High-volume surgeons vs high-volume hospitals: are best outcomes more due to who or where?

Toomey, Paul; Teta, Anthony; Patel, Krishen; Ross, Sharona; Rosemurgy, Alexander S.

doi:10.1016/j.amjsurg.2015.08.021

Cited by 57 publications

(36 citation statements)

References 22 publications

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“…A relationship between volume and outcome in colorectal cancer surgery has been suggested previously; patients treated at hospitals with high‐volume colorectal cancer surgery and by high‐volume surgeons have been shown to have a clear long‐term (up to 6 years) survival advantage and postoperative mortality rate. Such findings are consistent across other surgical specialties, including gynaecological, pancreatic and prostate cancer surgery, at both the surgeon and hospital level. This has led to many countries centralizing highly complex surgical procedures at high‐volume centres in order to streamline services, improve oncological and patient‐reported outcomes, and lower healthcare costs.…”

Section: Introductionsupporting

confidence: 79%

Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity

Venchiarutti

Solomon

Koh

et al. 2019

British Journal of Surgery

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Background Pelvic exenteration (PE) provides a potentially curative option for advanced or recurrent malignancy confined to the pelvis. A clear (R0) resection margin is the strongest prognostic factor predicting long‐term survival, driving most technical advances in PE surgery. The aim of this cohort study was to describe changing trends in extent of resection, postoperative complications, mortality and overall survival after PE surgery. Methods Consecutive patients who underwent PE for advanced or recurrent pelvic malignancy at a single institution in Sydney, Australia, were identified. The cohort was divided into three groups based on time periods reflecting annual surgical volume: 1994–2006 (20 or fewer procedures per year), 2007–2013 (21–50 procedures per year) and 2014–2017 (over 50 procedures per year). Primary outcomes were extent of resection, postoperative complications, 60‐day mortality and 3‐year overall survival. Secondary outcomes were patient characteristics, receipt of neoadjuvant therapy and duration of hospital stay. Results There were increases over time in rates of lateral and posterior compartment resections (P < 0·001), and bony pelvis (P = 0·002) and neurovascular (P < 0·001) excision. For patients undergoing reconstruction, the proportion receiving vertical rectus abdominus myocutaneous flaps increased significantly (P = 0·005). Rates of wound infection, dehiscence, and abdominal and pelvic collections increased over the study interval. Short‐term mortality decreased, and 1‐ and 3‐year survival rates improved. Conclusion Technical and surgical advancements have led to more complex PE resections, with R0 and mortality rates improving with higher annual volume. There were associated increases in intraoperative blood loss and postoperative morbidity.

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Section: Introductionsupporting

confidence: 79%

Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity

Venchiarutti

Solomon

Koh

et al. 2019

British Journal of Surgery

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“…These results also seem to indicate that hospital volume per se is less significant than has previously been reported [12], and instead underline that surgeon experience and training may be able to override the disadvantages of a low-volume center. Toomey et al [4] recently demonstrated that a high-volume surgeon who relocated to a low-volume center is able to achieve postoperative results similar to those previously obtained in the high-volume center.…”

Section: Discussionsupporting

confidence: 59%

“…Comparable rates of major postoperative complications (18 vs. 22%; p = 0.236) and pancreatic fistula (29 vs. 32%; p = ume center in pancreatic surgery has been shown [1], the processes leading to this result are not well understood. While some studies have indicated that better surgical outcomes are more correlated with center volume than with the specific surgeon [2], others have reported that surgeon volume is a key factor [3], with a high-volume surgeon relocated to a low-volume center able to achieve the same results as previously achieved in a high-volume setting [4]. It has also been shown that low-volume surgeons performing pancreatic procedures achieve comparable postoperative morbidity in both high-and low-volume centers, although other outcomes less directly related to surgeon volume may be improved in a high-volume setting, for example, shorter hospital length of stay [5].…”

Section: Introductionsupporting

confidence: 54%

Management and Outcomes of Pancreatic Resections Performed in High-Volume Referral and Low-Volume Community Hospitals Lead by Surgeons Who Shared the Same Mentor: The Importance of Training

