Low-volume Hospitals Research Articles

Medicaid Patients Undergo Total Joint Arthroplasty at Lower-Volume Hospitals by Lower-Volume Surgeons and Have Poorer Outcomes.

Medicaid insurance coverage among patients undergoing total hip arthroplasty (THA) or those undergoing total knee arthroplasty (TKA) has been associated with worse postoperative outcomes compared with patients without Medicaid. Surgeons and hospitals with lower annual total joint arthroplasty (TJA) volume have also been associated with worse outcomes. This study sought to characterize the associations between Medicaid insurance status, surgeon case volume, and hospital case volume and to assess the rates of postoperative complications compared with other payer types. The Premier Healthcare Database was queried for all adult patients who underwent primary TJA from 2016 to 2019. Patients were divided on the basis of their insurance status: Medicaid compared with non-Medicaid. The distribution of annual hospital and surgeon case volume was assessed for each cohort. Multivariable analyses were performed accounting for patient demographic characteristics, comorbidities, surgeon volume, and hospital volume to assess the 90-day risk of postoperative complications by insurance status. Overall, 986,230 patients who underwent TJA were identified. Of these, 44,370 (4.5%) had Medicaid. Of the patients undergoing TJA, 46.4% of those with Medicaid were treated by surgeons performing ≤100 TJA cases annually compared with 34.3% of those without Medicaid. Furthermore, a higher percentage of patients with Medicaid underwent TJA at lower-volume hospitals performing ≤500 cases annually, 50.8% compared with 35.5% for patients without Medicaid. After accounting for differences among the 2 cohorts, patients with Medicaid remained at increased risk for postoperative deep vein thrombosis (adjusted odds ratio [OR], 1.16; p = 0.031), pulmonary embolism (adjusted OR, 1.39; p < 0.001), periprosthetic joint infection (adjusted OR, 1.35; p < 0.001), and 90-day readmission (adjusted OR, 1.25; p < 0.001). Patients with Medicaid were more likely to undergo TJA performed by lower-volume surgeons at lower-volume hospitals and had higher rates of postoperative complications compared with patients without Medicaid. Future research should assess socioeconomic status, insurance, and postoperative outcomes in this vulnerable patient population seeking arthroplasty care. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Pediatric Disaster Readiness and Community Hospitals in a Rural American State

Introduction:Pediatric patients represent a small (but important) subset of the patient population routinely visiting emergency departments (ED) each year. With the aim of better understanding the disaster preparedness level for pediatric-specific mass casualty and surge incidents, a survey was conducted involving all hospitals that routinely manage pediatric patients in their emergency departments, to better understand the preparedness levels for these facilities.Method:This is a retrospective analysis of data collected in 2014 and repeated in 2021. Our focus included one predominantly rural state in the United States of America (USA). We examined results from surveys conducted where facilities self-reported objective criteria that resulted in a readiness score (as it relates to pediatric readiness). Reporting stratification reflected the annual pediatric ED volume with groups of; Low (&lt;1800/year), Medium (1800-4999 /year), Medium to High (5000-9999/year), and High (&gt;10,000/year).Results:Low-volume hospitals scored (Mean=59/Median=56), Medium volume hospitals scored (Mean=62/Median=60), Medium to High volume hospitals (Mean=67/Median=65), and hospitals with High volumes (Mean=82/Median=83). All hospital volume ranges had outlier hospitals that scored between 82-97. The general tendency, lower volume hospitals had a lower level of readiness, and higher volume hospitals had a higher (to much higher) level of readiness.Conclusion:Pediatric disaster readiness needs to be improved at the community level. It is encouraging that pediatric disaster readiness has been addressed in the larger medical centers. Yet, it should be noted that even very low-volume hospitals (had outliers with) scores as high as 94 indicating that with ample support, and resources, pediatric disaster preparedness is achievable in every hospital regardless of size or volume. The results point to a need to develop, improve, and distribute resources and support local hospitals with pediatric disaster readiness.

Volume-outcome relationship in complication-related mortality after percutaneous coronary interventions: an analysis on the failure-to-rescue rate in the Japanese Nationwide Registry.

