MIAMI BEACH – Studies continue to confirm it: When it comes to complex surgical procedures, higher volume equals better outcomes. But like the chicken-or-egg conundrum, researchers are asking which factor comes first – surgeon or facility.
Data presented at the annual meeting of the Americas Hepato-Pancreato-Biliary Association suggest that personal experience makes the biggest difference, at least for the difficult Whipple procedure. Surgeons who performed the highest number of pancreaticoduodenectomies each year had the best outcomes; when they transferred to low-volume hospitals with historically poor results, these surgeons improved perioperative complications, mortality, and readmissions, and lowered costs.
"The salutary effects of being a high-volume hospital for pancreaticoduodenectomy are transferred when high-volume surgeons relocate," said Dr. Paul Toomey. "It seems that the benefits of a high-volume hospital are more due to who does the surgery rather than where it’s undertaken."
Dr. Toomey, a surgical fellow at the Florida Hospital, Tampa, had a unique opportunity to study what happens when two surgeons highly experienced in the Whipple procedure transferred from a busy hospital to low-volume facilities. The surgeons, who together performed more than 100 of the procedures each year, moved for personal reasons, Dr. Toomey said in an interview.
The study focused on perioperative outcomes, mortality, and readmissions in two groups of Whipple patients: the last 50 undertaken at the high-volume hospital (more than 12 pancreaticoduodenectomies per year), and the first 50 at the low-volume hospital where they worked afterward.
The patient groups were similar. Their mean age was 78 years, a little more than half were men, and the average American Society of Anesthesiologists class was 3. The rates of malignancy were similar in the high- and low-volume centers (88% vs. 82%, respectively).
Overall, the average operative time was 252 minutes, with an estimated blood loss of 300 mL. Patients were in intensive care for 2 days, with an average hospital stay of 9 days. The readmission rate was 19% and 30-day mortality, 5%.
But when Dr. Toomey compared the two time periods, he found significant differences in outcomes, which appeared to be associated with the transfer of the highly experienced surgeons. In fact, he said, outcomes were actually much better at the low- than the high-volume centers after the transfer.
The mean operative time at the low-volume centers was 205 minutes, compared with 305 minutes at the high-volume centers. Estimated blood loss was also less at the low-volume centers (350 vs. 255 mL). ICU stays were significantly shorter (1 vs. 3 days), as was total length of stay (7 vs. 12 days). Readmission rates over 30 days were similar (20% vs. 18%), as was 30-day mortality (4% vs. 6%).
"The salutary benefits of being a high-volume hospital for pancreaticoduodenectomy seem to be transferred when high-volume surgeons relocate," Dr. Toomey said. "The benefits of a high-volume hospital may be more due to who does the pancreaticoduodenectomy rather than where the pancreaticoduodenectomy is undertaken."
Dr. Thomas Wood, also of the Florida Hospital, found a similar trend in his study, which examined Whipple outcomes statewide over 20 years. He related the outcomes to concentration, rather decentralization, of care.
For his study, Dr. Wood examined data from the Florida Agency for Health Care Administration, collected over three 3-year epochs: 1992-1994, 2001-2003, and 2010-2012. The data were sorted by surgeon volume of pancreaticoduodenectomy during these periods and correlated to length of stay, in-hospital mortality, and hospital charges, which were adjusted to 2012 dollars.
Over the 9 years, 893 surgeons performed 3,531 pancreaticoduodenectomies. During each epoch, the number of surgeons went down as the number of operations increased.
In the first epoch, 363 surgeons performed 729 operations. In the second, 334 surgeons performed 1,233 surgeries, and in the third, 196 performed 1,569 operations.
"By 2010-2012, 46% fewer surgeons undertook 115% more surgeries compared to the first period," Dr. Wood said. "In 1992-1994, 62% of pancreaticoduodenectomies were undertaken by surgeons who performed one or fewer per year. This fell to 13% by 2010-2012."
At the same time, the number of surgeons who performed more than 36 procedures in each 3-year period (12 per year) grew significantly. In the first epoch, one surgeon alone performed 45 procedures. In the second, six surgeons performed a total of 361. And in the third epoch, 11 surgeons performed 806 Whipples.
"From [the first through third periods,] there was an 11-fold increase in the number of high-volume surgeons and a corresponding 18-fold increase in the number of pancreaticoduodenectomies by surgeons who were performing at least 12 each year. They were performing more than 50% of these operations."