Low-volume Hospitals Research Articles

Association of Medicaid expansion with access to thyroidectomy for benign disease at high-volume centers

BackgroundInsurance-based disparities in access to thyroidectomy are well established. Patients undergoing thyroidectomy by high-volume surgeons have fewer complications and better postoperative outcomes. The aim of this study was to evaluate the association of Medicaid expansion with access to high-volume centers for thyroidectomy for benign disease. MethodsThe Vizient Clinical Data Base was queried for adult operations for benign thyroid disease from 2010 to 2019. Centers were sorted by volume into quartiles. Difference-in-difference analysis evaluated changes in insurance populations in expansion and non-expansion states after Medicaid expansion. Odds of patients undergoing operations in the 4 volume quartiles after stratifying by insurance and Medicaid expansion status were calculated. ResultsA total of 82,602 patients underwent operations at 364 centers. Expansion states increased Medicaid coverage in all volume quartiles compared to non-expansion states after Medicaid expansion (Q1, +4.87%, Q2, +5.35%, Q3, +8.57%, Q4, +4.62%, P < .002 for all). After Medicaid expansion, Medicaid patients had higher odds of undergoing operation at lower volume hospitals compared to the highest volume centers in both expansion states (Q1, ref, Q2, 1.82, Q3, 1.76, Q4, 1.67, P < .001) and non-expansion states (Q1, ref, Q2, 1.54, Q3, 2.04, Q4, 1.44, P < .001). Privately insured patients were most likely to undergo their operation at the highest volume centers in all states (E: Q1, ref, Q2, 0.78, Q3, 0.74, Q4, 0.66, P < .001; NE: Q1, ref, Q2, 0.89, Q3, 0.58, Q4, 0.85, P < .001). ConclusionMedicaid expansion increased Medicaid coverage in expansion states, but Medicaid patients in both expansion and non-expansion states were less likely to be operated on at the highest volume centers compared to privately insured patients. Persistent barriers to accessing high-volume care still exists for Medicaid patients.

Interhospital variability in cardiac rehabilitation use after cardiac surgery among Medicare beneficiaries

ObjectiveDespite guideline recommendation, cardiac rehabilitation (CR) after cardiac surgery remains underused, and the extent of interhospital variability is not well understood. This study evaluated determinants of interhospital variability in CR use and outcomes. MethodsThis retrospective cohort study included 166,809 Medicare beneficiaries undergoing cardiac surgery who were discharged alive between July 1, 2016, and December 31, 2018. CR participation was identified in outpatient facility claims within a year of discharge. Hospital-level CR rates were tabulated, and multilevel models evaluated the extent to which patient, organizational, and regional factors accounted for interhospital variability. Adjusted 1-year mortality and readmission rates were also calculated for each hospital quartile of CR use. ResultsOverall, 90,171 (54.1%) participated in at least 1 CR session within a year of discharge. Interhospital CR rates ranged from 0.0% to 96.8%. Hospital factors that predicted CR use included nonteaching status and lower-hospital volume. Before adjustment for patient, organizational, and regional factors, 19.3% of interhospital variability was attributable to the admitting hospital. After accounting for covariates, 12.3% of variation was attributable to the admitting hospital. Patient (0.5%), structural (2.8%), and regional (3.7%) factors accounted for the remaining explained variation. Hospitals in the lowest quartile of CR use had greater adjusted 1-year mortality rates (Q1 = 6.7%, Q4 = 5.2%, P < .001) and readmission rates (Q1 = 37.6%, Q4 = 33.9%, P < .001). ConclusionsIdentifying best practices among high CR use facilities and barriers to access in low CR use hospitals may reduce interhospital variability in CR use and advance national improvement efforts.

High but decreasing rates of reconstruction after total proctocolectomy for ulcerative colitis, and evidence of a direct volume outcome relationship.

