Skip to main content
SpringerLink
Log in

Quality Comes with the (Anatomic) Territory: Evaluating the Impact of Surgeon Operative Mix on Patient Outcomes After Pancreaticoduodenectomy

  • Health Services Research and Global Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Recent support for centralization of complex operations, such as pancreaticoduodenectomy (PD), is based on surgeon-specific volume–outcome relationships. This study examined whether volume of anatomically related operations (operative mix), besides PD, is also independently associated with postoperative outcomes after PD.

Methods

The study queried the Nationwide Inpatient Sample (2004–2009) for surgeons performing PD. Operative mix (OM) was defined as the year-specific number of other pancreatic, hepatic, biliary, and gastric operations performed by individual surgeons. Regression models included surgeon and hospital PD volume, adjusted for other hospital- and patient-specific factors.

Results

Among 1747 surgeons, 88.3% had low PD volume (≤ 5 cases/year), 8.9% had moderate PD volume (6–16 cases/year), and 2.8% had high PD volume (≥ 17 cases/year). Low-PD-volume surgeons with high OM (≥ 21 cases/year) (4.4%), moderate-PD-volume surgeons with high OM (3.4%), and high-PD-volume surgeons with high OM (2.7%) each had lower mortality than low-PD-volume surgeons with low OM (9.3%; all p ≤ 0.02). The frequency of prolonged hospitalization among low-PD/high-OM surgeons (45.3%) was lower than among low-PD/low-OM surgeons (61.6%; p < 0.001). Increasing OM volume was associated with decreased inpatient mortality, shorter hospital stay, and lower likelihood of any postoperative complication, using unadjusted regression (all p < 0.001). Adjusted regression results indicated that increasing OM volume is a significant predictor of decreased odds of a prolonged hospital stay (odds ratio [OR] 0.81; 95% confidence interval [CI] 0.73–0.90; p < 0.001).

Conclusions

Surgeon PD volume is an important predictor of outcomes after PD. However, surgeon OM volume identifies a subset of lower-PD-volume surgeons with more favorable outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. NEJM. 2002;346:1128–37.

    Article  Google Scholar 

  2. Finlayson EV, Goodney PP, Birkmeyer JD. Hospital volume and operative mortality in cancer surgery: a national study. Arch Surg. 2003;138:721–25.

    Article  Google Scholar 

  3. Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA, Stanley JC, Upchurch GR. Variation in postoperative complication rates after high-risk surgery in the United States. Surgery. 2003;134:534–41.

    Article  Google Scholar 

  4. Reames BN, Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and operative mortality in the modern era. Ann Surg. 2014;260:244–51.

    Article  Google Scholar 

  5. Fong Y, Gonen M, Rubin D, Radzyner M, Brennan MF. Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg. 2005;242:540–4.

    PubMed  PubMed Central  Google Scholar 

  6. Hata T, Motoi F, Ishida M, Naitoh T, Katayose Y, Egawa S, et al. Effect of hospital volume on surgical outcomes after pancreaticoduodenectomy: a systematic review and meta-analysis. Ann Surg. 2016;263:664–72.

    Article  Google Scholar 

  7. Boudourakis LD, Wang TS, Roman SA, Desai R, Sosa JA. Evolution of the surgeon-volume, patient-outcome relationship. Ann Surg. 2009;250:159–65.

    Article  Google Scholar 

  8. Burwell SM. Setting value-based payment goals: HHS efforts to improve US health care. N Engl J Med. 2015;372:897–9.

    Article  CAS  Google Scholar 

  9. Schneider EB, Hyder O, Wolfgang CL, Dodson RM, Haider AH, Herman JM, et al. Provider versus patient factors impacting hospital length of stay after pancreaticoduodenectomy. Surgery. 2013;154:152–61.

    Article  Google Scholar 

  10. Birkmeyer JD, Finlayson SR, Tosteson AN, Sharp SM, Warshaw AL, Fisher ES. Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery. 1999;125:250–6.

    Article  CAS  Google Scholar 

  11. Birkmeyer JD. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349:2117–27.

    Article  CAS  Google Scholar 

  12. Enomoto LM, Gusani NJ, Dillon PW, Hollenbeak CS. Impact of surgeon and hospital volume on mortality, length of stay, and cost of pancreaticoduodenectomy. J Gastrointest Surg. 2014;18:690–700.

