Hospital Volume Research Articles

Association between hospital surgical case volume and postoperative mortality in patients undergoing gastrectomy for gastric cancer: a systematic review and meta-analysis.

Postoperative mortality is an important indicator for evaluating surgical safety. Postoperative mortality is influenced by hospital volume; however, this association is not fully understood. This study aimed to investigate the volume-outcome association between the hospital surgical case volume for gastrectomies per year (hospital volume) and the risk of postoperative mortality in patients undergoing a gastrectomy for gastric cancer. Studies assessing the association between hospital volume and the postoperative mortality in patients who underwent gastrectomy for gastric cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random-effects model. The volume-outcome association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with Prospective Register of Systematic Reviews (PROSPERO). Thirty studies including 586993 participants were included. The risk of postgastrectomy mortality in patients with gastric cancer was 35% lower in hospitals with higher surgical case volumes than in their lower-volume counterparts (odds ratio: 0.65; 95% CI: 0.56-0.76; P <0.001). This relationship was consistent and robust in most subgroup analyses. Volume-outcome analysis found that the postgastrectomy mortality rate remained stable or was reduced after the hospital volume reached a plateau of 100 gastrectomy cases per year. The current findings suggest that a higher-volume hospital can reduce the risk of postgastrectomy mortality in patients with gastric cancer, and that greater than or equal to 100 gastrectomies for gastric cancer per year may be defined as a high hospital surgical case volume.

Characteristics Contributing to Survival Differences Between Black and White Patients Following Cystectomy.

Examine patient, tumor, and treatment characteristics effect on the disparity between black and white patients with muscle-invasive bladder cancer (MIBC) who undergo radical cystectomy (RC). 1,286 black patients in the 2004 to 2016 National Cancer Database fit inclusion criteria. A tapered match was performed from 17,374 white patients sequentially matched to the black cohort on demographics (age, gender, insurance, income, education, county, diagnosis year), presentation (demographic variables, stage, grade, tumor size, Charlson score), and treatment (demographic and presentation variables, lymph node count, hospital volume, neoadjuvant chemotherapy [NAC], treatment delay), creating 3 matched cohorts. Chi-square and Kruskal-Wallis tests were used to compare cohorts. Kaplan-Meier analysis was used to compare 5-year overall survival (OS). 5-year OS rate was 40.4% and 35.6% for unmatched white and black cohorts (P < 0.001), respectively. Following demographics and presentation match, 5-year OS rate for white patients decreased to 39.2% (P = 0.003) and 39.10% (P = 0.019), respectively. After treatment match, 5-year OS rate decreased to 36.7% for white patient (P = 0.32). Following presentation match, 7.2% of black patients vs. 5.8% of white patients had treatment delay, and 10.1% of black patients vs. 11.2% of white patients received NAC. The treatment match resulted in a 0.3% difference between groups for treatment delay and NAC. Our analysis demonstrates that disparity between black and white patients with muscle-invasive bladder cancer exists in demographic-, presentation-, and treatment-related variables. Treatment variables may be a large contributing factor to survival disparities. Further research is needed to identify social, biological, and organizational inputs that contribute to these disparities.

MP64-15 FROM NORTHEAST TO WEST: PATIENT AND HOSPITAL CHARACTERISTICS AFFECTING ACCESS TO PARTIAL NEPHRECTOMY IN THE UNITED STATES AS STRATIFIED BY GEOGRAPHIC LOCATION