In-hospital mortality following percutaneous coronary intervention (PCI) varies across institutions with different annual PCI volumes. The failure to rescue (FTR) rate, defined as the mortality rate following PCI-related complications, may account for the volume-outcome relationship. The Japanese Nationwide PCI Registry, a consecutive, nationally mandated registry between 2019 and 2020, was queried. The FTR rate is defined as 'the number of patients who died following PCI-related complications' divided by 'the number of patients who experienced at least one PCI-related complication.' Multivariate analysis was used to calculate the risk-adjusted odds ratio (aOR) of the FTR rates among hospitals stratified into tertiles as low (≤ 236/year), medium (237-405/year), and high (≥ 406/year). A total of 465,716 PCIs and 1007 institutions were included. A volume-outcome relationship was observed for in-hospital mortality, and the medium-volume (aOR 0.90, 95% confidence interval [CI] 0.85-0.96), as well as high-volume (aOR 0.84, 95% CI 0.79-0.89) hospitals, had significantly lower in-hospital mortality than low-volume hospitals. Complication rates were lower at high-volume centers (1.9%, 2.2%, and 2.6% for high-, medium-, and low-volume centers, respectively; p < 0.001). The overall FTR rate was 19.0%. The FTR rates for the low-, medium-, and high-volume hospitals were 19.3%, 17.7%, and 20.6%, respectively. The medium-volume hospitals had a lower FTR rate (aOR 0.82, 95% [CI] 0.68-0.99), whereas the FTR rate was similar at the high-volume hospitals compared with that of the low-volume hospitals (aOR 1.02, 95% CI 0.83-1.26). In-hospital mortality was low after PCI in high-volume hospitals. However, the FTR rate in high-volume hospitals was not necessarily lower than that in low-volume hospitals. The FTR rate did not account for the volume-outcome relationship in PCI.

Analysis of Obstetric Outcomes by Hospital Location, Volume, and Teaching Status Associated With Non–Medically Indicated Induction of Labor at 39 Weeks

Non-medically indicated induction of labor has been demonstrated to potentially improve some obstetric outcomes, such as decreasing cesarean birth. It has been reported that rates of cesarean birth and other obstetric outcomes vary among hospitals with different characteristics. To assess whether obstetric outcomes differ between nulliparous individuals with low-risk pregnancies managed with non-medically indicated induction of labor compared with expectant management in different types of hospitals. This retrospective cohort study included non-medically indicated induction of labor at 39 weeks' gestation compared with expectant management of singleton, nonanomalous, births in nulliparous women with low-risk pregnancies in California between January 1, 2007, and December 31, 2011. The initial analysis of these data was performed in 2021. Outcomes were assessed by 3 hospital characteristics: location (urban vs rural), obstetric volume, and teaching (academic vs community) status. Volume was categorized based on the average number of births per year and grouped into low (<1200 births per year), medium (1200-2399 births per year), and high (≥2400 births per year). Births with previous or planned cesarean delivery were excluded, and non-medically indicated induction of labor was defined as induction of labor without a specific medical indication. Testing with χ2 and multivariable logistic regression analyses was used for statistical comparisons with a cutoff level of P = .01. Non-medically indicated induction of labor at 39 weeks' gestation. The primary outcome was cesarean birth, and numerous secondary perinatal outcomes were also assessed. There were 455 044 births included in this study. When stratified by hospital variables, a number of sociodemographic characteristics were significantly different, such as race and ethnicity, age, body mass index, and insurance type. The adjusted odds ratios (aORs) of cesarean birth were significantly lower in all settings with induction of labor except for low-volume hospitals, in which there was no significant difference (aOR, 0.95; 95% CI, 0.82-1.09). Chorioamnionitis and postpartum hemorrhage were lower with induction of labor among nearly every hospital when stratified by hospital characteristics. Neonatal outcomes were improved in all settings with induction of labor compared with expectant management. These findings suggest that non-medically indicated induction of labor may be associated with a lower rate of cesarean births and some maternal and neonatal adverse outcomes in a range of hospital settings.

