Hospital Volume Can Serve as a Surrogate for Surgeon Volume for Achieving Excellent Outcomes in Colorectal Resection

Abstract

ObjectiveTo examine the association of surgeon and hospital case volumes with the short-term outcomes of in-hospital death, total hospital charges, and length of stay for resection of colorectal carcinoma. MethodsThe study design was a cross-sectional analysis of all adult patients who underwent resection for colorectal cancer using Maryland state discharge data from 1992 to 1996. Cases were divided into three groups based on annual surgeon case volume-low (Յ5), medium (5 to 10), and high (Ͼ10)-and hospital volume-low (Ͻ40), medium (40 to 70), and high (Ն70). Poisson and multiple linear regression analyses were used to identify differences in outcomes among volume groups while adjusting for variations in type of resections performed, cancer stage, patient comorbidities, urgency of admission, and patient demographic variables. ResultsDuring the 5-year period, 9739 resections were performed by 812 surgeons at 50 hospitals. The majority of surgeons (81%) and hospitals (58%) were in the low-volume group. The lowvolume surgeons operated on 3461 of the 9739 total patients (36%) at an average rate of 1.8 cases per year. Higher surgeon volume was associated with significant improvement in all three outcomes (in-hospital death, length of stay, and cost). Medium-volume surgeons achieved results equivalent to high-volume surgeons when they operated in high-or medium-volume hospitals. ConclusionsA skewed distribution of case volumes by surgeon was found in this study of patients who underwent resection for large bowel cancer in Maryland. The majority of these surgeons performed very few operations for colorectal cancer per year, whereas a minority performed Ͼ10 cases per year. Medium-volume surgeons achieved excellent outcomes similar to high-volume surgeons when operating in medium-volume or high-volume hospitals, but not in lowvolume hospitals. The results of low-volume surgeons improved with increasing hospital volume but never equaled those of the high-volume surgeons.Numerous studies have examined the association of surgeon case volume with clinical outcomes for various procedures and have shown higher surgeon volume to be associated with improved outcomes. This phenomenon has been described for an increasing number of procedures, including coronary artery bypass, angioplasty, gastrectomy, esophagectomy, thyroidectomy, arthroplasty, and aortic aneurysm repair. [1][2][3][4][5][6][7][8] We and others have reported a similar relation between surgeon volume and improved clinical and economic outcomes for resections of colon and rectal cancer.9 -18 Our study showed that in-hospital death, length of stay, and total hospital charges were found to be significantly inversely related to surgeon volume, with the best results being achieved by the high-volume surgeon group who performed Ͼ10 cases per year.

Prognostic value of lymph node evaluation in small bowel adenocarcinoma

“…[20][21][22] In addition, for colorectal cancer, it has been demonstrated that the number of assessed lymph nodes increases as surgical and hospital volumes increase. [22][23][24][25][26] The exact contribution of each of these factors to the improvement in survival with increasing TLN or whether TLN is a surrogate of overall quality as it pertains to postoperative care, follow-up, or subsequent therapy could not be determined in the current study. Irrespective of the reasons for these differences, patients with more TLNs assessed have improved survival, and this finding has important implications for clinical prognostication.…”

Evaluation of quality indicators following implementation of total mesorectal excision in primarily resected rectal cancer changed future management

“…For example, Harmon et al examined the association of surgeon and hospital case volumes with the outcome of patients with colorectal cancer. They showed that "medium-volume" surgeons achieved excellent outcomes similar to "high-volume" surgeons when operating in "medium-volume" or "highvolume" hospitals, while the results of "low-volume" surgeons improved with increasing hospital volume but never reached those of the "high-volume" surgeons [6]. In contrast, Marusch et al [7] failed to show significant associations between hospital caseload and postoperative outcome in 2,293 colorectal cancer patients undergoing surgery.…”

Disparities in quality of care for colon cancer between hospitals in the Netherlands

“…[16;17] However, studies on mortality among patients with colon cancer showed conflicting results: some demonstrated an association between mortality and hospital volume or teaching status, while others did not. [18][19][20][21][22][23][24] Aim of this study was to describe variation in staging, treatment patterns and outcome according to region and, according to type and volume of individual hospitals among patients with colon cancer in the Netherlands.…”