Volume-outcome Relationship Research Articles

Volume-outcome relationship in intra-abdominal robotic-assisted surgery: a systematic review.

As robotic-assisted surgery (RAS) expands to smaller centres, platforms are shared between specialities. Healthcare providers must consider case volume and mix required to maintain quality and cost-effectiveness. This can be informed, in-part, by the volume-outcome relationship. We perform a systematic review to describe the volume-outcome relationship in intra-abdominal robotic-assisted surgery to report on suggested minimum volumes standards. A literature search of Medline, NICE Evidence Search, Health Technology Assessment Database and Cochrane Library using the terms: "robot*", "surgery", "volume" and "outcome" was performed. The included procedures were gynecological: hysterectomy, urological: partial and radical nephrectomy, cystectomy, prostatectomy, and general surgical: colectomy, esophagectomy. Hospital and surgeon volume measures and all reported outcomes were analysed. 41 studies, including 983,149 procedures, met the inclusion criteria. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale and the retrieved data was synthesised in a narrative review.Significant volume-outcome relationships were described in relation to key outcome measures, including operative time, complications, positive margins, lymph node yield and cost. Annual surgeon and hospital volume thresholds were described. We concluded thatin centres with an annual volume of fewer than 10 cases of a given procedure, having multiple surgeons performing these procedures led to worse outcomes and, therefore, opportunities should be sought to perform other complimentary robotic procedures or undertake joint cases.

Hospital intervention volume affects outcomes of emergency transcatheter aortic valve implantations in Germany

The literature has shown an inverse volume-outcome relationship for transcatheter aortic valve implantation (TAVI). However, little is known about emergency admissions in Germany. Using German national electronic health records, we identified all isolated balloon-expandable and self-expanding transfemoral TAVI in 2018. The focus was on those patients with emergency admission. 17,295 patients were treated with TAVI, including 1682 emergency cases. 49.2% of the emergency admissions were female, the mean age was 81.2 years and the logistic EuroSCORE was 23.3%. The percentage of emergency cases was higher in lower volume than in higher volume centers (p < 0.001): In detail, centers performing < 50 TAVI showed an emergency admission rate of ~ 15%, those with > 200 TAVI a rate of ~ 11%. After propensity score adjustment, analyzing the outcomes for an increase in volume per 10 emergency admissions, higher volume centers showed significantly better outcomes regarding in-hospital mortality (OR = 0.872, p = 0.043), major bleeding (OR = 0.772, p = 0.001), stroke (OR = 0.816, p = 0.044), mechanical ventilation > 48 h (OR = 0.749, p = 0.001), length of hospital stay (risk adjusted difference in days of hospitalization per 10 emergency admissions: − 1.01 days, p < 0.001), and reimbursement (risk adjusted difference in reimbursement per 10 emergency admissions: -€314.89, p < 0.001). Results were not significant for acute kidney injury (OR = 0.951, p = 0.104), postoperative delirium (OR = 0.975, p = 0.480), and permanent pacemaker implantation (OR = 1.010, p = 0.732). In conclusion, regarding transfemoral TAVI, the percentage of emergency cases was higher in lower volume centers in Germany. However, higher volume centers show significantly better outcomes for in-hospital mortality and complication rates as well as resource utilization parameters.

Volume-outcome relationship in emergency transcatheter aortic valve implantations in Germany

