High Volume and Outcome After Liver Resection: Surgeon or Center?
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- Eppsteiner, R.W., Csikesz, N.G., Simons, J.P. et al. J Gastrointest Surg (2008) 12: 1709. doi:10.1007/s11605-008-0627-3
In a case controlled analysis, we attempted to determine if the volume–survival benefit persists in liver resection (LR) after eliminating differences in background characteristics.
Using the Nationwide Inpatient Sample (NIS), we identified all LR (n = 2,949) with available surgeon/hospital identifiers performed from 1998–2005. Propensity scoring adjusted for background characteristics. Volume cut-points were selected to create equal groups. A logistic regression for mortality was then performed with these matched groups.
At high volume (HV) hospitals, patients (n = 1423) were more often older, white, private insurance holders, elective admissions, carriers of a malignant diagnosis, and high income residents (p < 0.05). Propensity matching eliminated differences in background characteristics. Adjusted in-hospital mortality was significantly lower in the HV group (2.6% vs. 4.8%, p = 0.02). Logistic regression found that private insurance and elective admission type decreased mortality; preoperative comorbidity increased mortality. Only LR performed by HV surgeons at HV centers was independently associated with improved in-hospital mortality (HR, 0.43; 95% CI, 0.22–0.83).
A socioeconomic bias may exist at HV centers. When these factors are accounted for and adjusted, center volume does not appear to influence in-hospital mortality unless LR is performed by HV surgeons at HV centers.