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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 . . .

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 . . .

The increase in the number of carotid artery stenting (CAS) procedures over the last decade has necessitated critical appraisal of procedural outcomes and patterns of utilization including cost analysis. The main objectives of our study were to evaluate the postprocedural mortality and complications after CAS and the patterns of resource utilization in terms of length of stay (LOS) and cost of hospitalization. We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2006 to 2010 using the International Classification of Diseases, Ninth Revision, procedure code of 00.63 for CAS. Hierarchical mixed-effects models were generated to identify the independent multivariate predictors of in-hospital mortality, procedural complications, LOS, and cost of hospitalization. A total of 13,564 CAS procedures (weighted n = 67,344) were analyzed. The overall postprocedural mortality was low at 0.5%, whereas the complication rate was 8%, both of which remained relatively steady over the time frame of the study. Greater postoperative mortality and complications were noted in symptomatic patients, women, and those with greater burden of baseline co-morbidities. A greater operator volume was associated with a lower rate of postoperative mortality and complications, as well as shorter LOS and lesser hospitalization costs. In conclusion, the postprocedural mortality after CAS has remained low over the recent years. Operator volume is an important predictor of postprocedural outcomes and resource utilization.

Decompressive surgery <48 h from stroke onset reduces the prevalence of mortality and morbidity from malignant supratentorial infarction. We investigated if utilization of decompressive surgery changed in the Czech Republic (CZ) after the release of new guidelines regarding treatment of malignant brain infarction. The volume of decompressive surgery in 2009 in all centers in the CZ was assessed using the same methodology as in 2006. All neurosurgery departments in the CZ were asked to complete a questionnaire and asked to identify all cases of decompressive surgery for malignant brain infarction through a combination of discharge codes for “brain infarction” and “decompressive surgery” from electronic hospital charts. Data for 56 patients were obtained from 15 of the 16 neurosurgery departments in the CZ. The average age was 53 ± 13; number of males 20; median time to surgery was 48 h (range 24–62); median NIHSS score was 25 (IQR, 20–30); median infarct volume was 300 cm 3 [interquartile (IQR, 250–350)]; mean shift on CT was 10.6 ± 3.6 mm and size of hemicraniectomy was 125 cm 2 (IQR, 110–154). A favorable outcome was achieved in 45% of the patients. The number of procedures increased from 39 in 2,006 to 2,056 in 2009. Based on data from one stroke center, 10% suffered from malignant supratentorial infarction and 2.3% met the criteria for decompressive surgery. In 2009, as compared to 2006, the volume of decompressive surgery carried out moderately increased. However, procedures remained underutilized because only ~10% of those who needed decompressive surgery underwent surgery.

Previous research has shown that persons undergoing certain high-risk surgical procedures at high-volume hospitals (HVHs) have a lower risk of postoperative death than those undergoing surgery at low-volume hospitals (LVHs). We estimated the absolute number of operative deaths that could potentially be avoided if 5 major surgical procedures in Ontario were restricted to HVHs. We collected data on all persons who underwent esophagectomy (613), colon or rectal resection for colorectal cancer (18 898), pancreaticoduodenectomy (686), pulmonary lobectomy or pneumonectomy for lung cancer (5156) or repair of an unruptured abdominal aortic aneurysm (AAA) (6279) in Ontario from Apr. 1, 1994, to Mar. 31, 1999. We calculated the excess number of operative deaths (defined as deaths in the period from the day of the operation to 30 days thereafter), adjusted for age, sex and comorbidity, among the 75% of persons treated in LVHs, as compared with the 25% treated in the highest-volume quartile of hospitals. Bootstrap methods were used to estimate 95% confidence intervals (CIs). Of the 31 632 persons undergoing any of the 5 procedures, 1341 (4.24%) died within 30 days of surgery. If the 75% of persons treated at the LVHs had instead been treated at the HVHs, the annual number of lives potentially saved would have been 4 (95% CI, 0 to 9) for esophagectomy, 6 (95% CI, 1 to 11) for pancreaticoduodenectomy, 1 (95% CI, -10 to 13) for major lung resection and 14 (95% CI, 1 to 25) for repair of unruptured AAA. For resection of colon or rectum, the regionalization strategy would not have saved any lives, and 17 lives (95% CI, 36 to -3) would potentially have been lost. A small number of operative deaths are potentially avoidable by performing 4 of 5 complex surgical procedures only at HVHs in Ontario. In determining health policy, the most compelling argument for regionalizing complex surgical procedures at HVHs may not be the prevention of a large number of such deaths.