You have accessJournal of UrologyCME1 Apr 2023MP64-15 FROM NORTHEAST TO WEST: PATIENT AND HOSPITAL CHARACTERISTICS AFFECTING ACCESS TO PARTIAL NEPHRECTOMY IN THE UNITED STATES AS STRATIFIED BY GEOGRAPHIC LOCATION Tamir Sholklapper, Andrew Chen, Gus Miranda, Jie Cai, Amir Lebastchi, Andrew Hung, Andre Abreu, Mihir Desai, Inderbir Gill, and Giovanni Cacciamani Tamir SholklapperTamir Sholklapper More articles by this author , Andrew ChenAndrew Chen More articles by this author , Gus MirandaGus Miranda More articles by this author , Jie CaiJie Cai More articles by this author , Amir LebastchiAmir Lebastchi More articles by this author , Andrew HungAndrew Hung More articles by this author , Andre AbreuAndre Abreu More articles by this author , Mihir DesaiMihir Desai More articles by this author , Inderbir GillInderbir Gill More articles by this author , and Giovanni CacciamaniGiovanni Cacciamani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003322.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Partial nephrectomy (PN) is considered the gold standard treatment of small renal masses (SRM). With the recent changes in prevalence of open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN), access to care remains a point of interest. Herein, we examine the trends in surgical approach for PN through a geographic lens. METHODS: ICD and CPT codes were used to identify patient diagnoses and characteristics of PN encounters between January 1, 2000 and December 31, 2019 from the Premier Healthcare Database, a de-identified database with over 1,041 contributing hospitals/healthcare systems. We examined patient social, surgical, and hospital characteristics. Multivariable logistic regression models were used. All statistical tests were two-sided (p-value≤0.05 significant). RESULTS: Out of 42,762 surgeries, 12,856 (30.1%) were OPN and 29,906 (69.9%) were RPN. In the Northeast, non-Hispanic Black patients were more likely to receive RPN as compared to non-Hispanic White patients (OR=1.27 [95% CI=1.06-1.54] p=0.004). This was not the case in the South, Midwest, and West regions (0.91 [0.83-1.01] p=0.018; 0.93 [0.71-1.12] p=0.018; and 0.81 [0.56-1.17] p=0.031, respectively). Medicaid patients were less likely to receive RPN as compared to HMO/PPO patients in the Northeast and South (0.67 [0.56-0.79] p=0.002; 0.70 [0.70-0.81] p=0.004). In the Northeast, patients at urban hospitals were more likely to undergo RPN as compared to rural hospitals (3.55 [2.94-4.29] p<0.001) while the reverse was true in the West (0.45 [0.33-0.62 p<0.001). Across all geographic regions, there was a lower proportion of patients at high volume hospitals receiving RPN as compared to low volume hospitals. CONCLUSIONS: As RPN increases in prevalence in the management of the SRM, access to this surgical approach is influenced by a variety of patient and hospital characteristics. While certain hospital characteristics hold true across the United States in regard to hospital and surgeon volume, patient characteristics affecting receipt of RPN vary between geographic divisions. These differences can serve as a starting point for further analysis to address factors limiting access to urologic care. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e887 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tamir Sholklapper More articles by this author Andrew Chen More articles by this author Gus Miranda More articles by this author Jie Cai More articles by this author Amir Lebastchi More articles by this author Andrew Hung More articles by this author Andre Abreu More articles by this author Mihir Desai More articles by this author Inderbir Gill More articles by this author Giovanni Cacciamani More articles by this author Expand All Advertisement PDF downloadLoading ...

MP59-03 THULIUM LASER ENUCLEATION (ThuLEP) VERSUS TRANSURETHRAL BIPOLAR PROSTATE RESECTION (TURP): PROSPECTIVE RANDOMIZED STUDY: EARLY INTRA- AND POSTOPERATIVE RESULTS

You have accessJournal of UrologyCME1 Apr 2023MP59-03 THULIUM LASER ENUCLEATION (ThuLEP) VERSUS TRANSURETHRAL BIPOLAR PROSTATE RESECTION (TURP): PROSPECTIVE RANDOMIZED STUDY: EARLY INTRA- AND POSTOPERATIVE RESULTS Matteo Zanoni, Giuseppe Chiarelli, Paola Arena, Edoardo Beatrici, Maria Chiara Clementi, Cinzia Mazzieri, Paolo Vota, Giovanni Lughezzani, Nicolò Buffi, Milan, Gianluigi Taverna, and Castellanza Matteo ZanoniMatteo Zanoni More articles by this author , Giuseppe ChiarelliGiuseppe Chiarelli More articles by this author , Paola ArenaPaola Arena More articles by this author , Edoardo BeatriciEdoardo Beatrici More articles by this author , Maria Chiara ClementiMaria Chiara Clementi More articles by this author , Cinzia MazzieriCinzia Mazzieri More articles by this author , Paolo VotaPaolo Vota More articles by this author , Giovanni LughezzaniGiovanni Lughezzani More articles by this author , Nicolò BuffiNicolò Buffi More articles by this author , Milan Milan More articles by this author , Gianluigi TavernaGianluigi Taverna More articles by this author , and Castellanza Castellanza More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003312.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The aim is the comparison of early intra- and postoperative clinical results between transurethral enucleation of the prostate with thulium laser (ThuLEP) and transurethral bipolar resection of the prostate (TURP) for the treatment of benign prostatic hyperplasia (BPH) in a prospective randomized trial. METHODS: In the study 650 consecutive patients with BPH were randomized: ThuLEP (n=350) and TURP (n=300). The parameters evaluated were: blood loss, catheterisation time, irrigation volume, hospital stay and operating time. At 6 months after surgery they were evaluated: International Prostate Symptom Score (IPSS), maximum flow (Qmax) and postmintional residue (RPM). RESULTS: Patients in each study arm did not show any significant differences in preoperative parameters compared to TURP, ThuLEP required the same operating time (53.69±31.44 vs 61.66±18.7 minutes, p=.123) but resulted in a reduction in lower hemoglobin values (0.45 vs 2.83 g/dL, p=0.005). ThuLEP also determined less non statistically significant catheterisation time, lower irrigation volume (29.4 vs 69.2 L, p=0.002) and lower non-significant hospital stay (1.7 vs 2.5 days). During the 6-month follow-up, procedures did not show a significant difference in Qmax, IPSS, PVR and Quality of life Scale (QOLS). CONCLUSIONS: ThuLEP and TURP reduce both symptoms of the lower urinary tract with efficacy and safety. ThuLEP is statistically superior to TURP in terms of blood loss, irrigation volume. However, procedures do not differ significantly in Qmax, IPSS, RPM and QOLS for up to 6 months of follow-up. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e806 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matteo Zanoni More articles by this author Giuseppe Chiarelli More articles by this author Paola Arena More articles by this author Edoardo Beatrici More articles by this author Maria Chiara Clementi More articles by this author Cinzia Mazzieri More articles by this author Paolo Vota More articles by this author Giovanni Lughezzani More articles by this author Nicolò Buffi More articles by this author Milan More articles by this author Gianluigi Taverna More articles by this author Castellanza More articles by this author Expand All Advertisement PDF downloadLoading ...

