. Patients were categorized according to the decade in which they underwent resection (the 90s or 2000s) and trends in short and long-term outcomes were examined. Results544 pancreatic resections were performed for PDC. By decade, there were 114 resections in the 1990s (median=12/year) and 430 in the 2000s (median=41/year). The perioperative mortality has improved since the 1990s (2.6% versus 1.1% in 2000s). The length of hospital stay (LOS) decreased from 16 days in 90s to 10 days in 2000s (p<0.0001). The 1- and 3 year survival rate were 64% and 17% in the first period and 84% and 42% in the second, respectively (P<0.0001). The median disease specific survival significantly increased from 16 to 29 months (P< 0.0001). By multivariable analysis, poor differentiation, lymph node, R1 resection, no adjuvant therapy and the resection performed in the period 1990-2000 were significant independent predictors of poor outcome. Furthermore in order to focus specifically on the oncologic outcome early and intermediate deaths were excluded to minimize confounding factors such as improvements in operative mortality and patient selection. The long-term survival in patients who survived 1 year remained significantly better in the 2000s as compared to the 90s (P <0.0001). ConclusionThe overall survival after resection significantly improved over time. The improvement in mortality and LOS underlines a rising perioperative management. We postulate that improvements in 1-year survival is related to a better surgical outcome and preoperative staging. Whereas the use of an adjuvant therapy justified an improvement in survival realized beyond a year.

The spectrum of management practices in nontraumatic subarachnoid hemorrhage: A survey of high-volume centers in the United States

Background:There is a considerable variety of management practices for nontraumatic subarachnoid hemorrhage (ntSAH) across high-volume centers in the United States. We sought to design a survey which would highlight areas of controversy in the modern management of ntSAH and identify specific areas of interest fo further study.Methods:A questionnaire on management practices in ntSAH was formulated using a popular web-based survey tool (SurveyMonkey™, Palo Alto, CA) and sent to endovascular neurointerventionists and cerebrovascular surgeons who manage a high volume of these patients annually. Two-hundred questionnaires were delivered electronically, and after a period of 2 months, the questionnaire was resent to nonresponders.Results:Seventy-three physicians responded, representing a cross-section of academic and other high-volume centers of excellence from around the country. On average, the responding interventionists in this survey each manage approximately 100 patients with ntSAH annually. Over 57% reported using steroids to treat this patient population. Approximately 18% of the respondents use intrathecal thrombolytics in ntSAH. Over 90% of responding physicians administer nimodipine to all patients with ntSAH. Over 40% selectively administer antiepileptic drugs to patients with ntSAH. Several additional questions were posed regarding the methods of detecting and treating vasospasm, as well as the indications for CSF diversion in patients with ntSAH further demonstrating the great diversity in management.Conclusion:This survey illustrates the astonishing variety of treatment practices for patients with ntSAH and underscores the need for further study.

An Approach to Interventional Pulmonary Fellowship Training

Interventional pulmonology continues to be a specialty that is experiencing an evolution of new technologies, with an emphasis on multidisciplinary care. The diversity and application of these procedures in patients with more complex conditions is leading to the need for more specific recommendations in training within this area. As patient safety and outcomes-based measures of clinical practice and procedures are in the forefront, the need for standardization in procedural training in high-volume centers of excellence beyond pulmonary and critical care fellowships must be considered. Other procedure-based specialties have developed such training programs, with structured curricula to enhance patient safety and outcomes, develop validated metrics for competency assessment of trainees, improve trainee education, and further advance the field by fostering research.