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The Impact of Increasing Hospital Volume on 90-Day Postoperative Outcomes Following Pancreaticoduodenectomy

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Journal of Gastrointestinal Surgery

Abstract

Background

Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system.

Methods

A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients’ 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases.

Results

Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers (>40 PD/year), 36.9% at medium-volume centers (20–39 PD/year), and 24.1% at lower-volume centers (10–19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) (p < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p < 0.0001) compared to lower-volume centers.

Conclusion

Progressive increases in hospital volume correspond to improved 90-day outcomes following PD.

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Acknowledgements

The authors declare no conflicts of interest. This study is funded by an Operating Grant from the Cancer Research Society and Rob Lutterman Memorial Fund, 2013–2015. The principal investigator (N.G.C.) is the Sherif and Mary Lou Hanna Chair in Surgical Oncology Research for salary and operating funds. All funding was used for collection, management, analysis, and interpretation of data. This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. Nor endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by CIHI. However, the analyses, conclusions, opinions, and statements expressed herein are those of the author and not necessarily those of CIHI. Parts of this material are based on data and information provided by Cancer Care Ontario (CCO). The opinions, results, view, and conclusions reported in this paper are those of the authors and do not necessarily reflect those of CCO. No endorsement by CCO is intended or should be inferred.

Author Contribution

D.J.K. made substantial contributions to the conception and design of the work, the acquisition, analysis, and interpretation of data for the work. N.G., Q.L., A.K., and C.C.E. made substantial contributions to the acquisition, analysis, and interpretation of data for the work. P.J.K., A.C.W., and N.M. made substantial contributions to the conception and design of the work. N.G.C. made substantial contributions to the conception and design of work, the acquisition, analysis, and interpretation of data for the work. All authors participated in drafting the work and revising it critically for important intellectual content, and final approval of the version to be published. All authors are in agreement to be accountable for all aspects of the work in ensuring that questions relating to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Authors and Affiliations

  1. Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada

    Daniel J. Kagedan, Paul J. Karanicolas, Alice C. Wei & Natalie G. Coburn

  2. Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Nik Goyert, Lawrence Paszat, Alexander Kiss, Craig C. Earle, Paul J. Karanicolas, Nicole Mittmann & Natalie G. Coburn

  3. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

    Qing Li, Lawrence Paszat, Alexander Kiss, Craig C. Earle & Natalie G. Coburn

  4. Faculty of Medicine, University of Toronto, Toronto, ON, Canada

    Lawrence Paszat, Craig C. Earle, Paul J. Karanicolas, Alice C. Wei & Natalie G. Coburn

  5. Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada

    Alexander Kiss, Paul J. Karanicolas, Alice C. Wei & Natalie G. Coburn

  6. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada

    Alice C. Wei

  7. 2075 Bayview Ave., Rm. T2-11, Toronto, ON, M4N 3M5, Canada

    Natalie G. Coburn

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  1. Daniel J. Kagedan
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Correspondence to Natalie G. Coburn.

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Funding Sources

This study is funded by an Operating Grant from the Cancer Research Society and Rob Lutterman Memorial Fund, 2013–2015. The principal investigator (N.G.C.) is the Sherif and Mary Lou Hanna Chair in Surgical Oncology Research for salary and operating funds. This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.

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An abstract based on these results has been presented at the American College of Surgeons Clinical Congress, October 2016 in Washington DC as a poster. There are no accompanying submission or publication requirements.

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Kagedan, D.J., Goyert, N., Li, Q. et al. The Impact of Increasing Hospital Volume on 90-Day Postoperative Outcomes Following Pancreaticoduodenectomy. J Gastrointest Surg 21, 506–515 (2017). https://doi.org/10.1007/s11605-016-3346-1

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