IMPORTANCE Despite growing interest from various surgical societies and patient safety organizations, concerns remain that volume-based credentialing standards are arbitrary and may fail to recognize a surgeon's full scope of practice. OBJECTIVE To evaluate whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone. DESIGN, SETTING, AND PARTICIPANTS This proof-of-concept cohort study used the all-payer State Inpatient Databases from 6 geographically diverse states to identify all operations for surgeons who performed at least 1 pancreaticoduodenectomy from January 1, 2012, to December 31, 2014. Each surgeon's mean annual volume for pancreaticoduodenectomies and related complex hepatopancreatobiliary (HPB) procedures was calculated. Outcomes for surgeons above and below a threshold of 12 pancreaticoduodenectomies per year were evaluated. Whether related HPB procedure volume was also associated with better outcomes for surgeons not meeting the procedure-specific threshold was also evaluated. Data were analyzed from March 2 through 20, 2019. MAIN OUTCOMES AND MEASURES Thirty-day mortality and complications. RESULTS The study cohort included 176 043 patients, of whom 92 064 were female (52.3%), with Author affiliations and article information are listed at the end of this article.

IMPORTANCEAlthough dual eligibility (DE) status for Medicare and Medicaid has been used for social risk stratification in value-based payment programs, little is known about the interplay between hospital quality and disparities in outcomes and spending by social risk. OBJECTIVE To assess whether treatment at high-quality hospitals mitigates DE-associated disparities in outcomes and spending for cancer surgery.

Objective: This study evaluates the variation in spending by the highestquality hospitals performing complex cancer surgery in the United States. Summary Background Data: As mortality rates for high-risk cancer surgery have improved, increased attention has focused on other elements of quality, such as complications. However, high-value surgical care requires both high-quality care and cost savings. Therefore, understanding any residual cost variation among high-quality hospitals is essential to better direct efforts to achieve efficient, high-value care. Methods: Medicare beneficiaries age 65 to 99 who underwent surgery for pancreas, esophageal, lung, rectal, and colon cancer from 2014 to 2016 were identified. The highest-quality hospitals were identified as those in the quintile with the lowest risk-and reliability-adjusted serious complication rates for each operation. Within this cohort of high-quality hospitals, 30-day total episode, index hospitalization, physician, postacute care, and readmis-sion spending were analyzed. Logistic regression models were utilized to estimate the probability of postoperative outcomes and post-discharge resource utilization. Results: A total of 43,007 Medicare patients underwent either pancreas, esophageal, lung, rectal, or colon resection for cancer at a hospital within the highest-quality quintile.

Background: In patients with resected gallbladder cancer (GBC), the role of adjuvant chemotherapy (aCT) remains ill-defined, especially in elderly patients. This study evaluates the value of aCT in elderly patients with GBC and assesses response according to tumor stage.Methods: Patients of ≥65 years of age with resected GBC diagnosed from 2004-2015 were identified using a Surveillance, Epidemiology and End Results (SEER)/Medicare linked database. After propensity score matching, survival of patients treated with aCT was compared to survival of patients who did not receive aCT using Kaplan-Meier and Cox proportional hazards analysis.Results: Of 2,179 patients with resected GBC, 876 (25%) received aCT. In the full cohort of 810 propensity-score matched patients, survival did not differ between patients treated with aCT (17.6 months ) and without aCT (19.5 months, P=0.7720). Subgroup analysis showed that survival was significantly better after aCT in T3/T4 disease (12.3 vs. 7.2 months, P=0.013). Interaction analysis showed that benefit of aCT was primarily seen in combined T3/T4, node-positive disease (HR 0.612 , P=0.006). Conclusions:In this large cohort of elderly patients with resected GBC, aCT was not associated with increased survival. However, aCT may provide a survival benefit in T3/4, node-positive disease.

Background: Several large volume centers have published positive outcomes with laparoscopic and robotic pancreaticoduodenectomy (PD). The purpose of this study was to compare postoperative outcomes between open, laparoscopic and robotic pancreaticoduodenectomies using ACS National Quality Improvement Program (ACS-NSQIP). Methods: We performed a Retrospective review of 2014e 2015 NSQIP targeted data for patients undergoing pancreaticoduodenectomies for pancreatic cancer. Patient who underwent conversion from robotic or laparoscopic approach to open were excluded. Outcome measures were: hospital length of stay, operative time, 30-day postoperative complications, and mortality. Results: 11,219 patients who underwent pancreaticoduodenectomies were evaluated. Majority were performed in open fashion (n=8654) were open, followed by laparoscopic (n = 1508), and robotic approach (n = 591).Compared to open approach, laparoscopic PD had lower rates of SSI (11% vs 3%; p = 0.02), higher rates of DVT (2.8% vs 6.6%; p = 0.034) and longer operative time (341 vs 480 min; p < 0.001).In comparison with OP, Robotic PD had lower rates of pneumonia (6.7% vs 1%; p = 0.03) and longer operative time (341 vs 510 min; p < 0.001). There was no significant difference between the three groups with regards to post-operative LOS, overall morbidity or mortality. Conclusion: Smaller incisions did not predict a small hospital length of stay; or a reduced mortality or morbidity benefit in patients undergoing PD.Background: We examined the relationship between body mass index (BMI) and complications after pancreatectomy using the novel Comprehensive Complications Index (CCI), which processes cumulative events rather than only the most severe. Methods: We retrospectively reviewed 500 patients (250 from USA and 250 from Europe) who underwent pancreatoduodenectomy (PD, N = 351) or distal pancreatectomy (DP, N = 123) for postoperative complications using CCI. Patient BMI was stratified as Normal (N = 256, 51.4%), Underweight (N = 14, 2.8%), Overweight (N = 140, 28.1%), and Obese (N = 88, 17.7%). Binomial and mutivariable regression was performed for factors associated with complications. Results: Patients with non-ideal BMI had more complications (p < 0.05 each underweight/overweight/obese category). Obese patients had higher CCI (24.2 vs. 20.9, p = 0.000), more severe Clavien-Dindo indices (p = 0.007), and pancreatic fistulae rates (17.0 vs. 8.2%, HR 1.308, p = 0.026). In multivariable analysis, factors independently associated with higher CCI were higher patient BMI (HR 1.13, p = 0.009) and Comorbidity Index (HR = 1.79, p = 0.001).Overweight/obese patients undergoing PD demonstrated higher CCI (29.6 vs. 20.9, p = 0.000), postoperative drainage procedures (14.0 vs. 3.9%, HR 2.173, p = 0.002), and 30-day readmissions (23.6 vs. 12.5%, HR 1.358, p = 0.027), with a trend toward more pancreatic fistulas (12.1 vs. 8.2%, HR 1.469, p = 0.06). Overweight/ obese patients undergoing DP had a demonstrated a trend towards higher CCI (20.9 vs. 8.7, p = 0.062). Concl...