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Comparative Study
. 2014 Oct;16(10):899-906.
doi: 10.1111/hpb.12283. Epub 2014 Jun 6.

Patient selection and the volume effect in pancreatic surgery: unequal benefits?

Lindsay A Bliss  1 , Catherine J Yang, Zeling Chau, Sing Chau Ng, David W McFadden, Tara S Kent, A James Moser, Mark P Callery, Jennifer F Tseng
Affiliations
Comparative Study

Patient selection and the volume effect in pancreatic surgery: unequal benefits?

Lindsay A Bliss et al. HPB (Oxford). 2014 Oct.

Abstract

Background: The volume effect in pancreatic surgery is well established. Regionalization to high-volume centres has been proposed. The effect of this proposal on practice patterns is unknown.

Methods: Retrospective review of pancreatectomy patients in the Nationwide Inpatient Sample 2004-2011. Inpatient mortality and complication rates were calculated. Patients were stratified by annual centre pancreatic resection volume (low <5, medium 5-18, high >18). Multivariable regression model evaluated predictors of resection at a high-volume centre.

Results: In total, 129,609 patients underwent a pancreatectomy. The crude inpatient mortality rate was 4.3%. 36.0% experienced complications. 66.5% underwent a resection at high-volume centres. In 2004, low-, medium- and high-volume centres resected 16.3%, 24.5% and 59.2% of patients, compared with 7.6%, 19.3% and 73.1% in 2011. High-volume centres had lower mortality (P < 0.001), fewer complications (P < 0.001) and a shorter median length of stay (P < 0.001). Patients at non-high-volume centres had more comorbidities (P = 0.001), lower rates of private insurance (P < 0.001) and more non-elective admissions (P < 0.001).

Discussion: In spite of a shift to high-volume hospitals, a substantial cohort still receives a resection outside of these centres. Patients receiving non-high-volume care demonstrate less favourable comorbidities, insurance and urgency of operation. The implications are twofold: already disadvantaged patients may not benefit from the high-volume effect; and patients predisposed to do well may contribute to observed superior outcomes at high-volume centres.

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Figures

Figure 1
Figure 1
Patient outcomes performed during elective and non-elective admissions by pancreatectomy centre volume
Figure 2
Figure 2
Logistic regression model showing odds ratios for predicting resection at a high-volume centre (>18 pancreatic resections annually)
See this image and copyright information in PMC

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