Total (procto)colectomy is indicated in 15%-20% of ulcerative colitis(UC) patients during their disease course. Reconstruction options to avoid a permanent ileostomy include an ileoanal pouch anastomosis (IPAA) or ileorectal anastomosis (IRA). This study aimed to investigate reconstruction rates using Australian-based population-level data, and factors influencing reconstruction. A retrospective data linkage study of the NSW population over a 19-year period was performed. Patients with UC who underwent total (procto)colectomy with a minimum of 1-year follow up were included. The main outcome was reconstruction with either IPAA or IRA. The influence of hospital and patient factors on reconstruction rates was assessed by Cox regression. Overall, 1047 patients underwent a (procto)colectomy for UC (mean age 45.9 years [SD ± 18.3], 640 [61.1%] male). The 5-year reconstruction rate was 55% (IPAA 89%). Advanced age, emergent colectomy, higher comorbidity burden, and geographical remoteness were significantly associated with lower reconstruction rates. A lower reconstruction rate was also observed in the most recent time-period (2014-2019) (aHR 0.68[95% CI 0.54-0.86]), and where index (procto)colectomy was performed in low-volume (<1 pouch/year) pouch hospitals (aHR 0.60 [95% CI 0.43-0.82]). NSW Australia has the highest reported rate of reconstruction following UC (procto)colectomy globally. However, rates reduced in the most recent time-period. There was variation in reconstruction rates across centres, with primary and overall reconstruction rates proportionate to hospital pouch volume. Reconstruction rates were also lower for patients living outside major cities. To ensure equitable opportunities for reconstruction, patients being considered for IBD pouch surgery should be centralized to a limited number of specialist pouch centres.

Radiation therapy for retroperitoneal sarcoma: practice patterns in North America

BackgroundThe addition of radiation therapy (RT) to surgery in retroperitoneal sarcoma (RPS) remains controversial. We examined practice patterns in the use of RT for patients with RPS over time in a large, national cohort.MethodsPatients in the National Cancer Database (2004–2017) who underwent resection of RPS were included. Trends over time for proportions were calculated using contingency tables with Cochran-Armitage Trend test.ResultsOf 7,485 patients who underwent resection, 1,821 (24.3%) received RT (adjuvant: 59.9%, neoadjuvant: 40.1%). The use of RT decreased annually by < 1% (p = 0.0178). There was an average annual increase of neoadjuvant RT by 13% compared to an average annual decrease of adjuvant RT by 6% (p < 0.0001). Treatment at high-volume centers (OR 14.795, p < 0.0001) and tumor > 10 cm (OR 2.009, p = 0.001) were associated with neoadjuvant RT. In contrast liposarcomas (OR 0.574, p = 0.001) were associated with adjuvant RT. There was no statistically significant difference in overall survival between patients treated with surgery alone versus surgery and RT (p = 0.07).ConclusionIn the United States, the use of RT for RPS has decreased over time, with a shift towards neoadjuvant RT. However, a large percentage of patients are still receiving adjuvant RT and this mostly occurs at low-volume hospitals.

Operative Volumes and Postoperative Outcomes After Elective Resection of Congenital Lung Malformations in Infants.

To determine whether hospital- and surgeon-level operative volumes are associated with differences in postoperative outcomes among infants undergoing elective lung surgery for a congenital lung malformation (CLM). Infant lung surgery is a relatively uncommon procedure performed by pediatric surgeons nationwide. The relationship between surgical volume and postoperative outcomes remains unknown. A retrospective cohort study of asymptomatic infants who underwent elective lung resection of a CLM was conducted using the Pediatric Health Information System database (2016-2020). Multivariable linear and poisson regressions were performed based on annual lung resection tertiles. There were 1420 infants managed by 48 hospitals and 309 primary surgeons. Institutions that performed seven or fewer CLM resections per year (56%) were associated with significantly higher postoperative complication rates compared to medium- and high-volume hospitals (low: 134 [34%], medium: 110 [21%], high: 144 [29%]; P<0.001). Surgeons who performed one or fewer CLM resections per year (82%) were associated with significantly higher complication rates compared to medium- and high-volume surgeons (low: 171 [31%], medium: 75 [26%], high: 119 [24%]; P=0.02). Multivariable analyses confirmed that low-volume hospitals were associated with higher complications (OR 1.81, CI 1.38-2.37; P<0.001), and low-volume surgeons had an increased risk of complications (overall: OR 1.37, CI 1.01-1.84; P=0.04). In this cohort study of infants undergoing elective lung resection for a CLM, lower volume providers were associated with higher postoperative patient morbidity. These findings represent an opportunity to inform quality improvement initiatives on pediatric lung resection and the debate on surgical subspecialization for this unique patient population.

Obstetric imaging practice characteristics associated with prenatal detection of critical congenital heart disease in a rural US region over 20years.