PD09-05 STANDARD VERSUS EXTENDED LYMPH NODE DISSECTION AT THE TIME OF RADICAL CYSTECTOMY FOR BLADDER CANCER

You have accessJournal of UrologyCME1 Apr 2023PD09-05 STANDARD VERSUS EXTENDED LYMPH NODE DISSECTION AT THE TIME OF RADICAL CYSTECTOMY FOR BLADDER CANCER Alejandro Abello, Sumedh Kaul, Aaron Fleishman, Joaquim Bellmunt, Irving Kaplan, Simon Kim, Peter Chang, Andrew Wagner, Ruslan Korets, Aria Olumi, and Boris Gershman Alejandro AbelloAlejandro Abello More articles by this author , Sumedh KaulSumedh Kaul More articles by this author , Aaron FleishmanAaron Fleishman More articles by this author , Joaquim BellmuntJoaquim Bellmunt More articles by this author , Irving KaplanIrving Kaplan More articles by this author , Simon KimSimon Kim More articles by this author , Peter ChangPeter Chang More articles by this author , Andrew WagnerAndrew Wagner More articles by this author , Ruslan KoretsRuslan Korets More articles by this author , Aria OlumiAria Olumi More articles by this author , and Boris GershmanBoris Gershman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003240.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: It is uncertain whether lymphadenectomy (LND) provides a survival benefit in patients undergoing radical cystectomy (RC). In the only completed randomized trial on this topic – LEA AUO AB 25/02 – extended LND (eLND) was associated with improved survival compared to limited/standard (sLND), although these associations did not reach statistical significance. Herein, we emulated a pragmatic clinical trial designed to resemble the LEA trial. METHODS: We identified patients in the National Cancer Database who met the following eligibility criteria based on the LEA trial: adult 40-79 years old, Charlson 0-1, underwent RC with LND for high-grade cT1/cT2-T4a cNany cM0 urothelial carcinoma of the bladder from 2006-2015, without neoadjuvant chemotherapy, at a hospital performing ≥16 RC/year. sLND and eLND were defined as removal of 4-11 and ≥12 lymph nodes based on the LEA trial. A propensity score (PS) was estimated for receipt of eLND, and the associations of LND type with overall survival (OS) were evaluated adjusting with inverse probability of treatment weights (IPW). RESULTS: A total of 2248 patients formed the study cohort, including 429 with sLND and 1813 with eLND. Baseline characteristics were well-balanced after PS adjustment. During a median follow-up of 37.5 months, eLND was associated with significantly improved 5-year OS compared to sLND (60% vs 48%; HR 0.72, 95%CI: 0.61-0.85, p<0.01; Figure 1). Effect estimates were consistent across all potential treatment effect modifiers, including cT stage, cN stage, and age (Figure 2). Results were robust in sensitivity analyses that modified the definitions for LND and relaxed the annual RC hospital volume requirement. CONCLUSIONS: In observational analyses designed to emulate a completed clinical trial, eLND was associated with improved OS compared to sLND among patients undergoing RC. Survival and effect estimates were similar to those in the LEA trial but statistically significant due to larger sample size. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e241 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alejandro Abello More articles by this author Sumedh Kaul More articles by this author Aaron Fleishman More articles by this author Joaquim Bellmunt More articles by this author Irving Kaplan More articles by this author Simon Kim More articles by this author Peter Chang More articles by this author Andrew Wagner More articles by this author Ruslan Korets More articles by this author Aria Olumi More articles by this author Boris Gershman More articles by this author Expand All Advertisement PDF downloadLoading ...

Annual Endovascular Thrombectomy Case Volume and Thrombectomy-capable Hospitals of Korea in Acute Stroke Care.

