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Trends and Disparities in Regionalization of Pancreatic Resection

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

The current recommendation is that pancreatic resections be performed at hospitals doing >10 pancreatic resections annually.

Objective

To evaluate the extent of regionalization of pancreatic resection and the factors predicting resection at high-volume centers (>10 cases/year) in Texas.

Methods

Using the Texas Hospital Inpatient Discharge Public Use Data File, we evaluated trends in the percentage of patients undergoing pancreatic resection at high-volume centers (>10 cases/year) from 1999 to 2004 and determined the factors that independently predicted resection at high-volume centers.

Results

A total of 3,189 pancreatic resections were performed in the state of Texas. The unadjusted in-hospital mortality was higher at low-volume centers (7.4%) compared to high-volume centers (3.0%). Patients resected at high-volume centers increased from 54.5% in 1999 to 63.3% in 2004 (P = 0.0004). This was the result of a decrease in resections performed at centers doing less than five resections/year (35.5% to 26.0%). In a multivariate analysis, patients who were >75 (OR = 0.51), female (OR = 0.86), Hispanic (OR = 0.58), having emergent surgery (OR = 0.39), diagnosed with periampullary cancer (OR = 0.68), and living >75 mi from a high-volume center (OR = 0.93 per 10-mi increase in distance, P < 0.05 for all OR) were less likely to be resected at high-volume centers. The odds of being resected at a high-volume center increased 6% per year.

Conclusions

Whereas regionalization of pancreatic resection at high-volume centers in the state of Texas has improved slightly over time, 37% of patients continue to undergo pancreatic resection at low-volume centers, with more than 25% occurring at centers doing less than five per year. There are obvious demographic disparities in the regionalization of care, but additional unmeasured barriers need to be identified.

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Author information

Authors and Affiliations

  1. Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555-0542, USA

    Taylor S. Riall, Courtney M. Townsend Jr. & William H. Nealon

  2. Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA

    Karl A. Eschbach, Jean L. Freeman & James S. Goodwin

Authors
  1. Taylor S. Riall
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  2. Karl A. Eschbach
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  3. Courtney M. Townsend Jr.
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  4. William H. Nealon
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  5. Jean L. Freeman
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  6. James S. Goodwin
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Correspondence to Taylor S. Riall.

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Discussion

Russell G. Postier, M.D. (Oklahoma City, OK): I want to congratulate Dr. Riall and her colleagues on an informative paper that highlights the continued difficulty of getting the right patient to the right surgeon and the right center at the right time. Your manuscript data suggest that there are a number of factors in addition to medical politics that influence where a patient requiring pancreatic resection is referred. You postulate that the patients with less knowledge about volume outcome data might be more likely to be operated on by their local surgeon in a low-volume center. I would suggest that a lack of understanding regarding the appropriate treatment of patients requiring pancreatic surgery, especially in the case of pancreatic cancer, also represents a global lack of understanding of the uniqueness of approach required by these patients in the general physician population. At this meeting a year ago you presented disturbing data as to the surprisingly high number of patients with localized and presumably resectable and potentially curable pancreatic cancer who were not offered pancreatic resection. We all see patients whose referral to pancreatic surgical specialists has been delayed by weeks or months by unsuccessful attempts at obtaining a diagnosis percutaneously and by a lack of understanding of the low surgical mortality achieved in high-volume referral centers. It appears that we have more work to do in educating our referring physician colleagues than we may in educating our patients. I have four questions.

First of all, how do you explain the relatively good results in mortality achieved in the low-volume centers in Texas? Your operative mortality in the low-volume centers was 7.4% as compared to around 3% in your high-volume centers. This 7.4% is substantially lower than that seen in other studies, specifically the nearly 19% mortality seen in low-volume centers in Maryland.

Secondly, what is the volume necessary to achieve optimal results in pancreatic surgery? I am not sure that 10 cases, which is the Leapfrog criteria, are adequate, and I think the much higher volume than 10 per year done by the surgeons in your high-volume hospitals represents a substantially higher level of care.

Thirdly, the distal pancreatectomies, which were lumped with pancreaticoduodenectomies in your study, require the same level of expertise as do pancreaticoduodenectomies. In my view, the distal resection is a significantly less complex procedure, and a well-trained general surgeon may well be able to do that with good outcomes although they are not a high-volume provider. Do you have any data on this question or do you know of data?

And finally, you looked at hospital volume, not surgical volume. Do you think that low-volume surgeons operating in medium- or high- volume centers independently, without being mentored by high-volume surgeons, can achieve results equivalent to those of high-volume surgeons?

I think this is an important paper and I congratulate you and your colleagues for excellent work and you on a fine presentation. Thank you.

Taylor S. Riall, M.D. (Galveston, TX): Thank you, Dr. Postier. Your first question was regarding the good results at low-volume centers in Texas with a mortality rate of 7.4%. Our volume cutoff, as you mentioned, is arbitrary. If you made the volume cutoff at different points, you can see that mortality goes from as high as 12 or 13% to as low as 5%. It depends on where you make the cutoff, which brings me to your next question: what is the volume of pancreatic resections necessary and why did we choose a criteria of greater than 10?

We chose the Leapfrog criteria of greater than 10 resections per year primarily because organizations like the Leapfrog group and other health care purchasers are going to be the ones who are deciding where patients go. As of 2004 they are choosing greater than 10 cases as their cutoff. Also, with some of the concerns with regionalization, referring to Birkmeyer’s data, you need to pick a reasonable volume cutoff so that you don’t impose unreasonable travel burdens on patients. You don’t want patients having to travel several hundred miles to the nearest high-volume center. For these reasons, I think greater than 10 pancreatic resections per year is a reasonable cutoff.

Also, there was a paper presented at the SUS by Dr. Meguid and colleagues at Hopkins who looked at volume cutoff for pancreatic resection. They tried to pick the best volume cutoff. No matter where they chose the volume cutoff, they observed a difference between mortality between the high- and low-volume providers. So volume alone is not the only issue.

With regard to distal pancreatectomy, there are no data looking specifically at distal pancreatectomy comparing outcomes to low- and high-volume centers, although that would be simple to do.

With regard to multidisciplinary care, these patients are better served at centers that deal with pancreatic diseases and not done by the general surgeon. While distal pancreatectomy is technically easier, they have higher rates of fistulas than proximal pancreatectomies. I certainly think they should be performed at high-volume centers as well.

The question with regard to hospital and surgeon volume comes up all the time. Our data doesn’t have the ability to look at individual surgeons, but I am certain that individual surgeon experience plays a role. In order to achieve my suggestion of making some medium-volume centers high-volume centers, such centers will need mentoring from the high-volume centers to achieve the same results. Another interesting point is that if you look at the outcomes among high-volume centers only, there is incredible variability of care among the high-volume providers. We need to standardize the care among all the providers who are considered referral centers to optimize outcomes for patients undergoing pancreatic resection for any reason.

Work supported by the Society of University Surgeons_Wyeth Clinical Scholars Award and the Dennis W. Jahnigen Career Development Scholars Award.

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Riall, T.S., Eschbach, K.A., Townsend, C.M. et al. Trends and Disparities in Regionalization of Pancreatic Resection. J Gastrointest Surg 11, 1242–1252 (2007). https://doi.org/10.1007/s11605-007-0245-5

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