To identify clinical practice characteristics associated with the frequency of prenatal critical congenital heart disease (CCHD) detection (i.e., the number of liveborn infants with postnatally confirmed CCHD identified on prenatal sonography) over 20years in a rural setting comprised of 11 primarily low-volume obstetric hospitals and the single tertiary academic hospital to which they refer. This was a retrospective cohort study of all patients in the referral region with an initial prenatal and/or postnatal diagnosis of CCHD from 01/01/2002 to 12/31/2021. The frequency of prenatal CCHD detection at the time of an obstetric ultrasound was reported, as was the change in detection over time. Critical congenital heart disease detection was assessed as a function of cardiac lesion type, practice setting, and practice characteristics. There were 271 cases with a confirmed postnatal CCHD diagnosis, of which 49% were identified prenatally. The majority of community practices each averaged <10 CCHD cases in total over the study period. Prenatal detection at the tertiary academic hospital's obstetric ultrasound unit was 64%, compared to 22% at the combined referring community practices (p<0.001), though CCHD detection improved over time in both settings. Professional accreditation by the American Institute of Ultrasound in Medicine, image interpretation by radiology or Maternal Fetal Medicine, and use of video clips of ventricular outflow tracts were associated with improved prenatal CCHD detection. Our data demonstrate the infrequency of CCHD cases at small-volume, rural hospitals and the substantial variation in prenatal CCHD detection across practice settings. Our methods allowed for the identification of practice characteristics associated with prenatal CCHD detection.

High-Volume Hospital Had Lower Mortality of Severe Intracerebral Hemorrhage Patients.

Intracerebral hemorrhage (ICH) accompanies higher mortality rates than other type of stroke. This study aimed to investigate the association between hospital volume and mortality for cases of ICH. We used nationwide data from 2013 to 2018 to compare high-volume hospitals (≥32 admissions/year) and low-volume hospitals (<32 admissions/year). We tracked patients' survival at 3-month, 1-year, 2-year, and 4-year endpoints. The survival of ICH patients was analyzed at 3-month, 1-year, 2-year, and 4-year endpoints using Kaplan-Meier survival analysis. Multivariable logistic regression analysis and Cox regression analysis were performed to determine predictive factors of poor outcomes at discharge and death. Among 9,086 ICH patients who admitted to hospital during 18-month period, 6,756 (74.4%) and 2,330 (25.6%) patients were admitted to high-volume and low-volume hospitals. The mortality of total ICH patients was 18.25%, 23.87%, 27.88%, and 35.74% at the 3-month, 1-year, 2-year, and 4-year, respectively. In multivariate logistic analysis, high-volume hospitals had lower poor functional outcome at discharge than low-volume hospitals (odds ratio, 0.80; 95% confidence interval, 0.72-0.91; p < 0.001). In the Cox analysis, high-volume hospitals had significantly lower 3-month, 1-year, 2-year, and 4-year mortality than low-volume hospitals (p < 0.05). The poor outcome at discharge, short- and long-term mortality in ICH patients differed according to hospital volume. High-volume hospitals showed lower rates of mortality for ICH patients, particularly those with severe clinical status.

Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures

BackgroundThere is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications. MethodsWe identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879). ResultsThe search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis. ConclusionWe found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.

Unicompartmental knee arthroplasty questionnaire (UniQ-study): Unknown is unloved

BackgroundAlmost 50% of the patients requiring knee replacement are suitable for medial unicompartmental knee arthroplasty (UKA). However, national registries have shown a use far below 50%. AimThe aim of this study was to identify the factors that could influence the use of UKA. MethodsA questionnaire was conducted among practicing knee surgeons of the Dutch Orthopedic Association. The questionnaire was classified into three domains: surgeon, patient selection, and professional opinion. Associations between the domains and UKA volume and contra-indications were tested using Pearson’s chi-square tests. ResultsOf the 113 included respondents, 40% had no hands-on exposure during residency. Frequently reported contra-indications were obesity (68%), lateral osteophytes (21%), chondrocalcinosis (20%), and age (20%). Medial partial thickness lesions were considered a contra-indication by 49% and lateral joint space narrowing by 61% of the respondents. Respondents perceived UKA to outperform total knee arthroplasty regarding all outcomes, except survival (1.8% versus 42%). The reported barriers for UKA use were insufficient experience (20%), high revision rates (20%), and low hospital volume (16%), whereas 60% did not experience any at all. Hands-on UKA exposure during residency was associated with an increased use of correct indications. Furthermore, the use of correct indications was associated with an increased UKA volume. ConclusionWe showed a low UKA exposure during residency and considerable variations in contra-indications. These factors may contribute to an underuse of UKA. Improved UKA training could lead to increased experience and better patient selection among surgeons and consequently a higher use of medial UKA.

