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Operative mortality is lower at hospitals with a high volume of certain surgical procedures. In this analysis of Medicare data, operative mortality declined for eight surgical procedures studied over a decade. Higher hospital volumes explained much of the decline for three of the operations. Fueled by a growing number of studies reporting inverse relationships between hospital volume and surgical mortality, 1 – 3 there was considerable interest in the United States during the previous decade in concentrating selected operations in high-volume hospitals. The Leapfrog Group, a consortium of large corporations and public agencies that purchase health care, has been among the most prominent advocates of volume-based referral. In 2000, it established minimum volume standards for several surgical procedures as part of a broader, value-based purchasing initiative. 4 Private payers and professional organizations in the United States have also established minimum volume standards as part of Centers of . . .

To assess the utility of funnel plots in assessing publication bias (PB) in meta-analyses of proportion studies. Meta-analysis simulation study and meta-analysis of published literature reporting peri-operative mortality after abdominal aortic aneurysm (AAA) repair. Data for the simulation study were stochastically generated. A literature search of Medline and Embase was performed to identify studies for inclusion in the published literature meta-analyses. The simulation study demonstrated that conventionally constructed funnel plots (log odds vs. 1/standard error [1/SE]) for extreme proportional outcomes were asymmetric despite no PB. Alternative funnel plots constructed using study size rather than 1/SE showed no asymmetry for extreme proportional outcomes. When used in meta-analyses of the mortality of AAA repair, these alternative funnel plots highlighted the possibility for conventional funnel plots to demonstrate asymmetry when there was no evidence of PB. Conventional funnel plots used to assess for potential PB in meta-analyses are inaccurate for meta-analyses of proportion studies with low proportion outcomes. Funnel plots of study size against log odds may be a more accurate way of assessing for PB in these studies.

Objective To measure the association between a surgeon’s degree of specialization in a specific procedure and patient mortality.Design Retrospective analysis of Medicare data.Setting US patients aged 66 or older enrolled in traditional fee for service Medicare.Participants 25 152 US surgeons who performed one of eight procedures (carotid endarterectomy, coronary artery bypass grafting, valve replacement, abdominal aortic aneurysm repair, lung resection, cystectomy, pancreatic resection, or esophagectomy) on 695 987 patients in 2008-13.Main outcome measure Relative risk reduction in risk adjusted and volume adjusted 30 day operative mortality between surgeons in the bottom quarter and top quarter of surgeon specialization (defined as the number of times the surgeon performed the specific procedure divided by his/her total operative volume across all procedures).Results For all four cardiovascular procedures and two out of four cancer resections, a surgeon’s degree of specialization was a significant predictor of operative mortality independent of the number of times he or she performed that procedure: carotid endarterectomy (relative risk reduction between bottom and top quarter of surgeons 28%, 95% confidence interval 0% to 48%); coronary artery bypass grafting (15%, 4% to 25%); valve replacement (46%, 37% to 53%); abdominal aortic aneurysm repair (42%, 29% to 53%); lung resection (28%, 5% to 46%); and cystectomy (41%, 8% to 63%). In five procedures (carotid endarterectomy, valve replacement, lung resection, cystectomy, and esophagectomy), the relative risk reduction from surgeon specialization was greater than that from surgeon volume for that specific procedure. Furthermore, surgeon specialization accounted for 9% (coronary artery bypass grafting) to 100% (cystectomy) of the relative risk reduction otherwise attributable to volume in that specific procedure.Conclusion For several common procedures, surgeon specialization was an important predictor of operative mortality independent of volume in that specific procedure. When selecting a surgeon, patients, referring physicians, and administrators assigning operative workload may want to consider a surgeon’s procedure specific volume as well as the degree to which a surgeon specializes in that procedure.

Research has demonstrated that there is lower operative mortality at hospitals with higher surgical volume. Using administrative data from Medicare, this study found lower mortality associated with each of eight procedures when performed by surgeons who undertook the operation more frequently. Lower mortality with surgeons who operate frequently. For many surgical procedures, patients at hospitals where a high number of such procedures are performed (high-volume hospitals) have lower mortality rates than those at hospitals that are less experienced with the procedures. 1 – 4 In one recent study of the national population of Medicare recipients, we found strong relations between hospital volume and operative mortality associated with 14 high-risk cancer resections and cardiovascular procedures. 5 Despite the considerable body of research in this area, little is known about the mechanisms underlying the observed associations between volume and outcome. Because they tend to be much larger facilities, high-volume hospitals have a broader . . .