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.

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

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

Exploring the Surgical Outcomes of Pancreatic Cancer Resections Performed in Low- Versus High-Volume Centers.

Introduction Pancreatic cancer resections comprise a class of complex surgical operations with a high postoperative morbidity rate. Due to the complicated nature of pancreatic resection, individuals who undergo this procedure are advised to visit a high-volume medical center that performs such pancreatic surgeries frequently. However, this specialized treatment option may not be available for uninsured patients or patients with other socioeconomic limitations that may restrict their access to these facilities. To gain a better understanding of the impact of healthcare disparities on surgical outcomes, we aimed to explore if there were significant differences in mortality rate post-pancreatic resection between high- and low-volume hospitals within San Bernardino, Riverside, Los Angeles, and Orange Counties. Methods We utilized the California Health and Human Services Agency (CHHS) California Hospital Inpatient Mortality Rates and Quality Ratings public dataset to compare risk-adjusted mortality rates (RA-MR) of pancreatic cancer resections procedures. We focused on procedures performed in hospitals within San Bernardino, Riverside, Los Angeles, and Orange County from 2012 to 2015. To assess post-resection outcomes in relation to hospital volume, we utilized an independent T-test (significance level was set equal to 0.05) to determine if there is a statistically significant difference in RA-MR after pancreatic resection between high- and low-volume hospitals. Results During the 2012-2015 study period, 57 hospitals across San Bernardino, Riverside, Orange, and Los Angeles Counties were identified to perform a total of 6,204 pancreatic resection procedures. The low-volume hospital group (N=2,539) was associated with a higher RA-MR of M=4.45 (SD=11.86). By comparison, the high-volume hospital group (N=3,665) was associated with a lower RA-MR ofM=1.72 (SD=2.61). Conclusion Pancreatic resection surgeries performed at low-volume hospitals resulted in a significantly higher RA-MR compared to procedures done at high-volume hospitals in California.

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 ...

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 ...

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.

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.

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.

Juvenile Nasopharyngeal Angiofibroma: Outcomes Analysis Based Upon Hospital Volume.

To evaluate the management of juvenile nasopharyngeal angiofibroma (JNA) from a national perspective with outcomes comparison based on hospital volume. Ten-year Pediatric Health Information Systems (PHIS) data analysis. The PHIS database was queried for the diagnosis of JNA. Data regarding demographics, surgical approach, embolization, length of stay, charges, readmission, and revision surgery was collected and analyzed. Hospitals were classified as low volume if fewer than 10 cases and high volume if greater than or equal to 10 cases during the study period. A random effects model compared outcomes based on hospital volume. A total of 287 JNA patients were identified with a mean age of 13.8 (± 2.7) years. Nine hospitals were classified as high volume, accounting for a total of 121 patients. The mean length of hospitalization, blood transfusion rate, and 30-day readmissions did not differ significantly by hospital volume. Patients cared for at high-volume institutions were less likely to require postoperative mechanical ventilation (8.3% vs. 25.0%; adjusted RR=0.32; 95% CI 0.14-0.73; p < 0.01) or return to the operating room for residual disease than patients admitted to low-volume hospitals (7.4% vs. 20.5%; adjusted RR=0.38; 95% CI 0.18-0.79; p=0.01). The management of JNA is complex from both an operative and perioperative management standpoint. Over the past decade, nearly half (42.2%) of JNA patients have been managed at nine institutions in the United States. These centers have significantly lower rates of postoperative mechanical ventilation and the need for revision surgery. 3 Laryngoscope, 133:3216-3220, 2023.

Variation in the management of cT1 renal cancer by surgical hospital volume: A nationwide study.

