J. Modrall1, R. M. Minter1, A. Minhajuddin4, J. Eslava-Schmalbach3, G. P. Joshi2, S. Patel1, E. B. Rosero2 1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Department Of Anesthesiology And Pain Management,Dallas, TX, USA 3Hospital Universitario Nacional De Colombia,Bogota, COLOMBIA, Colombia 4University Of Texas Southwestern Medical Center,Department Of Clinical Sciences,Dallas, TX, USA
Introduction: Studies have demonstrated improved clinical outcomes for high-volume surgeons performing index operations. As skills may transfer between operations, we hypothesized that there may be surrogate experience that yields similar outcomes for surgeons with a low-volume experience with a specific index operation, but who have high-volume experience with related procedures. Using esophagectomy as a sample index operation, we compared the outcomes of surgeons with a high volume of index operations to low-volume surgeons with the index operation who had significant experience with related surrogate procedures.
Methods: The Nationwide Inpatient Sample (2003-2009) was analyzed to identify patients undergoing open esophagectomy. Surgeons were stratified into low-, medium-, and high-volume groups based on annual volume of esophagectomy (operation-specific volume), corresponding to the <10th, 10-90th, and >90th percentiles of volume, respectively. Surrogate volume was defined as the aggregate annual volume per surgeon of several upper GI operations: excision of esophageal diverticulum, gastrectomy, gastroduodenectomy, and repair of diaphragmatic hernia. Three-level hierarchal generalized mixed models were used to test the association between mortality and operation-specific and surrogate case volume, adjusting for both patient and hospital characteristics.
Results: 26,795 esophagectomies were performed nationwide (2003-2009) with a crude in-hospital mortality rate of 5.2%. As expected, in-hospital mortality decreased with increasing volume performed annually: 10.1%, 5.5%, and 3.8% for low-, medium-, and high-volume surgeons, respectively (P<0.0001). A similar relationship was seen between surrogate surgeon volume and in-hospital mortality for esophagectomy, as low-, medium-, and high-volumes of surrogate operations were associated with mortality rates for esophagectomy of 9.8%, 5.7%, and 2.6% (P<0.0001). Among surgeons with a low-volume esophagectomy experience, increasing volume of surrogate operations improved the outcomes observed for esophagectomy: 12.2%, 9.5%, and 1.9% for low-, medium-, and high-surrogate-volume surgeons, respectively (P=0.026). Hierarchical multivariate analysis showed that both esophagectomy and surrogate volume were significant predictors of lower in-hospital mortality for esophagectomy (Table).
Conclusion: Both operation-specific volume and surrogate volume are significant predictors of in-hospital mortality for esophagectomy. These data suggest that the relationship between surgeon volume and outcomes may be more complex than previously recognized. Based on these observations, it would be premature to limit hospital privileges based on operation-specific surgeon volume criteria.