Although it is difficult to define the quality of stroke care, acute ischemic stroke (AIS) patients with moderate-to-severe neurological deficits may benefit from thrombectomy-capable hospitals (TCHs) that have a stroke unit, stroke specialists, and a substantial endovascular thrombectomy (EVT) case volume. From national audit data collected between 2013 and 2016, potential EVT candidates arriving within 24 hours with a baseline National Institutes of Health Stroke Scale score ≥6 were identified. Hospitals were classified as TCHs (≥15 EVT case/y, stroke unit, and stroke specialists), primary stroke hospitals (PSHs) without EVT (PSHs-without-EVT, 0 case/y), and PSHs-with-EVT. Thirty-day and 1-year case-fatality rates (CFRs) were analyzed using random intercept multilevel logistic regression. Out of 35 004 AIS patients, 7954 (22.7%) EVT candidates were included in this study. The average 30-day CFR was 16.3% in PSHs-without-EVT, 14.8% in PSHs-with-EVT, and 11.0% in TCHs. The average 1-year CFR was 37.5% in PSHs-without-EVT, 31.3% in PSHs-with-EVT, and 26.2% in TCHs. In TCHs, a significant reduction was not found in the 30-day CFR (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.76 to 1.12), but was found in the 1-year CFR (OR, 0.84; 95% CI, 0.73 to 0.96). The 1-year CFR was significantly reduced when EVT candidates were treated at TCHs. TCHs are not defined based solely on the number of EVTs, but also based on the presence of a stroke unit and stroke specialists. This supports the need for TCH certification in Korea and suggests that annual EVT case volume could be used to qualify TCHs.

The Impact of a Liver Transplant Program on the Outcomes of Hepatocellular Carcinoma.

We sought to evaluate the impact of liver transplantation (LT) programs on the prognosis of hepatocellular carcinoma (HCC) patients who underwent liver resection (LR) and noncurative intent treatment. LT programs have an array of resources and services that would positively affect the prognosis of patients with HCC. Patients who underwent LT, LR, radiotherapy (RT), or chemotherapy (CTx) for HCC between 2004 and 2018 were included in the National Cancer Database. Institutions with LT programs were defined as those that performed 1 or more LT for at least 5 years. Centers were stratified by hospital volume. The impact of LT programs was assessed after propensity score matching to achieve covariate balance. A total of 71,735 patients were identified, of which 7997 received LT (11.1%), 12,683 LR (17.7%), 15,675 RT (21.9%), and 35,380 CTx (49.3%). Among a total of 1267 distinct institutions, 94 (7.4%) were categorized as LT programs. Designation as an LT program was also associated with a high volume of LR and noncurative intent treatment (both P <0.001). After propensity score matching, LT programs were associated with better survival among LR and noncurative intent treatment patients. Although hospital volume was also associated with improved prognosis, LT programs were associated with additional survival benefits in noncurative intent treatment. On the other hand, no such benefit was noted in patients who underwent LR. The presence of an LT program was associated with a higher volume of LR and noncurative intent treatment. Furthermore, designation as an LT program had a "halo effect" on the prognosis of patients undergoing RT/CTx that went beyond the procedure-volume effect.

Hospital and surgeon experience and patient health outcomes after coronary artery bypass graft surgery

AbstractThe Hospital Readmissions Reduction Program imposes financial penalties on hospitals with excess readmission rates for various conditions, including coronary artery bypass graft (CABG) surgery. While prior research has focused mainly on hospital‐specific factors and their impact on patient mortality, surgeon risk factors and patient outcomes, such as readmission risk, have received less attention. We study three drivers of CABG readmission risk—hospital and surgeon case volume, variation in surgeon volume, and surgeon familiarity with hospitals. Drawing on unique patient data sets of CABG surgeries spanning 3 years, we study the relationships between hospital and surgeon case volume, readmission risk, and postoperative length of stay (PLOS). We find evidence of an inverted U‐shaped relationship between case volume and readmission risk and a U‐shaped relationship with PLOS. Our results also indicate that surgeon volume variation moderates the relationship between surgeon volume and readmission risk, where readmission risk increases with greater variation in surgeon volume. We observe that the impact of surgeon experience on readmission risk at the focal hospital outweighs their experience at other hospitals. Our study has significant implications for hospital resource management as it highlights the role of surgeon and hospital experience in improving patient outcomes after CABG surgery.

Intracardiac Echocardiography Guidance for Percutaneous Transcatheter Closure of Atrial Septal Defects - Nationwide Registry Data Analysis.