Abstract Background An inverse volume-outcome relationship in transcatheter aortic valve implantation (TAVI) has been demonstrated in the literature but little is known about emergency cases. Methods All isolated balloon-expandable and self-expanding transfemoral TAVI in 2018 were identified using German national electronic health records. Additionally, those patients with an emergency admission were selected. Results A total of 17,295 patients received TAVI, 1,682 of these cases had an emergency admission. Of the emergency cases, 49.2% were female, mean age was 81.2 years and logistic EuroSCORE was 23.3%. Relatively more emergency cases were treated in lower volume centers than in higher volume centers (p&amp;lt;0.001): Centers performing &amp;lt;50 TAVI had an emergency admission rate of ∼15% while centers performing &amp;gt;200 TAVI were associated with a rate of ∼11%. Analyzing the outcomes for a volume increase per 10 emergency cases using propensity score adjustment, higher volume centers showed significantly better results than lower volume centers for in-hospital mortality (OR=0.872, p=0.043), major bleeding (OR=0.772, p=0.001), stroke (OR=0.816, p=0.044), mechanical ventilation &amp;gt;48h (OR=0.749, p=0.001), length of hospital stay (risk adjusted difference in days of hospitalization per 10 emergency admissions: −1.01 days, p&amp;lt;0.001), and reimbursement (risk adjusted difference in reimbursement per 10 emergency admissions: −€314.89, p&amp;lt;0.001). No correlation was seen in acute kidney injury (OR=0.951, p=0.104), postoperative delirium (OR=0.975, p=0.480), and permanent pacemaker implantation (OR=1.010, p=0.732). Conclusion In transfemoral TAVI, lower volume centers treat relatively more emergency cases in Germany, but higher volume centers provide significantly better outcomes regarding in-hospital mortality and complication rates as well as resource utilization parameters. Funding Acknowledgement Type of funding sources: None.

Disparities in overall survival (OS) outcomes based on treating facility volume in pancreatic neuroendocrine tumors.

150 Background: Pancreatic neuroendocrine tumors (pNETs) comprise less than 5% of all pancreatic tumors and 7% of all neuroendocrine tumors (NETs). There has been considerable progress in understanding the biology of pNETs and numerous therapeutic options emerged, especially with the collaboration of various specialties in the multidisciplinary setting. In this this study, we sought to analyze the association of facility volume, treatment modalities offered, and different risk adjusted outcomes in pNETs. Methods: We extracted data from National Cancer Data Base (NCDB) that covers 70% of all newly diagnosed cancer cases in the U.S and Puerto Rico. Patients with pNETs diagnosed between 2004 &amp; 2017 were included and classified into tertiles based on hospital volume. Volume–outcome relationship was determined by using Cox regression adjusting for patient demographics, comorbidities, tumor characteristics, insurance type and therapy received. Kaplan Meier estimates of OS were compared with log-rank test. The primary predictor of interest was the facility volume defined as number of pNETs treated/year. A total of 7202 patients with pathologically confirmed pNETS were treated at 840 facilities. The median annual facility volume was 5patients/year. Facilities were classified into (T:mean cases/year) T1: &lt; 3; T2:4-8; T3:≥9 cases/year. Results: A total of 7202 pNET patients were treated at 840 facilities. The median annual facility volume was 5 patients/year. Facilities were classified into (T: mean cases/year) T1:&lt;3; T2:4-8; T3:≥9 cases/year. The unadjusted median OS by facility volume was: T1: 71 months (m), T2: 136 m, and T3: not-reached (p &lt; 0.001). On multivariable analysis, compared with patients treated at T3 facilities, patients treated at lower-tertile facilities had higher risk of death [T2 hazard ratio (HR), 1.17 (95% CI, 1.03-1.33); T1 HR, 1.45 (CI, 1.30-1.67), p &lt; 0.0001] and such a difference in OS was more pronounced in stage IV disease (Table). Patients at T3 facilities (vs T1) were more likely to receive surgical resection of the primary tumor (75 vs 49%), lymph node dissection performed at the time of surgery (70 vs 42%), and a better R0 resection (72 vs 46%) (p &lt; 0.01). Conclusions: Patients who were treated for pNETs at high-volume centers (&gt; 9cases/year) had significantly higher OS and were more likely to receive surgical resection along with lymph node dissection and R0 resection. There was a 45% increased risk of death in patients treated at low volume centers (&lt; 3/year) as compared to high-volume centers (&gt; 9/year). While OS difference was noticed in all stages, the difference was more pronounced in stage IV disease demonstrating the importance of multi-disciplinary approach in pNETs management and incorporating such quality measures in low-volume facilities.[Table: see text]

Association between operator volume and mortality in primary percutaneous coronary intervention

BackgroundThere is a paucity of real-world data assessing the association of operator volumes and mortality specific to primary percutaneous coronary intervention (PPCI).MethodsDemographic, clinical and outcome data for all patients undergoing...