To analyse variation in clinical management of cT1 renal cell carcinoma (RCC) in the Netherlands related to surgical hospital volume (HV). Patients diagnosed with cT1 RCC during 2014-2020 were identified in the Netherlands Cancer Registry. Patient and tumour characteristics were retrieved. Hospitals performing kidney cancer surgery were categorised by annual HV as low (HV < 25), medium (HV = 25-49) and high (HV > 50). Trends over time in nephron-sparing strategies for cT1a and cT1b were evaluated. Patient, tumour and treatment characteristics of (partial) nephrectomies were compared by HV. Variation in applied treatment was studied by HV. Between 2014 and 2020, 10 964 patients were diagnosed with cT1 RCC. Over time, a clear increase in nephron-sparing management was observed. The majority of cT1a underwent a partial nephrectomy (PN), although less PNs were applied over time (from 48% in 2014 to 41% in 2020). Active surveillance (AS) was increasingly applied (from 18% to 32%). For cT1a, 85% received nephron-sparing management in all HV categories, either with AS, PN or focal therapy (FT). For T1b, radical nephrectomy (RN) remained the most common treatment (from 57% to 50%). Patients in high-volume hospitals underwent more often PN (35%) for T1b compared with medium HV (28%) and low HV (19%). HV is related to variation in the management of cT1 RCC in the Netherlands. The EAU guidelines have recommended PN as preferred treatmentfor cT1 RCC. In most patients with cT1a, nephron-sparing management was applied in all HV categories, although differences in applied strategy were found and PN was more frequently used in high HV. For T1b, high HV was associated with less appliance of RN, whereas PN was increasingly used. Therefore, closer guideline adherence was found in high-volume hospitals.

Hospital Procedural Volume Predicts Short-term Outcomes for Patients Undergoing Procedures Requiring Large-bore Access.

Large-bore access procedures (LBP), such as transcatheter aortic valve replacement (TAVR), endovascular aneurysm repair (EVAR), and implantation of mechanical circulatory support (MCS), have been increasing in practice.1 While hospitals with a higher volume of TAVR procedures showed reduced in-hospital mortality and related complications,2 the relationship between procedural volume and outcomes for LBPs, collectively, has not been established, which is the goal of this research letter. This is a retrospective cohort study whereby all hospitalizations with patients undergoing LBP from 1 January 2016 to 31 December 2018, in the United States, were identified using the Nationwide Readmissions Database (NRD).3 LBPs included TAVR, EVAR, balloon aortic valvuloplasty (BAV), and implantation of MCS. Outcomes of interest were in-hospital mortality, vascular complications, major bleeding, and 30-day readmissions. Major bleeding was defined as bleeding requiring blood transfusion. The annualized hospital volume of LBP was analysed as both continuous and categorical variables (in quartiles) for the mentioned outcomes. Quartiles were chosen to ensure an equal number of hospitalizations in each volume category—quartile 1 (Q1), quartile (Q2), quartile 3 (Q3), and quartile 4 (Q4). Q1 was defined as a low-volume hospital and Q4 as a high-volume hospital. Outcomes were compared against Q1 by controlling for age, sex, comorbidities, and the Elixhauser Comorbidity Index, and the related odds ratio (OR) was estimated. Restricted cubic splines with hierarchical models were created to incorporate hospital characteristics as random effects in the model to help assess any nonlinear relationship between the hospital’s volume and outcomes. We also divided LBPs into TAVR and non-TAVR populations to determine if such outcomes also applied to the non-TAVR LBP. The present study did not require the institutional review board approval per institutional policy for de-identified publicly available dataset.

Impact of National Accreditation Program for Rectal Cancer guidelines on surgical margin status

BackgroundThe American College of Surgeons established the National Accreditation Program for Rectal Cancer (NAPRC) to standardize rectal cancer care. We sought to assess the impact of NAPRC guidelines at a tertiary care center on surgical margin status. Materials and methodsThe Institutional NSQIP database was queried for patients with rectal adenocarcinoma undergoing surgery for curative intent two years prior to and following implementation of NAPRC guidelines. Primary outcome was surgical margin status before (pre-NAPRC) versus after (post-NAPRC) implementation of NAPRC guidelines. ResultsSurgical pathology in five (5%) pre-NAPRC and seven (8%) post-NAPRC patients had positive radial margins (p = 0.59); distal margins were positive in three (3%) post-NAPRC and six (7%) post-NAPRC patients (p = 0.37). Local recurrence was observed in seven (6%) pre-NAPRC patients, there were no recurrences to date in post-NAPRC patients (p = 0.15). Metastasis was observed in 18 (17%) pre-NAPRC patients and four (4%) post-NAPRC patients (p = 0.55). ConclusionNAPRC implementation was not associated with a change in surgical margin status for rectal cancer at our institution. However, the NAPRC guidelines formalize evidence-based rectal cancer care and we anticipate that improvements will be greatest in low-volume hospitals which may not utilize multidisciplinary collaboration.