Transesophageal echocardiography (TEE) has been used for percutaneous atrial septal defect (ASD) closure, with intracardiac echocardiography (ICE) guidance recently being introduced. The Japanese Structural Heart Disease Registry was established by the Japanese Association of Cardiovascular Intervention and Therapeutics. This study analyzed data from the Registry for 2,859 consecutive cases undergoing percutaneous ASD closure between January 2015 and December 2020. ASD closure was performed under ICE guidance (n=519; 18.2%), TEE guidance (n=1,428; 49.9%), or TEE plus ICE guidance ("Both"; n=900 cases; 31.5%). The success rates were similar in the TEE, ICE, and both groups (99.0%, 99.2%, vs. 98.0%, respectively; P=0.054), as were complication rates (1.2%, 0.5%, vs. 2.1%, respectively; P=0.24). In the TEE and Both groups, 92.4% and 79.6% of patients required general anesthesia, compared with only 2.9% of patients in the ICE group (P<0.001). Fluoroscopic time was longer in the ICE and Both groups than in the TEE group (median [interquartile range] 19 [14-28] and 21 [13-30] vs. 12 [8-19] min, respectively; P<0.001). Rim deficiency and larger defect diameter were inversely related, whereas hospital volume was positively related to ICE guidance. Percutaneous transcatheter ASD closure was as feasible under ICE as under TEE guidance. ICE guidance is used for less challenging cases in high-volume centers in Japan.

Prognostic impact of endoscopic response evaluation after neoadjuvant chemotherapy for esophageal squamous cell carcinoma: a nationwide validation study.

Our previous study reported the prognostic significance of endoscopic response (ER) evaluation, defined ER, and revealed ER as an independent prognostic factor of overall survival (OS) and recurrence-free survival (RFS) for esophageal squamous cell carcinoma (ESCC) treated with neoadjuvant chemotherapy (NAC) and surgery. The present study aimed to validate the prognostic impact of ER using a nationwide database from the authorized institute for board-certified esophageal surgeons by the Japan Esophageal Society. This study retrospectively reviewed patients with ESCC who underwent subtotal esophagectomy at 85 authorized institutes for esophageal cancer from 2010 to 2015. Patients were classified as ER when the tumor size was markedly reduced post-NAC compared to pre-NAC. The correlation between OS and RFS was investigated. Of 4781 patients initially enrolled, 3636 were selected for subsequent analysis. Of them, 642 (17.7%) patients were classified as the ER group. Patients with ER showed significantly better OS and RFS. Subgroup analysis revealed the statistical difference in OS and RFS in cStage II and III, while the magnitude of survival difference between ER and non-ER was not evident in cStage I and IV. The percentage of ER varied from 46 to 87% among groups when institutions were classified into 3 subgroups based on the hospital volume, which would indicate the interinstitutional inconsistency. The prognostic impact of ER was validated using a nationwide database. Standardization of ER evaluation is required to improve the interinstitutional consistency and clinical validity of the ER evaluation.

The Effects of Hospital Volume on Short-Term Outcomes of Laparoscopic Surgery for Rectal Cancer: A Large-Scale Analysis of 37,821 Cases on a Nationwide Administrative Database

Introduction: Laparoscopic low anterior resection (L-LAR) has become widely accepted for the treatment of rectal cancer. However, little is known about the superiority of L-LAR in a real-world setting (including low-volume hospitals) and the association between the short-term outcomes and hospital volume focusing on L-LAR. Methods: This is a retrospective cohort study. A total of 37,821 patients who underwent LAR for rectal cancer were analyzed using the Diagnosis Procedure Combination (DPC) database from January 2014 to December 2017. The short-term surgical outcomes were analyzed using a multilevel analysis. Hospital volumes were divided into quartiles, including low (1–31), middle (32–55), high (56–91), and very-high volume (92–444 resections per 4 years). The effects of hospital volume on the outcomes were investigated. Results: The study population included 8,335 patients (22%) who underwent open low anterior resection (O-LAR) and 29,486 patients (78%) who underwent L-LAR. The in-hospital mortality and morbidity were consistent with previous reports. In patients who underwent L-LAR, the in-hospital mortality (0.12% vs. 0.41%; OR: 0.33; p = 0.005), the rate of reoperation (3.76% vs. 6.48%; OR: 0.67; p < 0.001), and the perioperative transfusion rate (3.81% vs. 5.90%; OR: 0.66; p < 0.001) were significantly lower in very-high-volume hospitals than in low-volume hospitals. These effects of hospital volume were not observed in O-LAR. Conclusions: Our present study demonstrates that high volume improves outcomes in patients who underwent L-LAR in a real-world setting.