477. TEXTBOOK OUTCOMES FOR OESOPHAGECTOMY: AN EVALUATION OF OESOPHAGECTOMY QUALITY PERFORMANCE INDICATORS AT A SINGLE HIGH-VOLUME AUSTRALIAN OESOPHAGOGASTRIC CENTRE

Abstract In 2017 the Dutch Upper-Gastrointestinal Audit Group (DUCA) proposed a ten-item composite measure for a “textbook outcome” after oesophagogastric resection. Utilising this composite measure, studies have shown associations between textbook outcomes and better conditional and overall survival. The aim of our study was to evaluate the applicability of this measure in the setting of an Australian oesophagogastric centre and to ascertain whether textbook outcome was associated with improved survival. Data were obtained by retrospective analysis of a prospectively maintained database of oesophagogastric malignancies at a single oesophagogastric unit from 2013 to 2018. We used the DUCA group definition of textbook outcomes, encompassing resection radicality, resection margins, lymph node clearance, intra- and post-operative complications, length of stay, hospital and intensive care unit re-admissions, and post-operative mortality. Multivariable logistic regression analysis was conducted to assess association between patient factors and textbook outcome. Cox regression analysis was used to assess association between textbook outcome and survival. Post-operative complications were analysed in two separate groups (Clavien-Dindo ≥2 and Clavien-Dindo ≥3). A total of 246 patients were analysed, with 50.8% achieving a textbook outcome when complications were defined as Clavien-Dindo ≥2 and 58.9% when using Clavien-Dindo ≥3. Patients with age &amp;lt;75 or a respiratory co-morbidity were less likely to achieve a textbook outcome. The 30-, 90-day and 1-year mortality rates were 1.6%, 2.4% and 15% respectively. There was no difference in survival between those who did versus those who did not have a textbook outcome when complications were defined as Clavien-Dindo ≥2. There was improved overall survival if complications were defined as Clavien-Dindo ≥3 (HR0.58, p=0.015). Textbook outcome is a new multi-parameter metric that aims to better capture the quality of oesophageal cancer surgery compared to traditional volume-outcome relationships. We have demonstrated that it is applicable in our population, with the percentage of patients having a textbook outcome comparing favourably with published data. In our series, a textbook outcome was associated with improved overall survival when defining complications as Clavien-Dindo ≥3.

Association between physician's case volume in prehospital advanced trauma care and 30-day mortality: A registry-based analysis of 4,032 patients.

Seriously injured patients may benefit from prehospital interventions provided by a critical care physician. The relationship between case volume and outcome has been established in trauma teams in hospitals, as well as in prehospital advanced airway management. In this study, we aimed to assess if a volume-outcome relationship exists in prehospital advanced trauma care. We performed a retrospective cohort study using the national helicopter emergency medical services database, including trauma patients escorted from scene to hospital by a helicopter emergency medical services physician during January 1, 2013, to August 31, 2019. In addition, similar cases during 2012 were used to determine case volumes. We performed a multivariate logistic regression analysis, with 30-day mortality as the outcome. Age, sex, Glasgow Coma Scale, shock index, mechanism of injury, time interval from alarm to the patient and duration of transport, level of receiving hospital, and physician's trauma case volume were used as covariates. On-scene times, interventions performed, and status at hospital arrival were assessed in patients who were grouped according to physician's case volume. In total, 4,032 escorted trauma patients were included in the study. The median age was 40.2 (22.9-59.3) years, and 3,032 (75.2%) were male. Within 30 days, 498 (13.2%) of these patients had died. In the highest case volume group, advanced interventions were performed more often, and patients were less often hypotensive at handover. Data for multivariate analysis were available for 3,167 (78.5%) of the patients. Higher case volume was independently associated with lower mortality (odds ratio, 0.59; 95% confidence interval, 0.38-0.89). When a prehospital physician's case volume is higher in high-risk prehospital trauma, this seems to be associated with more active practice patterns and significantly lower 30-day mortality. The quality of prehospital critical care could be increased by ensuring sufficient case volume for the providers of such care. Prognostic and Epidemiologic; Level III.

