M. M. Symer1, L. Gade3, A. Sedrakyan2, H. Yeo1,2 1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy,New York, NY, USA 3NewYork-Presbyterian / Queens,Surgery,New York, NY, USA
Introduction: There is a strong volume-outcome relationship in pancreatectomy, but whether the same relationship exists for other complex hepatopancreatobiliary (HPB) procedures is not known. The role of surgeon experience is clearly important, but whether it should be defined by cumulative volume or a more contemporaneous measure like annual volume is unclear. We compared the outcomes of surgeons across the spectrum of experience to better define the volume-outcome relationship in complex HPB surgery.
Methods: We identified all patients undergoing major elective HPB operations in New York State from 2000 to 2014 using the Statewide Planning and Research Cooperative Database. Major resections such as liver lobectomy, proximal pancreatectomy, as well as bile duct resection and complex repair were included, while wedge resections, distal pancreatectomy, and percutaneous or endoscopic procedures were excluded. In-hospital mortality and perioperative outcomes were compared across four categories of surgeons based on high or low annual and high or low cumulative operative volume. Median volume was used as the cut-point for high vs. low categories.
Results:13,236 operations performed by 893 surgeons were included in the study. Median cumulative volume was 89 operations, and median annual volume was 21 operations. Similar numbers of procedures were performed by low cumulative/low annual (LCLA) volume surgeons and high cumulative/high annual (HCHA) volume surgeons (6106 vs. 6176 operations). HCHA surgeons treated slightly older patients than LCLA surgeons (63.0y vs. 61.1y, p<0.01). HCHA surgeons also treated fewer Medicaid (5.6% vs. 10.0%, p<0.01) or Black patients (5.2% vs. 10.2%, p<0.01). HCHA surgeons performed many more minimally invasive procedures (15.2% of HCHA operations vs. 5.7% of LCLA operations, p<0.01). Mortality was lowest for HCHA and highest for LCLA surgeons (1.6% vs. 3.7%, p<0.01). Adjusted odds of in-hospital mortality were lower only for those patients undergoing surgery by HCHA volume surgeons (OR 0.47 95%CI 0.32-0.67), but not HCLA volume surgeons (OR 0.58 95%CI 0.28-1.20), or LCHA volume surgeons (OR 0.82 95%CI 0.44-1.53). 30d major events (e.g. stroke, shock), reoperation, and readmission were not affected by cumulative or annual experience.
Conclusion:In this large New York State based study of complex, elective HPB operations only surgeons with high cumulative and high annual volume have improved in-hospital mortality. In isolation, neither high cumulative volume, nor high annual volume alone were associated with improved outcomes. Racial and socioeconomic disparities in access to high-volume care persist. Interventions to regionalize complex surgical care should account for these distinctions.