Equity of travel to access surgery and radiation therapy for lung cancer in New Zealand

PurposeCentralisation of lung cancer treatment can improve outcomes, but may result in differential access to care for those who do not reside within treatment centres.MethodsWe used national-level cancer registration and health care access data and used Geographic Information Systems (GIS) methods to determine the distance and time to access first relevant surgery and first radiation therapy among all New Zealanders diagnosed with lung cancer (2007–2019; N = 27,869), and compared these outcomes between ethnic groups. We also explored the likelihood of being treated at a high-, medium-, or low-volume hospital. Analysis involved both descriptive and adjusted logistic regression modelling.ResultsWe found that Māori tend to need to travel further (with longer travel times) to access both surgery (median travel distance: Māori 57 km, European 34 km) and radiation therapy (Māori 75 km, European 35 km) than Europeans. Māori have greater odds of living more than 200 km away from both surgery (adjusted odds ratio [aOR] 1.83, 95% CI 1.49–2.25) and radiation therapy (aOR 1.41, 95% CI 1.25–1.60).ConclusionsCentralisation of care may often improve treatment outcomes, but it also makes accessing treatment even more difficult for populations who are more likely to live rurally and in deprivation, such as Māori.

The Association of High-Quality Hospital Use on Health Care Outcomes for Pediatric Congenital Heart Defects in a Universal Health Care System.

Congenital heart disease (CHD) has an incidence of 0.8% to 1.2% worldwide, making it the most common birth defect. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and mortality after CHD surgery. In addition, researchers found critical CHD patients at low-volume/non-teaching facilities to be associated with higher odds of inpatient mortality when compared to CHD patients at high-volume/teaching hospitals (odds ratio 1.76). We examined the effects of high-quality hospital (HQH) use on health care outcomes and health care costs in pediatric CHD care using an instrumental variable (IV) approach. Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries with a diagnosis of CHD were tabulated based on relevant ICD-10 (International Classification of Diseases, 10th revision) codes. We examined the relationships between annual readmissions, annual emergency room (ER) use, and mortality and HQH use. We applied both the naive linear probability model (LPM), controlling for the observed patient and hospital characteristics, and the two-stage least squares (2SLS) model, accounting for the unobserved confounding factors. The differential distance between the patient and the closest HQH at the index date and the patient and nearest non-HQH was used as the IV. This protocol was approved by the Institutional Review Board at the University of Maryland, College Park (Approval Number: 1576246-2). The naive LPM indicated that HQH use was associated with a higher probability of annual readmissions (marginal effect, 18%; 95% CI, 0.12 to 0.23). The naive LPM indicated that HQH use was associated with a higher probability of mortality (marginal effect, 2.2%; 95% CI, 0.01 to 0.03). Using the differential distance of closest HQH and non-HQH, we identified a significant association between HQH use and annual ER use (marginal effect, -14%; 95% CI, -0.24 to -0.03). After controlling for patient-level and facility-level covariates and adjusting for endogeneity, (1) HQH use did not increase the probability of more than one admission post 1-year CHD diagnosis, (2) HQH use lowered the probability of annual ER use post 1-year CHD diagnosis, and (3) HQH use did not increase the probability of mortality post 1-year CHD diagnosis. Patients who may have benefited from utilizing HQH for CHD care did not, alluding to potential barriers to access, such as health insurance restrictions or lack of patient awareness. Although we used hospital quality rating for congenital cardiac surgery as reported by the Society of Thoracic Surgeons, the contributing data span a 4-year period and may not reflect real-time changes in center performance. Since this study focused on inpatient care within the first-year post-initial CHD diagnosis, it may not reflect the full range of health system utilization. It is necessary for clinicians and patient advocacy groups to collaborate with policymakers to promote the development of an overarching HQH designation authority for CHD care. Such establishment will facilitate access to HQH for military beneficiary populations suffering from CHD.

