Outcomes following pancreatic resection: Variability among high-volume providers

Background: A strong volume-outcome relationship has been demonstrated for pancreatic resection, and regionalization of care to high-volume centers (>11 resections/year) has been recommended. However, it is unclear if volume alone should be the sole criteria for regionalization. The objective of this study is to evaluate variability in outcomes among high-volume hospitals (>11 resections/year). Methods: We used the Texas Hospital Inpatient Discharge Database from 1999 through 2005 to evaluate variability in outcomes after pancreatic resection among high-volume hospitals in Texas. The outcome variables of interest were mortality, length of stay, discharge to a skilled nursing facility, operation within 24 hours of hospital admission, and total hospital charges. Unadjusted and adjusted models were performed. Results: A total of 12 high-volume hospitals were in Texas. The number of resections at each hospital ranged from 78-608 cases for the 7-year time period studied. In unadjusted models, there was significant variability in mortality (range, 0.7%-7.7%, P < .0001), duration of stay (range of medians, 9-21 days, P < .0001), the need for ongoing nursing care at discharge (range, 0.7%-41.4%, P < .0001), operation within 24 hours of admission (range, 41%-96%, P < .0001), and total hospital charges (median range, $38,318-$110,860, P < .0001). There were significant differences in the demographics, risks of mortality, and illness severity among the 12 high-volume hospitals. Therefore, multivariate models were used to control for age group, sex, race/ethnicity, risk of mortality, illness severity, admission status, diagnosis, procedure, and insurance status. In the multivariate models, the particular hospital at which the pancreatic surgery was performed was a significant independent predictor of every outcome variable except mortality. Conclusions: For pancreatic resection, there is significant variability in outcomes even among high-volume providers. Individual hospitals likely account for much of the variability not explained by hospital volume. Although the structure measure of hospital volume is easy to measure, these data suggest that it is not a reliable single measure of quality or outcomes after pancreatic surgery.