Hospital Surgical Volume Is Poorly Correlated With Delivery of Multimodal Treatment for Localized Pancreatic Cancer: A National Retrospective Cohort Study.

Objectives:Using Donabedian’s quality of care model, this study assessed process (hospital multimodal treatment) and structure (hospital surgical case volume) measures to evaluate localized pancreatic cancer outcomes.Background:Treatment at high surgical volume hospitals has been shown to improve short-term outcomes. However, multimodal treatment—surgery and chemotherapy—is the standard of care yet only received by 35% of US patients and has not been examined at the hospital level.Methods:The National Cancer Database was used to identify a cohort of clinical stage I pancreatic cancer patients eligible for multimodal treatment from 2004 to 2016. Hospital multimodal treatment was defined as the number of patients receiving surgery and chemotherapy by the number of eligible patients per hospital. Descriptive statistics and survival analyses were conducted.Results:A total of 16,771 patients met inclusion criteria, of whom 68.0% received curative-intent surgery and 35.8% received multimodal treatment. There was poor correlation between hospital surgical volume and delivery of multimodal treatment (Spearman correlation 0.214; P < 0.001). Of patients cared for at the highest surgical volume hospitals, 18.8% and 52.1% were treated at hospitals with low (0%–25%) and moderate (>25%–50%) multimodal treatment delivery, respectively. Higher hospital multimodal treatment delivery was associated with improved overall survival.Discussion:Although the volume–outcome relationship for pancreatic cancer has demonstrated improved outcomes, this work identified poor correlation between hospital surgical volume and delivery of multimodal treatment. The role of care coordination in the delivery of multimodal treatment warrants further investigation as it is associated with improved survival for patients with localized pancreatic cancer.

Do older surgeons have safer hands? A retrospective cohort study

BackgroundFor complex surgical procedures a volume-outcome relationship can often be demonstrated implicating multiple factors at a unit and surgeon specific level. This study aims to investigate this phenomenon in lung transplantation over a 30-year period with particular reference to surgeon age and experience, cumulative unit activity and time/day of transplant.MethodsProspective databases identified adult patients undergoing isolated lung transplantation at a single UK centre between June 1987 and October 2017. Mortality data was acquired from NHS Spine. Individual surgeon demographics were obtained from the General Medical Council. Student t-test, Pearson’s Chi-squared, Logistic Regression, and Kaplan–Meier Survival analyses were performed using Analyse-it package for MicrosoftExcel and STATA/IC.Results954 transplants (55.9% male, age 44.4 ± 13.8 years, 67.9% bilateral lung) were performed, with a median survival to follow-up of 4.37 years. There was no difference in survival by recipient gender (p = 0.661), between individual surgeons (p = 0.224), or between weekday/weekend procedures (p = 0.327).Increasing centre experience with lung transplantation (OR1.001, 95%CI: 1.000–1.001, p = 0.03) and successive calendar years (OR1.028, 95%CI: 1.005–1.052, p = 0.017) was associated with improved 5-year survival.Advancing surgeon age at the time of transplant (mean, 48.8 ± 6.6 years) was associated with improved 30-day survival (OR1.062, 95%CI: 1.019 to1.106, p = 0.003), which persisted 5 years post-transplant (OR1.043, 95%CI: 1.014–1.073, p = 0.003).Individual surgeon experience, measured by the number of previous lung transplants performed, showed a trend towards improved outcomes at 30 days (p = 0.0413) with no difference in 5-year survival (p = 0.192).ConclusionsOur study demonstrates a relationship between unit volume, increasing surgeon age and survival after lung transplantation. A transplant volume: outcome relationship was not seen for individual surgeons.