(361) National Trends of Male Urethroplasty Procedures: 2016-2019

Abstract Introduction Urethroplasty remains a valuable surgical option in the management of urethral stricture disease. However, current understanding of the patient- and hospital-level factors associated with inpatient versus (vs.) outpatient male urethroplasty is limited on a national scale. Objective We therefore sought to evaluate contemporary national trends of urethroplasty procedures among men. Methods We performed a retrospective review from 2016 to 2019 of urethroplasty procedures in men utilizing both the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample – the largest publicly available all-payer inpatient and ambulatory databases in the United States. Non-endoscopic urethroplasty procedures were identified by Current Procedural Terminology and International Classification of Diseases (10th Revision) Procedure Coding System codes. Utilizing both inpatient and outpatient encounters, we performed stratified cluster sampling to create weighted national estimates. The primary outcome was the rate of urethroplasty performed in inpatient and outpatient encounters over time. Multivariable logistic regression was used to evaluate patient- and hospital-level factors associated with inpatient urethroplasty. Results From 2016 to 2019, there were 28,532 weighted urethroplasty procedures analyzed (37% inpatient vs. 63% outpatient). Over the study period, there was a 27% increase in the total number of annual procedures (n=6270 to n=7980), and the proportion performed outpatient increased from 60% to 68% [Figure]. Mean total charge for inpatient urethroplasty encounters was $84,267 vs. $30,997 outpatient (p&amp;lt;0.0001). Predictors of inpatient urethroplasty included greater Elixhauser Comorbidity Index, use of buccal mucosal graft, non-private insurance status, and Western hospital region (vs. Northeast) (p&amp;lt;0.05) [Table]. Outpatient urethroplasty was associated with higher median income by Zip Code (vs. lowest quartile of median income), Southern hospital region (vs. Northeast), rural or urban non-teaching hospital (vs. urban teaching hospital), and higher urethroplasty case volume hospitals (vs. lowest case volume hospitals) (p&amp;lt;0.05). Conclusions An increasing proportion of urethroplasty procedures nationwide appears to be performed on an outpatient basis. Outpatient procedures have lower hospital charges than inpatient encounters – and are associated with higher volume hospitals, not using buccal mucosal graft, private insurance, and less comorbid patients who reside in areas of higher median income. Further investigation is warranted to assess how these factors may affect surgical outcomes. Disclosure No.

Abstract TP107: Quantifying Hospital Opportunities to Increase Thrombolysis

Introduction: Emergency-department-based implementation strategies to increase thrombolysis are promising. We sought to quantify the number of hospitals with opportunities to increase thrombolysis under various tPA treatment thresholds. Methods: We used data from the 2018 State Inpatient Databases (SID) from 17 states. The study population was limited to ischemic stroke patients admitted to the hospital. The primary outcome was the sum of patients receiving stroke thrombolysis (tPA) at each facility (DRG 61-63, ICD-10 procedure code 3E03317, ICD-10 diagnosis code Z92.82). The primary exposure was hospital stroke volume categorized into quartiles (1 st Quartile [Low]: 1-7, 2 nd Quartile: 8-53, 3 rd Quartile: 54-178, 4 th Quartile [High]: 179-1431). To estimate the number of additional patients treated if hospitals improve their thrombolysis rates across various thresholds, we calculated the expected number of thrombolysis treatments (tPA thresholds multiplied by hospital stroke volume and subtracted by the number of patients receiving tPA at each facility). Results: We identified 203,843 hospital admissions with a primary ischemic stroke diagnosis from 1608 hospitals. On average, 13.3% of patients received tPA. The proportion of stroke patients receiving tPA was higher in higher stroke volume hospitals (Table 1). Black people were more likely to receive care at high-stroke volume hospitals. Among 1608 hospitals, 1131 (70%) had tPA rates below 10%. If these 1131 hospitals improve their tPA rates to 10%, 2655 (2.3 patients/hospital/year) additional stroke patients would be treated with tPA. Conclusions: Low stroke volume hospitals have the lowest thrombolytic treatment rates, but interventions at these hospitals will have limited population benefits and may not be an efficient use of hospital resources. Intervening at high-volume, low-performing hospitals offers the largest opportunity to increase thrombolysis and will promote stroke racial equity.

Quality of surgery and treatment and its association with hospital volume: A population-based study in more than 5000 Belgian ovarian cancer patients

BackgroundDifferent sets of quality indicators are used to identify areas for improvement in ovarian cancer care. This study reports transparently on how (surgical) indicators were measured and on the association between hospital volume and indicator results in Belgium, a country setting without any centralisation of ovarian cancer care. MethodsFrom the population-based Belgian Cancer Registry, patients with a borderline malignant or invasive epithelial ovarian tumour diagnosed between 2014 and 2018 were selected and linked to health insurance and vital status data (n = 5119).Thirteen quality indicators on diagnosis and treatment were assessed and the association with hospital volume was analysed using logistic regression adjusted for case-mix. ResultsThe national results for most quality indicators on diagnosis and systemic therapy were around the predefined target value. Other indicators showed results below the benchmark: genetic testing, completeness of staging surgery, lymphadenectomy with at least 20 pelvic/para-aortic lymph nodes removed, and timely start of chemotherapy after surgery (within 42 days).Ovarian cancer care in Belgium is dispersed over 100 hospitals. Lower volume hospitals showed poorer indicator results compared to higher volume hospitals for lymphadenectomy, staging, timely start of chemotherapy and genetic testing. In addition, surgery for advanced stage tumours was performed less often in lower volume hospitals. ConclusionsThe indicators that showed poorer results on a national level were also those with poorer results in lower-volume hospitals compared to higher-volume hospitals, consequently supporting centralisation. International benchmarking is hampered by different (surgical) definitions between countries and studies.

