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Trends in Hospital Volume and Failure to Rescue for Pancreatic Surgery
Neda Amini*, Gaya Spolverato, Yuhree Kim, Timothy M. Pawlik
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
Background: Multiple studies have demonstrated that patients undergoing high-risk procedures, such as pancreatic surgery, at higher volume institutions have improved outcomes. We sought to evaluate trends in the use of high-volume hospitals for pancreatic surgery, as well as examine trends in postoperative complications, mortality and failure to rescue (FTR).
Method: Patients who underwent pancreatic resection between 2000-2011 were identified from the Nationwide Inpatient Sample (NIS). Postoperative morbidity, mortality and FTR (i.e. death after major complication) were examined over time (2000-2003 vs. 2004-2007 vs. 2008-2011). Hospital volume was stratified into tertiles (low, intermediate and high) based on the number of pancreatic resections per year for each time period. Logistic regression models were used to assess the effect of hospital volume on risk of complication, postoperative mortality, and FTR over time.
Result: Overall 35,986 patients were identified. Median hospital volume increased from 13 in 2000-2003 to 55 procedures/year in 2008-2011 (P<0.001). The incidence of complications was 49.4% in low-volume, 44.6% in intermediate-volume, and 38.1% in high-volume hospitals (P<0.001). Morbidity remained relatively the same over time at low-, intermediate-, and high-volume hospitals (all P>0.05). Overall postoperative mortality was 5%; mortality decreased over time across all hospital volumes (low volume, 2000-2003: 9.2% vs. 2008-2011: 5.9%; intermediate-volume, 2000-2003: 7.2% vs. 2008-2011: 3.3%; high-volume: 2000-2003: 3.9% vs. 2008-2011: 2.7%; all P<0.05). FTR was more common at low-(12.0%) and intermediate-(8.5%) volume hospitals compared with high-volume hospitals (6.4%) (reference, high volume: low-volume, OR 2.03 vs. intermediate-volume, OR 1.39; P<0.001). Of note, the improvement in FTR over time was most pronounced at low-(2000-2003: 14.6% vs. 2008-2011: 10.6%) and intermediate-(2000-2003: 11.3% vs. 2008-2011: 7.0%) hospitals versus high-volume hospitals (2000-2003: 6.7% vs. 2008-2011: 6.1%) (P=0.001).
Conclusion: Median hospital volume for pancreatic surgery has dramatically increased over the past decade. While the incidence of morbidity has remained relatively stable over time, mortality has improved with the most pronounced decrease at low- and intermediate-volume hospitals. This improvement in mortality seems to be related to improvements in the ability to rescue patients from death after major complications.
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