Pancreaticoduodenectomy in a low-resection volume region: a population-level study examining the impact of hospital-volume on surgical quality and longer-term survival

Narendra, Aaditya; Baade, Peter D.; Aitken, Joanne F.; Fawcett, Jonathan; Smithers, B. Mark

doi:10.1016/j.hpb.2019.11.015

Cited by 10 publications

(15 citation statements)

References 23 publications

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“…Improved long-term survival after PD has been associated with higher-volume hospitals. 6,13,14,16,25 However, the potentially confounding factors mostly associated with the underlying disease pathology are yet to be determined. In this study, there were no statistically significant differences in 1- or 3-year survival rates between the patients undergoing PD in the different hospital volume time periods despite an unexpected trend toward worse survival.…”

Section: Discussionmentioning

confidence: 99%

Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital

Mitsakos

Vohra

Fitzgerald

et al. 2021

The American Surgeon

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Background The literature is replete with studies that define the nexus of quantity and quality in complex surgical operations. These observations have heralded a call for centralization of care to high-volume centers. The purpose of this study was to chronicle improvements in quality associated with pancreaticoduodenectomy (PD) as a rural hospital matures from a low- to very high-volume center. Methods A retrospective review of a prospective pancreatic surgery database was undertaken from July 2007 to June 2020. Annual periods were characterized as low (≤12/year), high (13-29/year), and very high volume (≥30/year). Data for the following quality benchmarks were aggregated and compared: length of stay (LOS), 30-day readmissions, 30-day mortality, and 1- and 3-year survival. A subgroup analysis was undertaken in those patients undergoing PD for adenocarcinoma detailing margin status and number of lymph nodes harvested. Outcomes were compared using the Fisher’s exact and Student’s t-test. Results 375 PD were completed over the 13-year period; 62.1% were undertaken for ductal adenocarcinoma. There was a significant decrease in LOS and 30-day readmissions as the institution matured toward very high volume. There were no significant differences in 30-day mortality, 1- and 3-year survival, or margin negativity rates associated with volume. Extent of lymph node harvest significantly improved as institutional experience increased. Discussion Our pancreatic surgery program matured rapidly from low to very high volume with institutional commitment and dedicated resources. As the institution matured, operational efficiencies and surgical quality improved. Not unexpectedly, biology trumped volume as reflected in 1- and 3-year survival rates.

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Section: Discussionmentioning

confidence: 99%

Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital

Mitsakos

Vohra

Fitzgerald

et al. 2021

The American Surgeon

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“…Data were collected for all patients undergoing gastrectomy and oesophagectomy for cancer in Queensland from 1 January 2001 to 31 December 2015 from the Queensland Oncology Repository. This data set has been previously described 14–16 and contains information obtained from multiple administrative databases and from all 149 public and private hospitals located in Queensland. Morphology was restricted to adenocarcinoma of both cancers and squamous carcinoma of the oesophagus.…”

Section: Methodsmentioning

confidence: 99%

Hospital characteristics associated with better ‘quality of surgery’ and survival following oesophagogastric cancer surgery in Queensland: a population‐level study

Narendra

Baade

Aitken

et al. 2020

ANZ Journal of Surgery

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Background The impact of hospital characteristics on the quality of surgery and survival following oesophagogastric cancer surgery has not been well established in Australia. We assessed the interaction between hospital volume, service capability and surgical outcomes, with the hypothesis that both the quality of surgery and survival are better following treatment in high‐volume, high service capability hospitals. Methods All patients undergoing oesophagectomy and gastrectomy for cancer in Queensland, between 2001 and 2015, were included. Demographic, pathology and outcome data were collected. Hospitals were categorized into high (HV) (≥5 gastrectomies; ≥6 oesophagectomies) and low volume (LV). Hospital service capability was defined as high (HS) and low (LS), and then linked to hospital volume: HVHS, LVHS and LVLS. Higher quality surgery was defined using six perioperative parameters. Univariable comparisons of quality of surgery between hospital groups used chi‐squared tests. The 5‐year overall survival was compared using log‐rank tests and Cox proportional hazard models. Results For both gastrectomy and oesophagectomy, higher quality surgery occurred more frequently in HVHS hospitals (gastrectomy: HVHS = 44.2%, LVHS = 23.1%, LVLS = 29.1% (P < 0.01); oesophagectomy: HVHS = 34.5%, LVHS = 24.4%, LVLS = 21.7% (P = 0.01)). Following oesophagectomy, the 3‐ and 5‐year overall survival was better following treatment in HVHS (P < 0.01). There was no difference between the groups following gastrectomy. Conclusion In Queensland, the quality of surgery was higher in HVHS hospitals performing gastrectomy and oesophagectomy; however, the impact on cancer survival was only seen following oesophagectomy.