The volume–outcome hypothesis has created a policymaker's dilemma. In 1979, Luft and colleagues 1 reported in the Journal that the number of procedures performed at a hospital (hospital volume) and mortality rates for many surgical procedures were inversely related. Since then, this relation has been documented many times, 2 fueling a persistent debate about whether health care should be regionalized and certain sorts of complex, elective care restricted to high-volume medical centers. 3 – 5 Two studies reported in this issue of the Journal will undoubtedly fuel this controversy. In the first, Birkmeyer and colleagues 6 used Medicare claims data from 1994 through 1999 to . . .

Purpose: To measure contemporary practice patterns and compare outcomes of open and endovascular repair for chronic mesenteric ischemia (CMI). Methods: The New York State Health Department Statewide Planning and Research Cooperative System database was queried for the ICD-9-CM codes for CMI for the years 2000 to 2006. In this time period, 6549 patients were evaluated for CMI in New York State. Of these patients, 666 received an intervention and underwent either open (n=280) or endovascular (n=347) repair; 39 patients underwent both treatments and were excluded. Trends in operative management and short-term outcomes were analyzed. Results: Over the 7-year study period, there was a steady increase in the number of endovascular procedures from 28% in 2000 to 75% in 2006. The overall mortality rate for the 7-year period was significantly lower for endovascular versus open repair (11.0% versus 20.4%, respectively; p=0.0011). Endovascular repair was associated with a significantly lower rate of mesenteric ischemic complications compared to open repair (6.92% versus 17.1%, respectively; p<0.0001). Moreover, compared with open surgery, endovascular repair resulted in significantly lower rates of cardiac, pulmonary, and infectious complications (p<0.05). Only 37% of patients having open repair were discharged home compared to 55% of patients treated with endovascular procedures (p<0.0001). Conclusion: The number of patients treated for CMI continues to increase and correlates with the increasing utilization of endovascular procedures. The patients undergoing endovascular treatment had fewer complications, lower in-hospital mortality, and a greater likelihood of being discharged home.

The aim of this study was to investigate the relation between hospital volume and clinical surgical outcome for 10 cardiac, lung, and esophageal surgical procedures. The Committee for Scientific Affairs of the Japanese Association for Thoracic Surgery collected the pooled data on cardiac, lung, and esophageal surgical procedures between 2000 and 2004 from the annual reports. The relation between operative mortality (30-day or in-hospital mortality) and hospital volume was analyzed using a logistic regression model. The surgical procedures studied were surgery for acquired cardiac diseases [coronary artery bypass grafting (CABG), valve procedures, acute type A dissection surgery], total CABG (elective + emergency), elective CABG, emergency CABG, single-valve surgery, acute type A dissection surgery, open heart surgery for the newborn, open heart surgery for the infants, lung cancer surgery, and esophageal cancer surgery. The data used in this study were not risk-adjusted. The data on the relation between hospital volume and operative mortality generally tended to show an inverse correlation for all 10 cardiac, lung, and esophageal surgical procedures; that is, the higher was the volume the lower was the mortality. However, wide variations in operative mortality were noted among the very-low-volume hospital groups. An inverse correlation was noted between hospital volume and operative mortality in the present study, although wide variations in clinical outcome were noted among the very low-volume hospitals. Further analysis is warranted using risk-adjusted data.

There is considerable evidence that patients undergoing various types of complex treatments or high-risk surgical procedures have lower mortality rates and otherwise better outcomes if care is provided in hospitals that have a high caseload of patients with the same condition than if care is provided by institutions with low caseloads of such patients. Notwithstanding the fact that some low-volume institutions have good outcomes and some high-volume hospitals have relatively poor outcomes, this relation between high volume and better outcomes is strong and persistent, with approximately 300 studies on the subject having been reported in the English-language literature since the . . .