Patterns of Care and Outcomes of Rectal Cancer Patients from the Iowa Cancer Registry: Role of Hospital Volume and Tumor Location

BackgroundCentralization of rectal cancer surgery has been associated with high-quality oncologic care. However, several patient, disease and system-related factors can impact where patients receive care. We hypothesized that patients with low rectal tumors would undergo treatment at high-volume centers and would be more likely to receive guideline-based multidisciplinary treatment. MethodsAdults who underwent proctectomy for stage II/III rectal cancer were included from the Iowa Cancer Registry and supplemented with tumor location data. Multinomial logistic regression was employed to analyze factors associated with receiving care in high-volume hospital, while logistic regression for those associated with ≥ 12 lymph node yield, pre-operative chemoradiation and sphincter-preserving surgery. ResultsOf 414 patients, 38%, 39%, and 22% had low, mid, and high rectal cancers, respectively. Thirty-two percent were > 65 years, 38% female, and 68% had stage III tumors. Older age and rural residence, but not tumor location, were associated with surgical treatment in low-volume hospitals. Higher tumor location, high-volume, and NCI-designated hospitals had higher nodal yield (≥ 12). Hospital-volume was not associated with neoadjuvant chemoradiation rates or circumferential resection margin status. Sphincter-sparing surgery was independently associated with high tumor location, female sex, and stage III cancer, but not hospital volume. ConclusionsLow tumor location was not associated with care in high-volume hospitals. High-volume and NCI-designated hospitals had higher nodal yields, but not significantly higher neoadjuvant chemoradiation, negative circumferential margin, or sphincter preservation rates. Therefore, providing educational/quality improvement support in lower volume centers may be more pragmatic than attempting to centralize rectal cancer care among high-volume centers.

Impact of early ureteral drainage on mortality in obstructive pyelonephritis with urolithiasis: an analysis of the Japanese National Database.

The impact of early drainage on mortality in patients with obstructive pyelonephritis with urolithiasis was evaluated. We identified 34,924 patients in the Japanese Diagnosis Procedure Combination database with obstructive pyelonephritis with urolithiasis receiving ureteral drainage. The effects of early drainage (1-2days) compared to those of delayed drainage (on 3-4 and ≥ 5 hospital days) on mortality were evaluated among 31,696 patients hospitalized for ≥ 5days. Multivariate analysis was performed to identify independent factors for mortality. The mortality rates for overall cases and those hospitalized for ≥ 5days were 2.0% and 1.6%, respectively. Those receiving drainage on 1-2, 3-4, and ≥ 5days had mortality rates of 1.5%, 2.0%, and 2.5%, respectively (p < 0.001). Multivariate analysis revealed that delayed drainage was an independent factor for higher mortality (odds ratio [OR] on days 3-4 and ≥ 5; 1.44, p = 0.018; and 1.69, p < 0.001). Increasing age (OR for 60s, 70s, and ≥ 80years; 2.02, 3.85, and 7.77), Charlson comorbidity index score (OR, 1.41 by 1-point increase), disseminated intravascular coagulation (OR, 2.40), ambulance use (OR, 1.22), impaired consciousness at admission (disoriented, arousable with stimulation, and unarousable; OR 1.58, 2.84, and 5.50), and nephrostomy (OR, 1.65) were associated with higher mortality. In contrast, female sex (OR, 0.76) and high hospital volume (OR on 9-16, and ≥ 17 cases/year; 0.80, and 0.75) were associated with lower mortality. Ureteral drainage within 2 hospital days was an independent factor for low mortality in obstructive pyelonephritis with urolithiasis. Delayed drainage could increase mortality in a time-dependent manner.

Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock after acute myocardial infarction: Insights from a French nationwide database

BackgroundWe aimed to analyze the impact of timing of implantation (strategy-outcome relationship) and volume of procedures (volume-outcome relationship) on survival of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock complicating acute myocardial infarction (AMI). MethodsWe conducted an observational retrospective study through two propensity score-based analyses using a nationwide database between January 2013 and December 2019. We classified patients into early implantation (VA ECMO on the day of primary percutaneous coronary intervention [PCI]) and delayed implantation (VA ECMO beyond the day of PCI) groups. We classified patients into low- or high-volume groups based on the median hospital volume. ResultsDuring the study period 649 VA ECMO were implanted across 20 French hospitals. Mean age was 57.1 ± 10.4 years, 80% were male. Overall, 90-day mortality was 64.3%. Patients in the early implantation group (n = 479, 73.8%) did not show a statistical difference in 90-day mortality than in the delayed group (n = 170, 26.2%) (HR: 1.18; 95% CI 0.94–1.48; p = 0.153). The mean number of VA ECMO implanted during the study period by low-volume centers was 21.3 ± 5.4 as compared to 43.6 ± 11.8 in high-volume centers. There was no significant difference in 90-day mortality between high-volume and low-volume centers (HR: 1.00; 95% CI: 0.82–1.23; p = 0.995). ConclusionsIn this real-world nationwide study, we did not find a significant association between early VA ECMO implantation as well as high-volume centers and lower mortality in AMI-related refractory cardiogenic shock.

Elective ascending aortic aneurysm repair outcomes in a nationwide US cohort

ObjectiveTo quantify contemporary outcomes following elective ascending aortic aneurysm repair, to determine risk factors for adverse events and to evaluate difference by institutional surgical volume.MethodsWe included all elective hospitalisations of...

