High volume and outcome after liver resection: surgeon or center?

J Gastrointest Surg. 2008 Oct;12(10):1709-16; discussion 1716. doi: 10.1007/s11605-008-0627-3. Epub 2008 Aug 13.


Introduction: In a case controlled analysis, we attempted to determine if the volume-survival benefit persists in liver resection (LR) after eliminating differences in background characteristics.

Methods: Using the Nationwide Inpatient Sample (NIS), we identified all LR (n = 2,949) with available surgeon/hospital identifiers performed from 1998-2005. Propensity scoring adjusted for background characteristics. Volume cut-points were selected to create equal groups. A logistic regression for mortality was then performed with these matched groups.

Results: At high volume (HV) hospitals, patients (n = 1423) were more often older, white, private insurance holders, elective admissions, carriers of a malignant diagnosis, and high income residents (p < 0.05). Propensity matching eliminated differences in background characteristics. Adjusted in-hospital mortality was significantly lower in the HV group (2.6% vs. 4.8%, p = 0.02). Logistic regression found that private insurance and elective admission type decreased mortality; preoperative comorbidity increased mortality. Only LR performed by HV surgeons at HV centers was independently associated with improved in-hospital mortality (HR, 0.43; 95% CI, 0.22-0.83).

Conclusions: A socioeconomic bias may exist at HV centers. When these factors are accounted for and adjusted, center volume does not appear to influence in-hospital mortality unless LR is performed by HV surgeons at HV centers.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Case-Control Studies
  • Female
  • General Surgery / statistics & numerical data*
  • Hepatectomy / mortality
  • Hepatectomy / statistics & numerical data*
  • Hospitals / statistics & numerical data*
  • Humans
  • Liver Diseases / surgery*
  • Male
  • Middle Aged
  • Physicians / statistics & numerical data*
  • Retrospective Studies
  • Treatment Outcome