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Greater hospital and surgeon TAAA treatment volumes contribute to better outcome. Given the relative high perioperative mortality associated with TAAA repair, regionalization of care to high-volume providers with consistently lower postoperative mortality deserves consideration by patients, physicians, and health care planners.

High surgeon volume and hospital volume of AAA repair were both associated with lower mortality compared with low-volume providers. Increased specialization in vascular surgery was associated with markedly decreased mortality independent of AAA repair volume. Health policy in support of selective referral for AAA repair should consider surgical specialization in addition to provider volume thresholds.

Hypothesis: Complex operations performed in teaching hospitals have similar outcomes as those performed in nonteaching hospitals.Design: Observational cohort study with clinical patient data obtained from the Nationwide Inpatient Sample. The Nationwide Inpatient Sample data were linked to the American Hospital Association hospital survey data for 1997 to determine hospital characteristics. Hospitals were considered high volume if they performed more than the median (50th percentile) number of procedures per year.Setting: Nationally representative sample of hospitals during 1996 and 1997.Patients: Individuals undergoing esophageal resection (n=1247), hepatic resection (n = 2073), or pancreatic resection (n=3337) in Nationwide Inpatient Sample hospitals during 1996 and 1997 were included.Main Outcomes Measures: Unadjusted and adjusted in-hospital mortality and prolonged length of stay (Ͼ75th percentile).Results: None of the procedures had higher operative mortality rates at teaching hospitals. In unadjusted analyses, pancreatic resection (4.0% vs 8.8%; PϽ.001), hepatic resection (5.3% vs 8.0%; P=.03), and esophageal resection (7.7% vs 10.2%; P=.10) had lower operative mortality rates at teaching compared with nonteaching hospitals. However, after adjusting for hospital volume in the multivariate analysis, hospital teaching status was no longer a predictor of operative mortality.Conclusions: Teaching hospitals have lower operative mortality rates for complex surgical procedures. However, the lower mortality rates at teaching hospitals can be explained by higher procedural volume.

In patients with acute limb ischemia, the more widespread use of heparin anticoagulation and, in select patients, performance of embolectomy rather than pursuing thrombolysis may improve patient outcomes.

ABSTRACT

Withholding radiotherapy after a high-percentage resection of NFA leads to a higher recurrence rate, but it avoids exposing all patients to the risks of radiation. Deferring radiotherapy for patients with complete or near-complete resection seems to be a safe and prudent approach, as our data suggest that recurrences may be detected early with high-resolution imaging and treated effectively with radiation at time of recurrence. Therefore, immediate postoperative radiotherapy may be eliminated for patients with complete or near complete resection of NFA and who agree to undergo close follow-up for a long period.

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