Effects of Geographic Region, Hospital Volume, and Teaching Status on Perioperative Outcomes in Bariatric Surgery

Effects of Geographic Region, Hospital Volume, and Teaching Status on Perioperative Outcomes in Bariatric Surgery

Is there variation between hospitals within each region in postoperative mortality for lung cancer surgery in France? A nationwide study from 2013 to 2020.

The practice of thoracic surgery for lung cancer is subject to authorization in France. We evaluated the performance of hospitals using 30-day post-operative mortality as a quality indicator, estimating its distribution within each region and measuring its variability between regions. All data for patients who underwent pulmonary resection for lung cancer in France (2013-2020) were collected from the national hospital administrative database. Thirty-day mortality was defined as any patient who died in hospital (including transferred patients) within the first 30 days after the operation and those who died later during the initial hospitalization. The Standardized Mortality ratio (SMR) was the smoothed, adjusted, hospital-specific mortality rate divided by the expected mortality. To describe the variation in hospital mortality between hospitals in each region, we used different commonly used indicators of variation such as coefficients of variation (CV), interquartile interval or range (IQR), extreme ratio, and systematic component of variance (SCV). In 2013-2020, 87,232 patients underwent lung resection for cancer in France. The number of deaths was 2,537, a rate of 2.91%. The median SMR of 199 hospitals was 0.99 with an IQR of 0.86 to 1.18 and a CV of 0.25. Among the regions that had the most hospitals performing lung resections for cancer, the extreme ratio was >2, which means that the maximum value is twice as high as the minimum value. The SCV between hospitals was >10 for two of these regions, which is considered indicative of very high variation. For the other regions (with few hospitals performing lung resections for cancer), the variation between hospitals was lower. Globally, the variability between regions concerning the SMR was moderate, 6% of the variance was due to differences across regions. On the contrary, the hospital volume was significantly related to the SMR (p = 0.003) with a negative linear trend, whatever the region. This work shows significant differences in the practices of the various hospitals within regions. However, overall, the variability in the 30-day mortality rate between regions was moderate. Our findings raises questions regarding the regionalization of major surgical procedures in France.

3-Jahres-Revisionsrate von zertifizierten EndoProthetikZentren nach EndoCert

The EndoCert initiative does not yet allow along-term assessment of outcome quality. The assessment cannot be achieved without cooperation with the German arthroplasty registry (EPRD) and other quality assurance infrastructure, such as the quality assurance system of the nationwide healthcare insurance data for inpatient hospital treatment (QSR) by the German local healthcare fund (AOK). Therefore, the quality of care of all certified centres for joint replacement (EPZ) after primary hip and knee arthroplasty was to be examined for the first time. These data were subsequently compared to the data of the EPRD. In EPZ that provided care to at least one AOK-insured patient in 2016, the risk-adjusted 3‑year revision rate and the SMR-value (standardised mortality or morbidity ratio), which is the quotient of the observed and expected revision rate, were analysed as markers for the quality of care. Annual hospital volume, type of centre and audit results were examined as possible influencing factors. In the group comparison, significant differences (p = 0.042) for the SMR value of the 3‑year revision rate were demonstrated for hip arthroplasty with regard to the EPZ type. The annual number of primary hip arthroplasties, however, did not influence the 3‑year revision rate. For knee arthroplasties, no effect of the defined categories on the 3‑year revision rate and its SMR value was observed. The comparison of our 3‑year revision rates with those of the EPRD showed similar results for the hip but indicated significant differences for the knee. We did not observe acorrelation between quality of care and annual hospital volume in certified EPZ. However, different quality assurance procedures can lead to different results with respect to the outcome quality. Therefore, aconsiderably improved interaction of the German quality systems must be achieved. Participation in the EPRD is not sufficient for this. Rather, acomplete report of all arthroplasties must be required, at least with the achievement of aminimum reporting rate per participating hospital. Uniform inclusion and exclusion criteria should be defined.

Is it time for integrated academic pathways in SET training?