Abstract Objectives In February 2024, a nationwide resident resignation occurred in South Korea that persisted for more than one and a half years and caused unprecedented disruptions in teaching hospitals. This study evaluated the clinical and socioeconomic impact of resident absence on cardiovascular surgery at a tertiary teaching hospital. Methods We retrospectively reviewed 681 patients who underwent open-heart or aortic surgery between February 20 and November 30, 2023 (before resident absence) and in 2024 (resident absence). Each year was divided into 3 periods (Q1, Q2, and Q3) for temporal comparison. The primary outcomes were 30-day mortality, failure-to-rescue complications, and failure-to-rescue. Failure-to-rescue was defined as in-hospital mortality after one or more of the following failure-to-rescue complications: acute renal failure, respiratory complications (prolonged ventilation >24 h, pneumonia, or tracheostomy), stroke, reoperation, life-threatening arrhythmia, postoperative myocardial infarction, or culture-positive sepsis. Multivariable logistic regression was performed to identify independent risk factors. Results When comparing 2023 Q1 with 2024 Q1, surgical volume decreased from 154 to 65 cases (−58%) and did not return to 2023 Q1 baseline. Compared with the 2023 group, the median surgical waiting time of the 2024 group increased from 17 [IQR: 8-28] to 36 [IQR: 20-58] days (P < .001). Resident absence was not a risk factor for 30-day mortality but was an independent risk factor for both failure-to-rescue complications (OR 1.50, 95% CI 1.03-2.19, P = .035) and failure-to-rescue (OR 3.64, 95% CI 1.33-9.98, P = .012). Conclusions The nationwide resignation of residents revealed the structural vulnerability of South Korea’s healthcare system, which relies heavily on residents’ workforce. Surgical capacity decreased, waiting times increased, and rescue outcomes deteriorated. The resident-dependent healthcare system requires reform, with teaching hospitals treating residents primarily as trainees rather than as inexpensive labour. Residents hold a unique position, serving as both salaried employees and trainees. Graphical abstract

For surgical procedures, operative mortality varies inversely with the number of procedures performed at a hospital. This study quantified the relation between volume and outcome among Medicare patients for 14 different surgical procedures. The relative effect of surgical volume on outcome varied markedly among types of procedures. For pancreatic resection, the absolute difference in mortality rates between the highest-volume and the lowest-volume hospitals was over 12 percent, whereas for carotid endarterectomy, the difference was only 0.2 percent. This study quantified the relation for 14 surgical procedures in Medicare patients. Over the past three decades, numerous studies have described higher rates of operative mortality with selected surgical procedures at hospitals where few such procedures are performed (low-volume hospitals). 1 – 4 Several recent reviews suggest that thousands of preventable surgical deaths occur each year in the United States because elective but high-risk surgery is performed in hospitals that have inadequate experience with the surgical procedures involved. 5 – 7 As part of a broader initiative aimed at improving hospital safety, a large coalition of private and public purchasers of health insurance — the Leapfrog Group — is encouraging patients undergoing one of five high-risk . . .

Background Extracorporeal membrane oxygenation (ECMO) represents a valuable and rapidly evolving therapeutic option in patients with severe heart or lung failure following cardiovascular surgery. However, despite significant advances in ECMO techniques and management, prognosis remains poor and accurate risk stratification challenging. We therefore evaluated the predictive value of liver function variables on all-cause mortality in patients undergoing venoarterial ECMO support after cardiovascular surgery. Methods We included into our single-center registry a total of 240 patients undergoing venoarterial ECMO therapy following cardiovascular surgery at a university-affiliated tertiary care center. Results The median follow-up was 37 months (interquartile range 19–67 months), and a total of 156 patients (65 %) died. Alkaline phosphatase and total bilirubin were the strongest predictors for 30-day mortality, with adjusted hazard ratios (HRs) per 1–standard deviation increase of 1.36 (95 % confidence interval [CI] 1.10–1.68; P  = 0.004) and 1.22 (95 % CI 1.07–1.40; P  = 0.004), respectively. The observed associations persisted for long-term mortality, with adjusted HRs of 1.27 (95 % CI 1.03–1.56; P  = 0.023) for alkaline phosphatase and 1.22 (95 % CI 1.07–1.39; P  = 0.003) for total bilirubin. Conclusions The present study demonstrates that elevated values of alkaline phosphatase and total bilirubin are sensitive parameters for predicting the short-term and long-term outcomes of ECMO patients.