Capretti

Balzano

Gianotti³

et al. 2017

Dig Surg

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Background: High hospital volume improves outcomes after pancreatic resection. The aim of this study was to assess if practice and outcomes differed between high- and low-volume centers across which chief surgeons shared a similar training and mentoring. Methods: Data on patients undergoing standard pancreatic resections (2010-2013) at 7 Italian hospitals were collected. Chiefs of pancreatic surgery at each hospital had received the same training, with the same mentor. Two centers were high-volume referral hospitals for pancreatic disease, while 5 were low-volume hospitals. Results: A total of 856 patients were included, with median annual volume of resections 82 at high-volume referral hospitals and 11 at low-volume hospitals. Patients at low-volume hospitals were older, had more comorbidities, and were more often referred from the emergency room. Intraoperative techniques and reconstruction methods were similar. Comparable rates of major postoperative complications (18 vs. 22%; p = 0.236) and pancreatic fistula (29 vs. 32%; p = 0.287) were achieved in both groups, with no significant increases in failure to rescue from grade B-C fistula (6.2 vs. 15.0%; p = 0.108) and mortality (2.4 vs. 4.1%; p = 0.233) in low-volume hospitals. Postoperative length of stay was shorter in high-volume referral hospitals (10 vs. 15 days; p < 0.001). Conclusion: Similar postoperative outcomes can be achieved across high- and low-volume centers where chief surgeons shared a similar training and mentoring. However, multidisciplinary postoperative provision more often associated with high-volume centers may also affect outcomes.

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“…22 Conversely, studies also demonstrated that high-volume surgeons who operate at lower-volume hospitals may produce excellent outcomes. 23,24 Most national and statewide surgical registries do not include surgeon-specific data, and our study is unique in providing outcomes based on both surgeon and hospital volume. From an epidemiologic perspective, reducing hysterectomy-based preventable harm in the United States may depend upon optimizing not only where a patient is operated on but by whom.…”

Section: Commentmentioning

confidence: 99%

Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications

Mehta¹,

Xu²,

Hutfless

et al. 2017

American Journal of Obstetrics and Gynecology

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BACKGROUND Hysterectomy is among the most common major surgical procedures performed in women. Approximately 450,000 hysterectomy procedures are performed each year in the United States for benign indications. However, little is known regarding contemporary US hysterectomy trends for women with benign disease with respect to operative technique and perioperative complications, and the association between these 2 factors with patient, surgeon, and hospital characteristics. OBJECTIVE We sought to describe contemporary hysterectomy trends and explore associations between patient, surgeon, and hospital characteristics with surgical approach and perioperative complications. STUDY DESIGN Hysterectomies performed for benign indications by general gynecologists from July 2012 through September 2014 were analyzed in the all-payer Maryland Health Services Cost Review Commission database. We excluded hysterectomies performed by gynecologic oncologists, reproductive endocrinologists, and female pelvic medicine and reconstructive surgeons. We included both open hysterectomies and those performed by minimally invasive surgery, which included vaginal hysterectomies. Perioperative complications were defined using the Agency for Healthcare Research and Quality patient safety indicators. Surgeon hysterectomy volume during the 2-year study period was analyzed (0–5 cases annually = very low, 6–10 = low, 11–20 = medium, and ≥21 = high). We utilized logistic regression and negative binomial regression to identify patient, surgeon, and hospital characteristics associated with minimally invasive surgery utilization and perioperative complications, respectively. RESULTS A total of 5660 hospitalizations were identified during the study period. Most patients (61.5%) had an open hysterectomy; 38.5% underwent a minimally invasive surgery procedure (25.1% robotic, 46.6% laparoscopic, 28.3% vaginal). Most surgeons (68.2%) were very low– or low-volume surgeons. Factors associated with a lower likelihood of undergoing minimally invasive surgery included older patient age (reference 45–64 years; 20–44 years: adjusted odds ratio, 1.16; 95% confidence interval, 1.05–1.28), black race (reference white; adjusted odds ratio, 0.70; 95% confidence interval, 0.63–0.78), Hispanic ethnicity (adjusted odds ratio, 0.62; 95% confidence interval, 0.48–0.80), smaller hospital (reference large; small: adjusted odds ratio, 0.26; 95% confidence interval, 0.15–0.45; medium: adjusted odds ratio, 0.87; 95% confidence interval, 0.79–0.96), medium hospital hysterectomy volume (reference ≥200 hysterectomies; 100–200: adjusted odds ratio, 0.78; 95% confidence interval, 0.71–0.87), and medium vs high surgeon volume (reference high; medium: adjusted odds ratio, 0.87; 95% confidence interval, 0.78–0.97). Complications occurred in 25.8% of open and 8.2% of minimally invasive hysterectomies (P < .0001). Minimally invasive hysterectomy (adjusted odds ratio, 0.22; 95% confidence interval, 0.17–0.27) and large hysterectomy volume hospitals (reference ≥200 hysterectomies;...

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High-volume surgeons vs high-volume hospitals: are best outcomes more due to who or where?

Cited by 57 publications

References 22 publications

Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity

Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity

Management and Outcomes of Pancreatic Resections Performed in High-Volume Referral and Low-Volume Community Hospitals Lead by Surgeons Who Shared the Same Mentor: The Importance of Training

Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications

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