Abstracts
1997 Digestive Disease Week

Should hepatic resections be performed at high-volume referral centers?

MA Choti, HM Bowman, HA Pitt, JA Sosa, JV Sitzmann, JL Cameron, TA Gordon. Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD.

Current trends in the delivery of health care services have directed many patients to "low-cost" hospitals. However, some recent analyses suggest that certain high-risk surgical procedures can be performed more safely at high-volume referral centers which tend to be "high-cost" institutions. Therefore, the aim of this analysis was to determine whether the mortality and cost of performing hepatic resection are related to surgical volume. This analysis was performed by accessing data on selected surgical procedures performed at Maryland acute care hospitals from January, 1991 through December, 1995. Of 477 operations, 306 partial hepatectomies (64%) and 171 hepatic lobectomies (36%) were performed at 33 of the 54 (61%) acute care hospitals. However, 204 liver resections (43%) were performed at one high-volume provider (HVP) which averaged 41 procedures per year. In comparison, 89 liver resections (19%) were performed at 25 of the 33 hospitals (76%) for an average of two or less procedures per year. Two institutions performed 107 procedures and averaged 11 and 7 procedures per year, respectively. Data were also analyzed for the two most common indications for liver resection, liver metastases and hepatocellular carcinoma (Ca). Complexity adjusted results for length of stay (LOS), hospital charges and mortality were:

                             Average  Average    Mortality    Relative
                   Patients  LOS(d)   Charge(0     (%)         Risk
All Procedures
   HVP               204      12.1    19,762        2.0         1.0
   Others            273      11.7    21,970        9.3*        4.7
Liver Metastases
   HVP                91      11.1    19,129        0.0         1.0
   Others            118      11.8    21,746        7.1†        >10.0
Hepatocellular Ca
   HVP                46      15.6    24,643        6.5         1.0
   Others             33      10.9    22,644       15.5         2.4
                     * p <0.01, † p =0.06 vs High-Volume Provider (HVP)

The data on length of stay, charges, and mortality were similiar for the low-volume (<2/yr) and moderate-volume (7-11 /year) hospitals. We conclude that hepatic resection can be performed more safely and at comparable cost at high-volume referral centers.