Institutional case volume and mortality after aortic and mitral valve replacement: a nationwide study in two Korean cohorts

BackgroundThere are only a handful of published studies regarding the volume-outcome relationship in heart valve surgery. We evaluated the association between institutional case volume and mortality after aortic valve replacement (AVR) and mitral valve replacement (MVR).MethodsTwo separate cohorts of all adults who underwent AVR or MVR, respectively, between 2009 and 2016 were analyzed using a Korean healthcare insurance database. Hospitals performing AVRs were divided into three groups according to the average annual case volume: the low- (< 20 cases/year), medium- (20–70 cases/year), and high-volume centers (> 70 cases/year). Hospitals performing MVRs were also grouped as the low- (< 15 cases/year), medium- (15–40 cases/year), or high-volume centers (> 40 cases/year). In-hospital mortality after AVR or MVR were compared among the groups.ResultsIn total, 7875 AVR and 5084 MVR cases were analyzed. In-hospital mortality after AVR was 8.3% (192/2318), 4.0% (84/2102), and 2.6% (90/3455) in the low-, medium-, and high-volume centers, respectively. The adjusted risk was higher in the low- (OR 2.31, 95% CI 1.73–3.09) and medium-volume centers (OR 1.53, 95% CI 1.09–2.15) compared to the high-volume centers. In-hospital mortality after MVR was 9.3% (155/1663), 6.3% (94/1501), and 2.9% (56/1920) in the low-, medium-, and high-volume centers, respectively. Compared to the high-volume centers, the medium- (OR 1.97, 95% CI 1.35–2.88) and low-volume centers (OR 2.29, 95% CI 1.60–3.27) showed higher adjusted risk of in-hospital mortality.ConclusionsLower case volume is associated with increased in-hospital mortality after AVR and MVR. The results warrant a comprehensive discussion regarding regionalization/centralization of cardiac valve replacements to optimize patient outcomes.

SP9.1.2 Investigating the association between trust case volume and perioperative outcomes in colorectal cancer surgery

Abstract Background Whilst current colorectal cancer care pathways operate by referral to local hospitals, there has been a recent drive to centralise cancer services to improve patient outcomes. Centralisation will inevitably increase trust case volume and the existing literature is inconclusive regarding a possible volume-outcome association. This study aims to investigate the association between case volume and unplanned readmission or unplanned return to theatre (URTT) rates in patients undergoing colorectal surgery across England and Wales. Methods A retrospective analysis was conducted of 14028 patients across 135 trusts using the 2020 NBOCA dataset. Primary outcome measures were 30-day unplanned readmission and 30-day URTT rates. Trusts were dichotomised into low or high-volume sites. Statistical analysis used Spearman's ρ correlation, Mann-Whitney U and Student T-test. Results 11.2% (2.30–24.5) and 8.31% (0.00–23.3) of 14028 patients underwent an unplanned readmission and URTT respectively. There was no significant correlation between the number of cases and 30-day unplanned readmission (r=0.0628, 95%CI: -0.112–0.234, p=0.469), with no significant difference between low and high-volume trusts (p=0.432). Similarly, no significant correlation was found between the number of cases and 30-day URTT rate (r=-0.0848, 95%CI: -0.255–0.0904, p=0.328), with no significant difference between low and high-volume trusts (p=0.285). Conclusions No association was discovered between volume and unplanned readmission or URTT in this cohort. Increasing volume among trusts who demonstrate favourable outcomes, rather than indiscriminately increasing volume may be beneficial. This study increases our understanding of volume-outcome relationships, however further prospective studies at a national level into other outcomes should be conducted to rule out centralisation.