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“…comm., 2021). Previous studies from other Australian states suggest an overall mortality between 3% and 4%, [8][9][10][12][13][14][15][16][17][18][19][20] similar to Europe, but greater than the USA. [21][22][23] Almost one-fifth of American patients offered a PD would accept a sixfold increased risk in exchange for locally delivered care.…”

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confidence: 99%

“…11 Centralizing PD would disadvantage regional patients and their families. Almost half of all PD are still undertaken in low-volume hospitals 12,13 and this may in part reflect patient preference. Centralists believe patients cannot possibly understand data that confound the experts.Since the two WA units were established in their current hospitals, the contemporary statewide 90-day mortality is three (0.6%) in over 500 consecutive PD (pers.…”

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Pancreaticoduodenectomy in Australia: a national quality improvement clinical registry is long overdue

Aitken

2022

ANZ Journal of Surgery

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Pancreaticoduodenectomy in Australia: a national quality improvement clinical registry is long overdue 'Practice makes perfect' is an axiom of life and for those who believe in centralizing low-volume, complex, high-risk operations. During the last 40 years, multiple studies, systemic reviews and meta-analysis have attempted to determine whether centralizing pancreaticoduodenectomy (PD) into high-volume hospitals improves outcomes. The many studies over so long attest to their limitations and conflicted interpretation. 1,2 The centralists quote the many volume-outcome studies showing lower mortality in high-volume hospitals. They will in future quote two studies in this issue of the journal. In one study, Kovoor et al. 3 have extended their earlier review 2 by undertaking a meta-analysis that confirms a lower in-hospital mortality in high-volume hospitals whatever the cut off. 4,5 In the other study, Yau et al. 6 report how a 16% statewide mortality prompted the Western Australia Health Department to centralize PD to three, now two, specialist units. 7 Their 90-day mortality fell from 4.9% to 1.2% with a statistical reduction in major PD-related complications.Australian regionalists will claim that previous, predominately overseas, studies were based on observational, administrative data, rarely risk adjusted and that almost one-third found no volumeoutcome relationship. 2 High volume in some studies overlapped with low volumes in others. They believe volume may be proxy for other factors and that low-volume, specialist units can achieve good outcomes. [8][9][10] The regionalists will also emphasize the imperative to fully utilize Australia's regional hospitals. The centralists know this as their hospitals are already at capacity and facing increasing demands. They have limited ability to take on cases that could be managed in a regional hospital. The adverse consequences of the COVID-19 pandemic on PD centralization are already being reported. 11 Centralizing PD would disadvantage regional patients and their families. Almost half of all PD are still undertaken in low-volume hospitals 12,13 and this may in part reflect patient preference. Centralists believe patients cannot possibly understand data that confound the experts.Since the two WA units were established in their current hospitals, the contemporary statewide 90-day mortality is three (0.6%) in over 500 consecutive PD (pers. comm., 2021). Previous studies from other Australian states suggest an overall mortality between 3% and 4%, [8][9][10][12][13][14][15][16][17][18][19][20] similar to Europe, but greater than the USA. [21][22][23] Almost one-fifth of American patients offered a PD would accept a sixfold increased risk in exchange for locally delivered care. 24 It is not known how far Australian patients would travel for a sixfold reduction in mortality.Other states will object to such comparison noting their different geography and population distribution. They will also argue that

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Pancreaticoduodenectomy in a low-resection volume region: a population-level study examining the impact of hospital-volume on surgical quality and longer-term survival

Abstract: examining the impact of hospital-volume on surgical quality and longer-term survival.

Cited by 10 publications

References 23 publications

Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital

Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital

Hospital characteristics associated with better ‘quality of surgery’ and survival following oesophagogastric cancer surgery in Queensland: a population‐level study

Pancreaticoduodenectomy in Australia: a national quality improvement clinical registry is long overdue

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