The effect of centralization on short term outcomes of pancreatoduodenectomy in a universal health care system

Abstract

Background: Centralization of pancreatic resections is advocated due to a volume-outcome association. Pancreatic surgery is in Norway currently performed only in five teaching hospitals. The aim was to describe the short-term outcomes after pancreatoduodenectomy (PD) within the current organizational model and to assess for regional disparities.Methods: All patients who underwent PD in Norway between 2012 and 2016 were identified. Mortality (90 days) and relaparotomy (30 days) were assessed for predictors including demographic data and multi-visceral or vascular resection. Aggregated length-of-stay and national and regional incidences of the procedure were also analysed.Results: A total of 930 patients underwent PD during the study period. In-hospital mortality occurred in 20 patients (2%) and 34 patients (4%) died within 90 days. Male gender, age, multi-visceral resection and relaparotomy were independent predictors of 90-day mortality. Some 131 patients (14%) had a relaparotomy, with male gender and multi-visceral resection as independent predictors. There was no difference between regions in procedure incidence or 90-day mortality. There was a disparity within the regions in the use of vascular resection (p = 0.021). Conclusion:The short-term outcomes after PD in Norway are acceptable and the 90-day mortality rate is low. The outcomes may reflect centralization of pancreatic surgery.

Variation in use of open and laparoscopic distal pancreatectomy and associated outcome metrics in a universal health care system

“…Thus, the findings reported herein are associations and not causations e they are hypothesis-generating data that warrant research effort into a better understanding of the reported variation across the four regions in Norway. As a similar variation was not noted for the same regions and hospitals for pancreatoduodenectomies [8], we assume that the variation lies in the practice of distal pancreatectomy and likely as an effect of minimal invasive access that may influence choice to operate over observation for some indications. This should be kept in mind when comparing results and outcomes from single-center studies.…”

“…We have previously shown that use of distal pancreatectomy is increasing overall in Norway, and this is related to a significant increase in laparoscopic procedures [7]. One should keep in mind that while resection rates in Norway (during the same time period) also increased for pancreatoduodenectomies, the difference in population-adjusted resection rates between regions was negligible for this procedure [8]. Thus, rates of pancreatoduodenectomies stand in contrast to the current findings that demonstrate a 176% relative difference in the populationadjusted resection rate between the region with the lowest and the highest rates.…”

“…This was a longitudinal, observational national 5-year cohort study covering the universal health care system in Norway (from 1.1.2012 to 31.12.2016), as described in detail previously for nationwide data and time-trends [7,8,10] and consulting the guidelines for Strengthening the Reporting of Observational Studies in Epidemiology in Epidemiology (STROBE) [11].…”

“…The selected NPR variables have good data quality and high completeness [12]. A more detailed description of data capture and coding retrieval have been described previously [10], and reported for pan-creatoduodenectomy [8] and distal pancreatic resections [7] in a nationwide perspective. Operations were identified from the Nordic Medico-Statistical Committee (NOMESCO) Classification of Surgical Procedures (NCSP), version 2014 [13], with codes for open (JLC10) and laparoscopic (JLC11) distal pancreatectomy with or without inclusion of splenectomy code (open or laparoscopic; JMA10 or JMA11).…”

“…We have previously shown that there was little variation in the population-based resections rates for pancreatoduodenectomy (Whipples procedure) across four health regions in Norway [8]. Notably, pancreatoduodenectomy is exclusively performed as open surgery in Norway and predominantly for malignant/premalignant conditions according to national guidelines.…”