Impact of Procedure Volume on the Outcomes of Surgical Aortic Valve Replacement.

Literature demonstrated that procedure volumes affect outcomes of patients undergoing transcatheter aortic valve implantation. We evaluated the outcomes of surgical aortic valve replacement. All isolated surgical aortic valve replacement procedures in Germany in 2017 were identified. Hospitals were divided into five groups from ≤25 (very low volume) until >100 (very high volume) annual procedures. In 2017, 5,533 patients underwent isolated surgical aortic valve replacement. All groups were of comparable risk (logistic EuroSCORE, 5.12-4.80%) and age (66.6-68.1 years). In-hospital mortality and complication rates were lowest in the very high-volume group. Multivariable logistic regression analyses showed no significant volume-outcome relationship for in-hospital mortality, stroke, postoperative delirium, and mechanical ventilation > 48 hours. Regarding acute kidney injury, patients in the very high-volume group were at lower risk than those in the very low volume group (odds ratio [OR] = 0.53, p = 0.04). Risk factors for in-hospital mortality were previous cardiac surgery (OR = 5.75, p < 0.001), high-grade renal disease (glomerular filtration rate < 15 mL/min, OR = 5.61, p = 0.002), surgery in emergency cases (OR = 2.71, p = 0.002), and higher grade heart failure (NYHA [New York Heart Association] III/IV; OR = 1.80, p = 0.02). Risk factors for all four complication rates were atrial fibrillation and diabetes mellitus. Patients treated in very low volume centers (≤25 operations/year) had a similar risk regarding in-hospital mortality and most complications compared with very high-volume centers (>100 operations/year). Only in the case of acute kidney injury, very high-volume centers showed better outcomes than very low volume centers. Therefore, surgical aortic valve replacement can be performed safely independent of case volume.

Providing high-quality open aortic surgical care in the endovascular era

Several articles have sought to investigate the volume-outcome relationship for open abdominal aortic aneurysm (AAA) repair; however, in their study Scali et al1 are the first to use the failure to rescue (FTR) metric, which encompasses system-based competencies. This study found that centers performing more than 10 open AAA repairs per year had a reduced risk of FTR, which is in line with the current Society for Vascular Surgery (SVS) AAA guideline recommendation that centers should perform at least 10 open AAA repairs per year with perioperative mortality of less than 5%.

Volume-Outcome Relationship in Surgical and Cardiac Transcatheter Interventions with a Focus on Transcatheter Aortic Valve Implantation.

“Practice makes perfect” is an old saying that can be true for complex interventions. There is a strong and persistent relationship between high volume and better outcomes with more than 300 studies being reported on the subject. The more complex the procedure, the greater the volume-outcome relationship is. Failure to rescue was shown to be one of the factors explaining higher mortality rates post complex surgery. High-volume centers provide a better safety net, thanks to the structure and better protocols, and low-volume operators have better results at high-volume centers than at low-volume centers. Finally, effort should be made to regroup complex procedures in high-volume centers, but without compromising patient access to the procedures. Adaptation to local and geographic constraints is important.

Association of annual hospital septic shock case volume and hospital mortality

BackgroundThe burden of sepsis remains high in China. The relationship between case volume and hospital mortality among patients with septic shock, the most severe complication of sepsis, is unknown in China.MethodsIn this retrospective cohort study, we analyzed surveillance data from a national quality improvement program in intensive care units (ICUs) in China in 2020. Association between septic shock case volume and hospital mortality was analyzed using multivariate linear regression and restricted cubic splines.ResultsWe enrolled a total of 134,046 septic shock cases in ICUs from 1902 hospitals in China during 2020. In this septic shock cohort, the median septic shock volume per hospital was 33 cases (interquartile range 14–76 cases), 41.4% were female, and more than half of the patients were over 61 years old, with average hospital mortality of 21.2%. An increase in case volume was associated with improved survival among septic shock cases. In the linear regression model, the highest quartile of septic shock volume was associated with lower hospital mortality compared with the lowest quartile (β − 0.86; 95% CI − 0.98, − 0.74; p < 0.001). Similar differences were found in hospitals of respective geographic locations and hospital levels. With case volume modeled as a continuous variable in a restricted cubic spline, a lower volume threshold of 40 cases before which a substantial reduction of the hospital mortality rate was observed.ConclusionsThe findings suggest that hospitals with higher septic shock case volume have lower hospital mortality in China. Further research is needed to explain the mechanism of this volume–outcome relationship.