Patients benefit from receiving care in hospitals with a strong engagement in clinical research. Some of these benefits result from institutional factors such as hospital volume and resources, but the academic competencies of surgical teams play a significant role in high quality patient care.1, 2 Surgeons with doctorate degrees are more likely to publish and obtain research grants throughout their career, and units they work in report higher rates of trainee research success and satisfaction, improved patient outcomes and greater clinical guideline adherence.3 When research is fully integrated into organizational structures, health-care performance is superior to less formal research.3 Whilst not all trainees aspire for long-term academic career trajectories, it is important for surgical training programs to address the sustainability of academic pathways. Prevalent models of surgical training do not readily support simultaneous acquisition of clinical competencies alongside more focused academic training and higher research degrees. In Australia and Aotearoa New Zealand, most surgical education and training (SET) programs allow trainees to suspend training for up to 1–2 years to complete higher research degrees. Some trainees can arrange less-than-full-time (LTFT) training positions that allow them extra time for research, but these LTFT positions can be difficult to arrange, and often are not geographically located near the trainee's research centre. Engaging in part-time research is also hindered by financial concerns, as most RACS research scholarships are only available for trainees undertaking full-time research. When re-entering clinical training after prolonged research-related absence, trainees can encounter significant challenges. The stress of returning to work, combined with loss of confidence and skills, significantly impacts trainee wellbeing and performance.4 In Nash's study of paediatric surgical trainees returning to clinical work after an interval away from training, clinical confidence needed time to be re-established: ‘I don't think your hands forget how to operate, I think it's your brain that does not have the confidence to do it’.4 Clinical and technical skills may need to be redeveloped, and time-based training programs have little flexibility to allow for this. Reestablishment of professional identity and connections with peers was also important, with many returning trainees feeling doubts about their career.4, 5 Trainees returning to academia after completing a full-time training period, typically have a considerable reduction in their research output and publications. Reduced academic output during these clinical training years hinder future competitiveness for larger research grant funding, and limit their eligibility for grants targeted towards early career researchers. Experiences from international training programs provide insights into how we can address this challenge. The integrated Clinical Academic Fellowship pathways for surgical training in the United Kingdom (UK) are well established and have been demonstrated to improve both research output and clinical skill development.6, 7 Research pathways integrated into residency training in the United States resulted in participants scoring higher on national board examinations, improved research productivity and sustained academic success.8, 9 UK ENT trainees who undertook LTFT in dedicated integrated research programs achieved more publications and academic output than non-integrated trainees in both full-time and part-time clinical positions.10 Trainees benefit from the cognitive synergy of combining clinical training and academic research relevant to their areas of expertise.11, 12 Integration of research within clinical practice, rather than prolonged intervals of full-time research, is a mechanism to provide support, link clinical skill acquisition to academic competency development, and recognize progression through training pathways.13 Trainees who participate in integrated research programs report positive work-life balance, ability to develop longitudinal research interests and sustained engagement in academic surgery.6 Despite inbuilt pathways in other surgical training systems, academic trainees continue to face challenges, including accessing protected time away from clinical duties, negative attitudes from others in the workplace, and difficulties accessing academic supervision.6 In vascular surgery, we are undertaking research to explore and codesign alternative models of training, including integrated pathways for academic development in clinical training. It is important to obtain input from trainees, supervisors and healthcare employers as to how these models can be implemented in our local context in Australia and Aotearoa. We anticipate logistical, educational and cultural challenges as these pathways are developed. Ensuring trainees are able to complete higher degrees will require strong partnerships with universities, with a clear vision for a sustainable academic surgical workforce. As we move forward in this process, we aspire for training to be flexible and adaptive to the needs of our trainees, hospitals and communities. Carina Cutmore: Conceptualization; data curation; writing – original draft; writing – review and editing. Hamid Hajian: Conceptualization; data curation; writing – review and editing. Sarah Aitken: Conceptualization; data curation; resources; supervision; writing – original draft; writing – review and editing.

A contemporary analysis of the volume–outcome relationship for extracorporeal membrane oxygenation in the United States

BackgroundA paradoxical increase in mortality following extracorporeal membrane oxygenation at high-volume centers has previously been demonstrated. We examined the association between annual hospital volume and outcomes within a contemporary, national cohort of extracorporeal membrane oxygenation patients. MethodsAll adults requiring extracorporeal membrane oxygenation for postcardiotomy syndrome, cardiogenic shock, respiratory failure, or mixed cardiopulmonary failure were identified in the 2016 to 2019 Nationwide Readmissions Database. Patients undergoing heart and/or lung transplantation were excluded. A multivariable logistic regression with hospital extracorporeal membrane oxygenation volume parametrized as restricted cubic splines was developed to characterize the risk-adjusted association between volume and mortality. The volume corresponding to the maximum of the spline (43 cases/year) was used to categorize centers as low- or high-volume. ResultsAn estimated 26,377 patients met the study criteria, and 48.7% were managed at high-volume hospitals. Patients at low- and high-volume hospitals had similar age, sex, and rates of elective admission. Notably, patients at high-volume hospitals less frequently required extracorporeal membrane oxygenation for postcardiotomy syndrome but more commonly for respiratory failure. After risk adjustment, high-volume hospital status was associated with reduced odds of in-hospital mortality, relative to low-volume hospitals (adjusted odds ratio 0.81, 95% confidence interval 0.78–0.97). Interestingly, patients at high-volume hospitals faced a 5.2-day increment in length of stay (95% confidence interval 3.8–6.5) and $23,500 in attributable costs (95% confidence interval 8,300–38,700). ConclusionThe present study found that greater extracorporeal membrane oxygenation volume was associated with decreased mortality but higher resource use. Our findings may help inform policies regarding access to and centralization of extracorporeal membrane oxygenation care in the United States.