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Surgeon Volume Correlates with Reduced Mortality and Improved Quality in the Surgical Management of Diverticulitis

  • 2015 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Volume has been shown to be an important determinant of quality and cost outcomes.

Methods

We performed a retrospective study of patients who underwent surgery for diverticulitis using the University HealthSystem Consortium database from 2008–2012. Outcomes evaluated included minimally invasive approach, stoma creation, intensive-care admission, post-operative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized into four categories by mean annual volumes: very-high (VHVS) (>31), high (HVS) (13–31), medium (MVS) (6–12), and low (LVS) (≤5).

Results

A total of 19,212 patients with a mean age of 59 years, 54 % female makeup, and 55 % rate of private insurance were included. Similar to the unadjusted analysis, multivariable analysis revealed decreasing odds of stoma creation, complications, ICU admission, reoperation, readmission, and inpatient mortality with increasing surgeon volume. Additionally, compared with LVS, a higher surgeon volume was associated with higher rates of the minimally invasive approach. Median length of stay and costs were also notably lower with increasing surgeon volume.

Conclusion

Quality and the use of minimally invasive technique are tightly associated with surgeon volume. Further studies are necessary to validate the direct association of volume with outcomes in surgery for diverticulitis.

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Author information

Authors and Affiliations

  1. Department of Surgery, University of Massachusetts Medical School, 55 Lake Ave Room S3-752, Worcester, MA, 01655, USA

    Rachelle N. Damle

  2. Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA

    Julie M. Flahive

  3. Division of Colon and Rectal Surgery, University of Massachusetts Medical School, Worcester, MA, USA

    Jennifer S. Davids, W. Brian Sweeney, Paul R. Sturrock, Justin A. Maykel & Karim Alavi

Authors
  1. Rachelle N. Damle
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  2. Julie M. Flahive
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  3. Jennifer S. Davids
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  4. W. Brian Sweeney
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  5. Paul R. Sturrock
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  6. Justin A. Maykel
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  7. Karim Alavi
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Corresponding author

Correspondence to Rachelle N. Damle.

Additional information

Primary Discussant

Martin E. Kreis, M.D., MHBA (Berlin, Germany): Congratulations to this interesting study and thanks for the privilege to review the paper ahead of time.

It is well-established that quality of complex surgical procedures such as esophagectomy, pancreas resections or rectal cancer surgery improves with increasing volume. Rachelle Damle and coauthors now showed that this also seems to apply for surgery for diverticular disease i.e., that patients operated by low-volume surgeons for diverticular disease have worse outcomes compared to patients operated by high-volume surgeons.

I have the following questions:

1. The data set is huge, so that even small difference may become significant. Differences in complications vary from 7 to 13 %. Are these clinically relevant according to your opinion?

2. You mentioned in the manuscript that emergency procedures were more frequently performed by low-volume surgeons. As operations on emergency basis normally have worse outcome, may this have biased your results in disfavor of low-volume surgeons?

3. The same applies for comorbidity and age. Patients who are older or not well may choose to have surgery from a non-specialized surgeon nearby which may affect outcome for low-volume surgeons negatively due to patient selection. Was quality assessment corrected for a potential bias by comorbidity and age in your study?

I think we need to be careful not to implicitly attribute low volume and subsequently poorer outcome exclusively to surgical expertise. Other concomitant factors may explain these inferior results for low-volume surgeons and if this is correct, sanctions by health care providers for this “lower quality” are not acceptable.

Again, congratulations to this study and analysis of such a comprehensive database.

Closing Discussant

Dr. Damle: 1. Yes, the dataset is large, and we are susceptible to finding statistically significant differences in outcomes between groups that are not necessarily clinically relevant. However, in the case of these complication rates, we do believe the difference is clinically relevant, as these include major complications, such as stroke, myocardial infarction, deep wound space infections, etc. The absolute number of patients experiencing these outcomes is large, given the size of our cohort, thus it bears a certain level of significance.

2. This is an excellent point, and we did acknowledge that prior to our analysis. In order to account for this, we adjusted for the procedure status (elective, urgent, emergent) in our multivariable models, so the differences we observed remain, even when adjusting for low-volume surgeons being more likely to perform the procedure emergently.

3. This is an excellent point. As per the previous discussion, we did account for this baseline difference between groups by including the patient’s severity of illness and age in our multivariable models.

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Damle, R.N., Flahive, J.M., Davids, J.S. et al. Surgeon Volume Correlates with Reduced Mortality and Improved Quality in the Surgical Management of Diverticulitis. J Gastrointest Surg 20, 335–342 (2016). https://doi.org/10.1007/s11605-015-2990-1

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  • DOI: https://doi.org/10.1007/s11605-015-2990-1

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