Use of Radial Artery Grafts for Coronary Artery Bypass Grafting.

Coronary artery bypass grafting (CABG) is the primary surgical treatment for coronary artery disease (CAD). However, long-term clinical practice has confirmed the poor long-term patency of saphenous vein grafts (SVG), prompting surgeons to investigate alternatives, such as the use of radial artery (RA) grafts. In this report, we review and discuss the current status of radial artery application during CABG and current controversies in the field. Ultimately, evidence indicates that RA-CABG is associated with good long-term patency and is suitable for patients with severe stenosis. However, the compensatory capacity of the ulnar artery should be assessed prior to RA harvesting. Given that the RA is prone to spasms, routine application of calcium channel blockers is recommended. Several studies also have indicated that sequential grafting is an effective method for maximizing radial artery application and that patency rates are similar for the radial artery and right internal mammary artery. In contrast, the use of the bilateral internal mammary arteries is technically more demanding and exhibits a significant volume-outcome relationship. The decision to use the right internal mammary artery or radial artery should be based on individual patient characteristics and the experience of the surgical team.

Surgeon Volume and Laryngectomy Outcomes.

To examine the relationship between surgeon volume and operative morbidity and mortality for laryngectomy. The Nationwide Inpatient Sample was used to identify 45,156 patients who underwent laryngectomy procedures for laryngeal or hypopharyngeal cancer between 2001 and 2011. Hospital and surgeon laryngectomy volume were modeled as categorical variables. Relationships between hospital and surgeon volume and mortality, surgical complications, and acute medical complications were examined using multivariable regression. Higher-volume surgeons were more likely to operate at large, teaching, nonprofit hospitals and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, admitted electively, and to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Surgeons treating more than 5 cases per year were associated with lower odds of medical and surgical complications, with a greater reduction in the odds of complications with increasing surgical volume. Surgeons in the top volume quintile (>9 cases/year) were associated with a decreased odds of in-hospital mortality (OR=0.09 [0.01-0.74]), postoperative surgical complications (OR=0.58 [0.45-0.74]), and acute medical complications (OR=0.49 [0.37-0.64]). Surgeon volume accounted for 95% of the effect of hospital volume on mortality and 16%-47% of the effect of hospital volume on postoperative morbidity. There is a strong volume-outcome relationship for laryngectomy, with reduced mortality and morbidity associated with higher surgeon and higher hospital volumes. Observed associations between hospital volume and operative morbidity and mortality are mediated by surgeon volume, suggesting that surgeon volume is an important component of the favorable outcomes of high-volume hospital care. Laryngoscope, 133:834-840, 2023.