Breast cancer care and surgery in Australia and New Zealand: compliance of the BreastSurgANZ quality audit with international standards.

The Breast Surgeons of Australia and New Zealand (BreastSurgANZ) Quality Audit (BQA) of Breast Cancer Care is a prospective population-based database designed for annual audit of compliance with internally derived Quality Indicators (QI)s. While there is no international consensus for QIs, audit against an external international benchmark is possible through use of QIs defined by the 2017 European Society of Breast Cancer Specialists (EUSOMA) Guidelines. BQA data from 29,088 female patients between 1/1/2018 and 31/12/2019 were stratified by the EUSOMA definition of low-volume hospitals (LVH <150 patients p.a.) and high-volume hospitals (HVH ≥150 patients p.a.), and percentage compliance (±95% CI) with 14 mandatory EUSOMA QI sub-parts were determined. ANZ LVH met the quality threshold for 10, and HVH for 8 EUSOMA QI that assessed MDT, surgical approach, adjuvant radiotherapy in the LVH setting, avoidance of overtreatment, and use of endocrine therapy. ANZ did not meet the quality thresholds for QIs assessing use of neoadjuvant chemotherapy, and adjuvant radiotherapy in the HVH setting. Breast cancer care in ANZ is comparable with an international standard. ANZ surgeons performed at a high standard in discussion of breast cancer patients by MDT, and appropriate use of adjuvant radiotherapy by LVH. Improvements can be made in completeness of data capture, and inclusion of genetic syndromeand Ki67% in data collection. Due to the rapid evolution of breast cancer treatments, there is need for contemporary update of QI relating to the use of neoadjuvant systemic therapies.

Interinstitutional analysis of the outcome after surgery for type A aortic dissection

PurposeTo evaluate the impact of individual institutions on the outcome after surgery for Stanford type A aortic dissection (TAAD).MethodsThis is an observational, multicenter, retrospective cohort study including 3902 patients who underwent surgery for TAAD at 18 university and non-university hospitals.ResultsLogistic regression showed that four hospitals had increased risk of in-hospital mortality, while two hospitals were associated with decreased risk of in-hospital mortality. Risk-adjusted in-hospital mortality rates were lower in four hospitals and higher in other four hospitals compared to the overall in-hospital mortality rate (17.7%). Participating hospitals were classified as overperforming or underperforming if their risk-adjusted in-hospital mortality rate was lower or higher than the in-hospital mortality rate of the overall series, respectively. Propensity score matching yielded 1729 pairs of patients operated at over- or underperforming hospitals. Overperforming hospitals had a significantly lower in-hospital mortality (12.8% vs. 22.2%, p < 0.0001) along with decreased rate of stroke and/or global brain ischemia (16.5% vs. 19.9%, p = 0.009) compared to underperforming hospitals. Aggregate data meta-regression of the results of participating hospitals showed that hospital volume was inversely associated with in-hospital mortality (p = 0.043). Hospitals with an annual volume of less than 15 cases had an increased risk of in-hospital mortality (adjusted OR, 1.345, 95% CI 1.126–1.607).ConclusionThe present findings indicate that there are significant differences between hospitals in terms of early outcome after surgery for TAAD. Low hospital volume may be a determinant of poor outcome of TAAD.Trial registrationClinicalTrials.gov Identifier: NCT04831073.

Long-term effect of hospital volume on the postoperative prognosis of 158,618 patients with esophageal squamous cell carcinoma in China.

