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2006 Abstracts: Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA): Is there a volume-outcomes effect?
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Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA): Is there a volume-outcomes effect?
John Morton, Andrew Shelton, Mark Welton; Surgery, Stanford University, Stanford, CA

Background: Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is a procedure requiring significant commitment and expertise. Little is known about the relationship between IPAA hospital volume and outcomes. To determine if a volume effect exists between the number of IPAA procedures and outcomes, national outcomes for IPAA surgery were examined from 1997-2003. Methods: The National Inpatient Sample, a 20% sample of all non-federal hospital discharges, was queried for all patients who had IPAA surgery denoted by ICD9 procedure code 45.95. Hospital transfers and pediatric patients were excluded. Two hospital volume cohorts of less or greater than 15 annual IPAA procedures were established: Low Volume Hospitals (LVHs) or High Volume Hospitals (HVHs). Both demographic and outcome variables were compared by either T-test or Chi-Square analysis with a P value of < 0.05 as significant. Confounding variables were controlled for with linear and logistic regression models for LOS and mortality respectively. Results: No clinically significant differences existed between the two volume groups for age or gender. Significant differences between LVHs and HVHs did exist for the general (Charlson) comorbidity index >0 respectively: %, 41 vs. 30, p<0.0001. Significant differences in LOS and mortality between LVHs and HVHs also existed respectively: LOS>14 Days (%, 11 vs. 7.5, p<0.0001), and in-patient mortality (%, 0.74 vs. 0.27, p<0.0001). In addition, logistic regression analysis indicated potential predictors for mortality in all IPAA procedures. HVHs were associated with a protective effect upon mortality with an Odds Ratio (OR) of 0.45. The following factors were associated with increased risk of in-patient mortality (OR): age >65 (1.94), male gender (1.14), Charlson Index >0 (1.09). Conclusions: This population-based study indicates a hospital volume-outcomes effect for IPAA procedures. Higher volume hospitals may have better outcomes due to patient selection, surgeon experience, and hospital resources. Further investigation may reveal the effect factors other than volume exert on IPAA surgery outcomes.


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