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Bariatric Surgical Outcomes in NY State, the Role of Hospital and Surgeon Volume: An Analysis of 52,690 Patients
Ilana Regenbogen1, Vamsi V. Alli*1, Jie Yang3,4, Mark A. Talamini1, Aurora Pryor1, Dana A. Telem1,2
1Surgery, Stony Brook Medicine, Stony Brook, NY; 2Program in Public Health, Stony Brook Medicine, Stony Brook, NY; 3Department of Family, Population and Preventive Medicine, Stony Brook Medicine, Stony Brook, NY; 4Department of Applied Mathematics and Statistics, Stony Brook Medicine, Stony Brook, NY
Background:
For more than 25 years, there has been an interest in the association between operative volume and outcomes. Accreditation of specialty programs and centers across surgical specialties utilize minimum volume requirements. More generally, volume has been utilized as a surrogate marker for quality & patient outcomes surgery. The factors that ultimately determine patient outcomes are multiple, however reliable methods of predicting outcomes based on non-volumetric measures remains lacking.
Methods:
The New York State Planning and Research Cooperative System (NY SPARCS), a longitudinal administrative database encompassing all inpatient, outpatient and hospital discharges in NY State was utilized to identify a total of 52,690 patients who underwent bariatric surgery [adjustable gastric banding (AGB), laparoscopic sleeve gastrectomy (LSG), or roux-en-Y gastric bypass (RYGB)] from 2010-2014The data encompassed a total of 84 hospitals & 360 operating physicians. Patient demographics, surgical details and insurance type, comorbidities, complications were caputured. Hospital and surgeon specific volumes were tabulated.. Generalized linear mixed models were used to compare hospital volume & operating physician volume against hospital readmission, emergency department (ED) revisit, admitted ED revisit, & complications within 30 days of index operation.
Results:
In aggregate, hospital volume & physician volume were not associated with hospital readmission (p= 0.6569 and p= 0.6311 respectively), ED revisit (p=0.9506 and p=0.3828) or admitted ED rates (p=0.7361 and p=0.3516) within the first 30 days after bariatric surgery. Multivariate analysis revealed that independent of comorbidities & operation type surgeon volume demonstrated a statistically significant impact on complications within 30 days of bariatric surgery (p<0.0001). Analysis of surgeon volume by quartile (cases per year): <25, 25-50, 50-100, >100 reveals an inflection in complication risk between the 2nd & 3rd quartiles, commensurate with a rise in odds ratio to 1.7.
Conclusions:
Neither hospital nor surgeon volumes determine presentation to ED, admitted ED, or hospital readmission rates. Lower volume surgeons are more likely to have complications within 30 days of index operation. As bariatric surgery has migrated to outpatient status, with most postoperative stays spanning <48 hours, hospital volume as a surrogate for perioperative care has had less impact on bariatric outcomes than for other operations, namely cardiac and pancreatobiliary surgery. Technical considerations, with surgeon volume serving as a surrogate marker has surfaced as a better predictor of patient outcome. As such, quality improvement should focus on surgeon specific, not site specific volumes as a major component of postoperative outcomes prediction.
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