The impact of hospital volume on the long-term survival of esophageal squamous cell carcinoma (ESCC) has not been well assessed in China, especially for stage I-III stage ESCC. We performed a large sample size study to assess the relationships between hospital volume and the effectiveness of ESCC treatment and the hospital volume value at the lowest risk of all-cause mortality after esophagectomy in China. To investigate the prognostic value of hospital volume for assessing postoperative long-term survival of ESCC patients in China. The date of 158,618 patients with ESCC were collected from a database (1973-2020) established by the State Key Laboratory for Esophageal Cancer Prevention and Treatment, the database includes 500,000 patients with detailed clinical information of pathological diagnosis and staging, treatment approaches and survival follow-up for esophageal and gastric cardia cancers. Intergroup comparisons of patient and treatment characteristics were conducted with the X2 test and analysis of variance. The Kaplan-Meier method with the log-rank test was used to draw the survival curves for the variables tested. A Multivariate Cox proportional hazards regression model was used to analyze the independent prognostic factors for overall survival. The relationship between hospital volume and all-cause mortality was assessed using restricted cubic splines from Cox proportional hazards models. The primary outcome was all-cause mortality. In both 1973-1996 and 1997-2020, patients with stage I-III stage ESCC who underwent surgery in high volume hospitals had better survival than those who underwent surgery in low volume hospitals (both P<0.05). And high volume hospital was an independent factor for better prognosis in ESCC patients. The relationship between hospital volume and the risk of all-cause mortality was half-U-shaped, but overall, hospital volume was a protective factor for esophageal cancer patients after surgery (HR<1). The concentration of hospital volume associated with the lowest risk of all-cause mortality was 1027 cases/year in the overall enrolled patients. Hospital volume can be used as an indicator to predict the postoperative survival of ESCC patients. Our results suggest that the centralized management of esophageal cancer surgery is meaningful to improve the survival of ESCC patients in China, but the hospital volume should preferably not be higher than 1027 cases/year. Hospital volume is considered to be a prognostic factor for many complex diseases. However, the impact of hospital volume on long-term survival after esophagectomy has not been well evaluated in China. Based on a large sample size of 158,618 ESCC patients in China spanning 47 years (1973-2020), We found that hospital volume can be used as a predictor of postoperative survival in patients with ESCC, and identified hospital volume thresholds with the lowest risk of death from all causes. This may provide an important basis for patients to choose hospitals and have a significant impact on the centralized management of hospital surgery.

Descriptive statistics and risk factor analysis of children with community-acquired septic shock

BackgroundChildren with community-acquired septic shock can rapidly deteriorate and die in acute-care hospitals. This study aimed to describe the mortality, timing, and risk factors in children with community-acquired septic shock.MethodsThis is a retrospective cohort study using a national inpatient database in Japan. The study population included children (age < 20 years) who were admitted to acute-care hospitals with a diagnosis of sepsis from July 2010 to March 2020, who were treated with antibiotics, and who were supported with vasoactive drugs within three days of hospitalization. We used a Cox proportional-hazards regression model to identify risk factors for earlier death.ResultsAmong 761 eligible children, the median age was 3 (interquartile range, 0–11) years and 57.2% had underlying conditions. Among these, 67.1% were admitted to accredited intensive care units within three days of hospitalization and 38.6% were transported from other hospitals. The median hospital volume, defined as the number of eligible children in each hospital over the study period, was 4 (interquartile range, 2–11). Overall, 244 children died (in-hospital mortality rate, 32.1%). Among them, 77 (31.6%) died on the first day, and 156 (63.9%) died within three days of hospitalization. A Cox proportional-hazards regression model showed that earlier death was associated with lower hospital volume and age 1–5 years, whereas it was inversely associated with admission to an accredited intensive care unit and transport from other hospitals. Among 517 survivors, 178 (34.4%) were discharged with comorbidities.ConclusionsChildren with community-acquired septic shock had high mortality, and early death was common. Our findings may warrant future efforts to enhance the quality of initial resuscitation for sepsis in low-volume hospitals and to ensure a healthcare system in which children with sepsis can be treated in accredited intensive care units.