P1153 Hospital surgical volumes and outcomes in ileocaecal resection for Crohn’s disease in Sweden 2000-2019: A national cohort study

Abstract Background Intestinal resection for Crohn’s disease (CD) is often complex and remains associated with significant postoperative morbidity. In several other types of complex surgery, increased case volumes have been associated with better outcomes. In surgery for CD, such an association has not yet been demonstrated. Methods In this nationwide cohort study, we used the National Patient Register to identify all CD patients who underwent their first (primary) ileocaecal resection in Sweden 2000-2019 at age 15 years or above. Hospitals were grouped into low, middle, and high-volume centres based on the number of intestinal resections for CD the previous calendar year (1-24, 25-36 and ≥37 resections, respectively). Length of hospital stay, severe postoperative complications and deaths during the first 100 days after the date of index surgical admission were compared between groups, and adjusted for sex, age, duration of disease, preoperative corticosteroid therapy, and year of surgery. Rates of surgical reintervention were used as a measure of severe postoperative morbidity. Results In the 20-year study period, 3396 patients underwent primary ileocaecal resection for CD in Sweden; 2371 (69.8%), 527 (15.5%) and 498 (14.7%) in low, middle, and high-volume hospitals, respectively. Median age at surgery was 41, 39 and 34 years, respectively, and the proportion of patients with a diagnostic record of perianal disease was 9, 10 and 16%. Sex, extraintestinal manifestations and preoperative medical therapies and hospital admissions did not differ between hospital types. Laparoscopic surgery was performed in 351 (15%), 126 (24%) and 122 (24%) patients, respectively. Surgical reintervention within 100 days was performed in 117 (4.9%), 19 (3.6%) and 13 (2.6%) patients in the three groups (adjusted odds ratios 0.72 (95% confidence interval 0.43-1.15) for middle-volume and 0.52 (0.28-0.89) for high-volume hospitals, compared to low-volume hospitals, Figure). There were no differences in the length of index admission hospital stay or mortality. Conclusion In primary ileocaecal resection for CD, high-volume hospitals had lower odds of early surgical reintervention, compared to low-volume hospitals. This finding may inform considerations of subspecialisation and centralisation in surgery for Crohn’s disease.

In the patient’s shoes: The impact of hospital proximity and volume on stage I endometrial cancer care patterns and outcomes

ObjectiveTo compare the impact of travel burden and hospital volume on care patterns and outcomes in stage I endometrial cancer. MethodsThis retrospective cohort study identified patients from the National Cancer Database with stage I epithelial endometrial carcinoma who underwent hysterectomy between 2012 and 2020. Patients were categorized into: lowest quartiles of travel distance and hospital surgical volume for endometrial cancer (Local) and highest quartiles of distance and volume (Travel). Primary outcome was overall survival. Secondary outcomes were surgery route, lymph node (LN) assessment method, length of stay (LOS), 30-day readmission, and 30- and 90-day mortality. Results were stratified by tumor recurrence risk. Outcomes were compared using propensity-score matching. Propensity-adjusted survival was evaluated using Kaplan-Meier curves and compared using log-rank tests. Cox models estimated hazard ratios for death. Sensitivity analysis using modified Poisson regressions was performed. ResultsAmong 36,514 patients, 51.4% were Local and 48.6% Travel. The two cohorts differed significantly in demographics and clinicopathologic characteristics. Upon propensity-score matching (p < 0.05 for all), more Travel patients underwent minimally invasive surgery (88.1%vs79.1%) with fewer conversions to laparotomy (2.0%vs2.6%), more sentinel (20.5%vs11.3%) and fewer traditional LN assessments (58.1vs61.7%) versus Local. Travel patients had longer intervals to surgery (≥30 days:56.7%vs50.1%) but shorter LOS (<2 days:76.9%vs59.8%), fewer readmissions (1.9%vs2.7%%), and comparable 30- and 90-day mortality. OS and HR for death remained comparable between the matched groups. ConclusionsCompared to surgery in nearby low-volume hospitals, patients with stage I epithelial endometrial cancer who travelled longer distances to high-volume centers experienced more favorable short-term outcomes and care patterns with comparable long-term survival.

