Daniel J Kagedan1, Nik Goyert2, Qing Li3, Lawrence Paszat2,3,4, Alexander Kiss2,3,5, Craig C Earle2,3,4, Paul J Karanicolas1,2,4,5, Alice C Wei1,4,5,6, Nicole Mittmann2, Natalie G Coburn7,8,9,10,11,12. 1. Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. 2. Sunnybrook Health Sciences Centre, Toronto, ON, Canada. 3. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. 4. Faculty of Medicine, University of Toronto, Toronto, ON, Canada. 5. Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada. 6. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada. 7. Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. natalie.coburn@sunnybrook.ca. 8. Sunnybrook Health Sciences Centre, Toronto, ON, Canada. natalie.coburn@sunnybrook.ca. 9. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. natalie.coburn@sunnybrook.ca. 10. Faculty of Medicine, University of Toronto, Toronto, ON, Canada. natalie.coburn@sunnybrook.ca. 11. Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada. natalie.coburn@sunnybrook.ca. 12. , 2075 Bayview Ave., Rm. T2-11, Toronto, ON, M4N 3M5, Canada. natalie.coburn@sunnybrook.ca.
Abstract
BACKGROUND: Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system. METHODS: A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients' 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases. RESULTS: Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers (>40 PD/year), 36.9% at medium-volume centers (20-39 PD/year), and 24.1% at lower-volume centers (10-19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) (p < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p < 0.0001) compared to lower-volume centers. CONCLUSION: Progressive increases in hospital volume correspond to improved 90-day outcomes following PD.
BACKGROUND: Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system. METHODS: A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients' 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases. RESULTS: Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers (>40 PD/year), 36.9% at medium-volume centers (20-39 PD/year), and 24.1% at lower-volume centers (10-19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) (p < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p < 0.0001) compared to lower-volume centers. CONCLUSION: Progressive increases in hospital volume correspond to improved 90-day outcomes following PD.
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