NATIONWIDE COMPARISON OF ELECTIVE PARAESOPHAGEAL HERNIA REPAIR (PEHR) IN HIGH (HVC)- AND LOW-VOLUME CENTERS (LVC)
Hadley H. Wilson*, Sullivan Ayuso, Mikayla Rose, Dau Ku, Gregory T. Scarola, Vedra A. Augenstein, B Todd Heniford, Paul D. Colavita
Surgery, Carolinas Medical Center, Charlotte, NC
Introduction
Complex operations have become increasingly centralized at HVCs, which are believed to deliver improved outcomes. While readmission rates have been used administratively to measure surgical performance, surgical volume, as it relates to readmission rates, has not been studied using a population-based database. This study aimed to compare outcomes between HVCs and LVCs in the performance of PEHR.
Methods
The Nationwide Readmissions Database was queried for all patients undergoing PEHR from 2016 to 2018. Patients were excluded if they were <18 years old or had an emergent operation, concurrent bariatric procedure, or a diagnosis of gastrointestinal malignancy. Centers were stratified into percentiles based on elective procedure volume by year. HVCs were defined as in the top 5th percentile (>42 procedures/year), and LVCs were defined as 50th percentile or less (£ 5 procedures/year). Patient characteristics and outcomes were compared with standard statistical methods.
Results
During the 3-year period, 36,484 PEHR patients were identified. Of these, 11,355 (31.1%) underwent PEHR at a HVC and 4,904 (13.4%) at a LVC. Patients were similar in age (65 [55, 72] vs 65 [54, 72] years, p=0.621) and sex (71.8% vs 72.9% female, p=0.145). HVC patients were more concentrated in metropolitan teaching (95.4% vs 48.8%) and large (82.7% vs 33.5%) hospitals (p<0.001). Hospital charges were higher at HVCs ($54,190 [$36,396, $86,599] vs $50,054 [$31,596, $81,821], p<0.001). HVCs performed a higher proportion of laparoscopic (73.3% vs 69.6%, p<0.001), similar proportion of robotic (16.2% vs 15.9%, p=0.661), and lower proportion of open (9.9% vs 13.5%, p<0.001) procedures. HVC patients had less perioperative mortality (0.2% vs 0.5%, p<0.001), major bleeding (0.2% vs 0.4%, p=0.040), pneumonia (0.8% vs 2.3%, p<0.001), respiratory failure (2.2% vs 4.4%, p<0.001), acute renal failure (1.6% vs 2.6%, p<0.001), and sepsis (0.6% vs 1.5%, p<0.001) and shorter length of stay (LOS) (3.0 ± 3.9 vs 3.4 ± 4.6 days, p=0.003). HVCs had lower 30-day (6.6% vs 8.2%, p<0.001), 90-day (9.5% vs 11.1%, p=0.003), and 180-day (11.5% vs 13.0%, p=0.010) readmission rates and readmissions requiring reoperation (0.4% vs 0.9%, p=0.002). In regression analysis, HVCs were protective for 30-day (OR=0.781 [0.642-0.950]) and 90-day readmission (OR=0.837 [0.707-0.990]), mortality (OR=0.247 [0.112-0.544]), and complications (OR=0.764 [0.641-0.910]).
Conclusions
HVCs performed more laparoscopic and fewer open PEHR than LVCs. HVCs had a shorter LOS, lower readmission rates at 30- and 90-days, a reduced rate of readmissions requiring reoperation, fewer complications, and lower mortality rates. Procedure volume was independently predictive of improved outcomes in PEHR. These results support centralization of PEHR to HVCs.
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