Commentary on the Volume-Outcome Relationship in CRS/HIPEC for Peritoneal Carcinomatosis

Background: Peritoneal carcinomatosis historically has a poor prognosis; however, Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) have shown improved outcomes. While a volume-outcome relationship is established in oncologic surgeries, its applicability to CRS/HIPEC remains unexplored. This study examines the impact of hospital volume on CRS/HIPEC outcomes. Methods: Using the national Vizient Clinical Database, this retrospective analysis evaluated 5,165 HIPEC cases from 149 hospitals between January 2020 and December 2022. Hospitals were stratified into tertiles based on procedural volume. Chi-squared analysis and one-way ANOVA assessed the associations between hospital volume and patient demographics, morbidity, mortality, ICU utilization, length of stay, readmission rates, and costs. Results: No significant differences were found in morbidity (low- 9.4% vs. medium- 7.1% vs. high- 9.0%, p = 0.71) or mortality rates across hospital volume tertiles (0.9% vs. 0.6% vs. 0.7%, p = 0.93). Postoperative ICU use was higher in low-volume hospitals, yet this factor did not affect the overall length of stay or costs. Hospitals with Magnet nursing status had lower observed mortality (0.5% vs 1.7%, p = 0.048), but Magnet status did not significantly affect post-operative complications. CMI was similar between low-, medium-, and high-volume hospitals. While Magnet status and CMI were influential, hospital volume alone was not indicative of patient outcomes. Costs remained consistent across all volumes, indicating a trend toward cost-effective care. Conclusion: The anticipated volume-outcome relationship for CRS/HIPEC is not supported by this study's findings. Outcomes were more closely related to institutional quality and case complexity rather than procedural volume. These results suggest a reconsideration of the current emphasis on regionalization, advocating for the expansion of high-quality CRS/HIPEC care beyond high-volume centers, potentially increasing accessibility for patients.

Low-Volume Elective Surgery and Outcomes in Medicare Beneficiaries Treated at Hospital Networks

Minimum volume standards have been advocated as a strategy to improve outcomes for certain surgical procedures. Hospital networks could avoid low-volume surgery by consolidating cases within network hospitals that meet volume standards, thus optimizing outcomes while retaining cases and revenue. The rates of compliance with volume standards among hospital networks and the association of volume standards with outcomes at these hospitals remain unknown. To quantify low-volume surgery and associated outcomes within hospital networks. This cross-sectional study used Medicare Provider Analysis and Review data to examine fee-for-service beneficiaries aged 66 to 99 years who underwent 1 of 10 elective surgical procedures (abdominal aortic aneurysm repair, carotid endarterectomy, mitral valve repair, hip or knee replacement, bariatric surgery, or resection for lung, esophageal, pancreatic, or rectal cancers) in a network hospital from 2016 to 2018. Hospital volume for each procedure (calculated with the use of the National Inpatient Sample) was compared with yearly hospital volume standards for that procedure recommended by The Leapfrog Group. Networks were then categorized into 4 groups according to whether or not that hospital or another hospital in the network met low-volume standards for that procedure. Data were analyzed from February to June 2023. Receipt of surgery in a low-volume hospital within a network. Primary outcomes were postoperative complications, 30-day readmission, and 30-day mortality, stratified by the volume status of the hospital and network type. The secondary outcome was the availability of a different high-volume hospital within the same network or outside the network and its proximity to the patient (based on hospital referral region and zip code). In all, data were analyzed for 950 079 Medicare fee-for-service beneficiaries (mean [SD] age, 74.4 [6.5] years; 621 138 females [59.2%] and 427 931 males [40.8%]) who underwent 1 049 069 procedures at 2469 hospitals within 382 networks. Of these networks, 380 (99.5%) had at least 1 low-volume hospital performing the elective procedure of interest. In 35 137 of 44 011 procedures (79.8%) that were performed at low-volume hospitals, there was a hospital that met volume standards within the same network and hospital referral region located a median (IQR) distance of 29 (12-60) miles from the patient's home. Across hospital networks, there was 43-fold variation in rates of low-volume surgery among the procedures studied (from 1.5% of carotid endarterectomies to 65.0% of esophagectomies). In adjusted analyses, postoperative outcomes were inferior at low-volume hospitals compared with hospitals meeting volume standards, with a 30-day mortality of 8.1% at low-volume hospitals vs 5.5% at hospitals that met volume standards (adjusted odds ratio, 0.67 [95% CI, 0.61-0.73]; P < .001). Findings of this study suggest that most US hospital networks had hospitals performing low-volume surgery that is associated with inferior surgical outcomes despite availability of a different in-network hospital that met volume standards within a median of 29 miles for the vast majority of patients. Strategies are needed to help patients access high-quality care within their networks, including avoidance of elective surgery at low-volume hospitals. Avoidance of low-volume surgery could be considered a process measure that reflects attention to quality within hospital networks.