PurposeTo define the effects of body mass index (BMI) on operative outcomes for both gastroenterological and cardiovascular surgery, using the National Clinical Database (NCD) of the Japanese nationwide web-based database.MethodsThe subjects of this study were 288,418 patients who underwent typical surgical procedures between January 2011 and December 2012. There were eight gastroenterological procedures, including esophagectomy, distal gastrectomy, total gastrectomy, right hemicolectomy, low anterior resection, hepatectomy of >1 segment excluding the lateral segment, pancreaticoduodenectomy, and surgery for acute diffuse peritonitis (n = 232,199); and five cardiovascular procedures, including aortic valve replacement, total arch replacement (TAR), descending thoracic aorta replacement (descending TAR), and on- or off-pump coronary artery bypass grafting (n = 56,219). The relationships of BMI with operation time and operative mortality for each procedure were investigated, using the NCD.ResultsOperation times were longer for patients with a higher BMI. When a BMI cut-off of 30 was used, the operation time for obese patients was significantly longer than that for non-obese patients, for all procedures except esophagectomy (P < 0.01). The mortality rate based on BMI revealed a U-shaped distribution, with both underweight and obese patients having high mortality rates for almost all procedures.ConclusionsThis Japanese nationwide study provides solid evidence to reinforce that both obesity and excessively low weight are factors that impact operative outcomes significantly.

The objective of this study is to evaluate neonatal outcomes of total anomalous pulmonary venous return (TAPVR) and identify fetal echocardiography findings associated with preoperative pulmonary venous obstruction (PPVO). This retrospective study evaluated TAPVR cases from 2005 to 2014 for preoperative and postoperative outcomes based on prenatal diagnosis, PPVO, and heterotaxy syndrome. Fetal pulmonary and vertical vein Dopplers were analyzed as predictors of PPVO. Of 137 TAPVR cases, 12% were prenatally diagnosed; 60% had PPVO, and 21% had heterotaxy. Of the prenatally diagnosed patients, 63% also had heterotaxy. TAPVR repair was performed in 135 cases and survival to discharge was 82% (112/137). Heterotaxy was the only independent predictor of mortality on multiple regression analysis [OR 5.5 (CI 1.3–16.7), p  = 0.02]. PPVO was associated with preoperative acidosis, need for inhaled nitric oxide, and more emergent surgery, but not postoperative mortality. Fetal vertical vein Doppler peak velocity > 0.74 m/s mmHg predicted PPVO (93% sensitivity; 83% specificity) while pulmonary vein Doppler did not. TAPVR has severe neonatal morbidity and mortality with low prenatal diagnosis rates in the absence of heterotaxy. Patients with obstructed TAPVR had greater preoperative morbidity, but only heterotaxy was independently associated with increased postoperative mortality. Vertical vein velocity helped prenatally identify those at risk of PPVO.

Frailty syndrome is a significant risk factor for elderly patients undergoing cardiovascular surgery. However, there is no consensus on which criteria are most effective for assessing frailty in this context. This study aimed to evaluate the relationship between different widely cited frailty syndrome criteria and postoperative morbidity and mortality. Patients aged ≥ 60 years scheduled for coronary artery bypass graft, valve, and/or ascending aortic surgery were assessed for frailty preoperatively. Frailty was defined by Clinical Frailty Scale (CFS) ≥ 4, Katz Index ≥ 1, Short Physical Performance Battery (SPPB) ≤ 6, Fried Frailty Phenotype (FFP) ≥ 3 or abnormal values in 15-feet gait speed (GS) test, or hand grip strength. Clinical outcomes, including mortality and major adverse cardiovascular and cerebral events (MACCE), were assessed 30 days post-surgery. Among 137 patients (70.1% male, mean age 69.43 ± 5.98 years), frailty prevalence ranged from 13.1% to 43.1%, depending on criterion, with no significant differences by age strata or surgery type. At 30-day follow-up, mortality was 5.1% (n = 7), and a total of 29 MACCE (21.1%) were recorded. Patients identified as frail by the FFP, CFS, SPPB, and GS criteria showed a significant association with mortality and MACCE. Multivariate analysis indicated FFP and CFS as independent risk factors for MACCE with equivalent prognostic prediction. Frailty is a prevalent condition among elderly patients undergoing cardiovascular surgery and is associated with mortality and morbidity. Frailty defined by FFP and CFS criteria was independently associated with higher MACCE rates.