Volume and Outcomes of Joint Arthroplasty

BackgroundJoint arthroplasties are among the most commonly performed elective surgeries in the United States. Surgical outcomes are known to improve with volume but it is unclear whether this has led to consolidation among elective surgeries. We examined trends in volumes per surgeon and hospital to assess whether the known volume-outcome relationship has led to consolidation in elective joint arthroplasty and to determine if there exist volume thresholds above which outcomes do not change. MethodsAmong Medicare beneficiaries who underwent either total knee or total hip arthroplasty from 2009 through 2015, we described volume trends and used mixed-effect models to relate annual surgeon and hospital volumes with 30-day complications or mortality. We tested for optimal volume cut points at both the hospital and surgeon level. ResultsAdjusted annual complication rates were inversely associated with volume for both procedures at both the surgeon level and hospital level, but there was minimal consolidation between 2009 and 2015. Complications no longer declined after volumes of each case exceeded 260 per year. The vast majority of cases (around 93% of hip and 88% of knee arthroplasties) were performed by surgeons operating at suboptimal volumes. ConclusionMore than 2 decades after the volume-outcome relationship was established for joint arthroplasty, many cases continue to be performed by low-volume surgeons, with far more cases performed by surgeons operating at suboptimal volumes. Further improvement could be expected through consolidation at both the hospital and surgeon level, with a target of at least 260 cases per surgeon annually for each operation. Payers seem best-equipped to drive consolidation.

Short-term mortality of patients ≥80 years old admitted to European intensive care units: an international observational study

BackgroundLimited evidence suggests variation in mortality of older critically ill adults across Europe. We aimed to investigate regional differences in mortality among very old ICU patients. MethodsMultilevel analysis of two international prospective cohort studies. We included patients ≥80 yr old from 322 ICUs located in 16 European countries. The primary outcome was mortality within 30 days from admission to the ICU. Results are presented as n (%) with 95% confidence intervals and odds ratios (ORs). ResultsOf 8457 patients, 2944 (36.9% [35.9–38.0%]) died within 30 days. Crude mortality rates varied widely between participating countries (from 10.1% [6.4–15.6%] to 45.1% [41.1–49.2%] in the ICU and from 21.3% [16.3–28.9%] to 55.3% [51.1–59.5%] within 30 days). After adjustment for confounding variables, the variation in 30-day mortality between countries was substantially smaller than between ICUs (median OR 1.14 vs 1.58). Healthcare expenditure per capita (OR=0.84 per $1000 [0.75–0.94]) and social health insurance framework (OR=1.43 [1.01–2.01]) were associated with ICU mortality, but the direction and magnitude of these relationships was uncertain in 30-day follow-up. Volume of admissions was associated with lower mortality both in the ICU (OR=0.81 per 1000 annual ICU admissions [0.71–0.94]) and in 30-day follow-up (OR=0.86 [0.76–0.97]). ConclusionThe apparent variation in short-term mortality rates of older adults hospitalised in ICUs across Europe can be largely attributed to differences in the clinical profile of patients admitted. The volume–outcome relationship identified in this population requires further investigation.

Volume-outcome relationships in laryngeal trauma processes of care: a retrospective cohort study.

The extent to which patients with laryngeal trauma undergo investigation and intervention is largely unknown. The objective of this study was to therefore determine the association between hospital volume and processes of care in patients sustaining laryngeal trauma. This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database. Adult patients (≥ 18) who sustained traumatic laryngeal injuries between 2012 and 2016 were eligible. The exposure of interest was average annual laryngeal trauma volume categorized into quartiles. The primary and secondary outcomes of interest were the performances of diagnostic and therapeutic laryngeal procedures respectively. Multivariable logistic regression under a generalized estimating equations approach was utilized. In total, 1164 patients were included. The average number of laryngeal trauma cases per hospital ranged from 0.2 to 7.2 per year. Diagnostic procedures were performed in 31% of patients and therapeutic in 19%. In patients with severe laryngeal injuries, diagnostic procedures were performed on a higher proportion of patients at high volume centers than low volume centers (46% vs 25%). In adjusted analysis, volume was not associated with the performance of diagnostic procedures. Patients treated at centers in the second (OR 1.94 [95% CI 1.29-2.90]) and third (OR 1.67 [95% CI 1.08-2.57]) volume quartiles had higher odds of undergoing a therapeutic procedure compared to the lowest volume quartile. Hospital volume may be associated with processes of care in laryngeal trauma. Additional research is required to investigate how these findings relate to patient and health system outcomes.