Outcomes of Guided Personalized Surgery (GPS)-Navigated Reverse Polarity Total Shoulder Joint Replacement in a Low-Volume Hospital.

Introduction Reversepolarity shoulder arthroplasty (RSA) is an evolving surgery, and its indications have expanded over time. Apart from cuff tear arthropathy (CTA), it is recommended for complex proximal humerus fractures in the elderly, inflammatory arthritis, primary osteoarthritis in the elderly, and revision for failed hemiarthroplasty. Glenoid base plate placement and fixation are important to prevent complications, especially glenoid base plate loosening, dislocation, and scapular notching, and to improve longevity. Guided personalized surgery (GPS)-navigated RSA was devised to optimize the glenoid base plate position and fixation. Methodology A retrospective study was carried out in a low-volume district general hospital in England. All the patients who underwent GPS-navigated RSA were included. Their preoperative glenoid version, bone stock, glenoid base plate, and glenoid screw lengths were analysed. Preoperative and post-surgery patient-reported outcomes were gathered using the Oxford Shoulder Score (OSS) at six months and annually thereafter. Results Fourteen patients have undergone GPS-navigated RSA in our institute since 2018. Ten patients were female. All of them had a retroverted glenoid with a mean value of 13.6 degrees. Ten out of 14 patients had an augmented glenoid base plate. This included six eight-degree posterior augmentations, three 10-degree superior augmentations, and one extended cage peg. The follow-up period was six months to five years, depending on the date of surgery, and none of the patients dropped out of follow-up. The OSS revealed statistically significant improvement from preoperative values to six months postoperative, an improvement of 21.64±7.175. It also showed progressive improvement over time during postoperative follow-up, and the three-year mean was 47. The commonest complication was fractures, which happened in four cases. There were no infections or dislocations. Discussion Guided personalized surgery-navigated RSA was performed on selected patients at our institution when they were not suitable for conventional RSA due to distorted glenoid anatomy. Glenoid base plate positioning and fixation are important to optimize the outcome of RSA. Guided personalized surgery navigation is helpful in achieving optimum glenoid base placement, especially when the normal glenoid anatomy is distorted. There were no dislocations, glenoid base plate loosening, or scapular notching in the study group. There were four reported fractures, which was comparable with the published literature.

Hospital Volume and Quality of Care for Emergency Gynecologic Care.

To evaluate the association between hospital volume and the quality of gynecologic emergency care for tubal ectopic pregnancies, ovarian torsion, and pelvic inflammatory disease (PID). In this cross-sectional analysis, we analyzed patients who presented for emergency care for tubal ectopic pregnancies, ovarian torsion, and PID using the Premier Healthcare Database from 2006 to 2020. We measured the following outcomes: methotrexate use for ectopic pregnancy, ovarian cystectomy for torsion, and guideline-based antibiotic use for PID. For each condition, we measured outlier hospitals that performed the above interventions at below the 10th percentile. Multivariable logistic regression models were used to analyze associations between outlier care and hospital factors such as annualized mean case volume, urban or rural location, teaching status, bed capacity, and geographic region, as well as hospital-level patient population factors, including age, insurance status, and race. A total of 602 hospitals treated patients with tubal ectopic pregnancies, of which 21.9% were outliers, with no cases managed with methotrexate. Of 512 hospitals treating patients with ovarian torsion, 17.4% were outliers, with no cases managed with cystectomy. Of 929 hospitals that treated patients with PID, 9.9% were deemed outliers with low rates of guideline-adherent antibiotic administration. Low-volume hospitals were more likely to be outliers with low rates of use of methotrexate for ectopic pregnancy (6.7% of high-volume hospitals vs 49.7% of low-volume hospitals were outliers; adjusted odds ratio [aOR] 0.13, 95% CI, 0.05-0.31 for high-volume hospitals) and cystectomy for torsion (34.9% of low-volume vs 2.4% of high-volume hospitals were outliers; aOR 0.05, 95% CI, 0.01-0.18 for high-volume hospitals). There was no association between hospital volume and lower rates of guideline-based antibiotic use for PID. Higher hospital volume is associated with use of conservative, fertility-preserving treatment of emergency gynecologic conditions, including ectopic pregnancy and ovarian torsion.