    Article  Google Scholar 

  13. Toomey PG, Teta AF, Patel KD, Ross SB, Rosemurgy AS. High-volume surgeons vs high-volume hospitals: are best outcomes more due to who or where? Am J Surg. 2016:211:59–63.

    Article  Google Scholar 

  14. Al-Refaie WB, Muluneh B, Zhong W, Parsons HM, Tuttle TM, Vickers SM, et al. Who receives their complex cancer surgery at low-volume hospitals? J Am Coll Surg. 2012;214:81–7.

    Article  Google Scholar 

  15. Chang DC, Zhang Y, Mukherjee D, Wolfgang CL, Schulick RD, Cameron JL, et al. Variations in referral patterns to high-volume centers for pancreatic cancer. J Am Coll Surg. 2009;109:720–26.

    Article  Google Scholar 

  16. Riall TS, Eschbach KA, Townsend C, Goodwin JS. Trends and disparities in regionalization of pancreatic resection. J Gastrointest Surg. 2007;11:1242–52.

    Article  Google Scholar 

  17. Epstein AJ, Gray BH, Schlesinger M. Racial and ethnic differences in the use of high-volume hospitals and surgeons. Arch Surg. 2010;145:179–86.

    Article  Google Scholar 

  18. Liu JH, Zingmond DS, McGory ML, SooHoo NF, Ettner SL, Brook RH, et al. Disparities in the utilization of high-volume hospitals for complex surgery. JAMA. 2006;296:1973–80.

    Article  CAS  Google Scholar 

  19. Massarweh NN, Flum DR, Symons RG, Varghese TK, Pellegrini CA. A critical evaluation of the impact of Leapfrog’s evidence-based hospital referral. J Am Coll Surg. 2011; 212:150–59.

    Article  Google Scholar 

  20. Sachs TE, Ejaz A, Weiss M, Spolverato G, Ahuja N, Makary MA, et al. Assessing the experience in complex hepatopancreatobiliary surgery among graduating chief residents: is the operative experience enough? Surgery. 2014;156:385–93.

    Article  Google Scholar 

  21. Sachs TE, Pawlik TM. See one, do one, and teach none: resident experience as a teaching assistant. J Surg Res. 2015;195:44–51.

    Article  Google Scholar 

  22. Bellal J, Morton JM, Hernandez-Boussard T, Rubinfeld I, Faraj C, Velanovich V. Relationship between hospital volume, system clinical resources, and mortality in pancreatic resection. J Am Coll Surg. 2009;208:520–7.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Boston University School of Medicine, Boston, MA, USA

    Krista Hachey MD, MPH, Ryan Morgan BS, Amy Rosen PhD, Sowmya R. Rao PhD, David McAneny MD, Jennifer Tseng MD, MPH, Gerard Doherty MD & Teviah Sachs MD, MPH

  2. Division of Surgical Oncology, Boston Medical Center, Boston, MA, USA

    David McAneny MD, Jennifer Tseng MD, MPH, Gerard Doherty MD & Teviah Sachs MD, MPH

Authors
  1. Krista Hachey MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ryan Morgan BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Amy Rosen PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sowmya R. Rao PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. David McAneny MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jennifer Tseng MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Gerard Doherty MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Teviah Sachs MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Teviah Sachs MD, MPH.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 29 kb)

Appendix 1: ICD-9 Codes for Operative Mix Operations

Appendix 1: ICD-9 Codes for Operative Mix Operations

Other pancreatic operations, exclusive of pancreaticoduodenectomy (PD), included 52.6, 52.51, 52.59, 52.52, 52.53, and 52.5. The ICD-9 codes for bile duct operations included 51.79, 51.39, 51.14, 51.36, 51.39, 51.41, 51.42, 51.43, 51.49, 51.51, 51.59, 51.61, 51.62, 51.63, 51.69, 51.71, 51.72, 51.79, 51.81, 51.82, 51.92, 51.93, and 51.94. The ICD-9 codes for hepatic operations included 50.0, 50.22, 50.29, 50.3, and 50.4. The ICD-9 codes for gastric operations included 43.9, 43.91, 43.99, 43.5, 43.6, 43.7, and 43.8.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hachey, K., Morgan, R., Rosen, A. et al. Quality Comes with the (Anatomic) Territory: Evaluating the Impact of Surgeon Operative Mix on Patient Outcomes After Pancreaticoduodenectomy. Ann Surg Oncol 25, 3795–3803 (2018). https://doi.org/10.1245/s10434-018-6732-y

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-018-6732-y

Keywords

Search

Navigation