Hospital teaching status associated with reduced inpatient mortality and perioperative complications in surgical neuro-oncology
Studies have demonstrated that higher surgical volumes correlate with improved neurosurgical outcomes yet none exist evaluating the effects of hospital teaching status on the surgical neuro-oncology patient. We present the first analysis comparing brain tumor surgery perioperative outcomes at academic and non-teaching centers.
Brain tumor surgeries in the Nationwide Inpatient Sample (NIS) from 1998 to 2014 were identified. A teaching hospital, defined by the NIS, must have ≥ 1 Accreditation Council of Graduate Medical Education (ACGME) approved residency programs, Council of Teaching Hospitals membership, or have a ratio ≥ 0.25 of full-time residents to hospital beds. Annual treatment trends were stratified by hospital teaching status, assessing yearly caseload with linear regression. Multivariable logistic regression determined predictors of inpatient mortality/complications. Hospitals were further divided into quartiles by case volume and teaching status was compared in each.
Teaching hospitals (THs) exhibited an average annual increase in brain tumor surgeries (+ 1057/year, p < 0.0001). In multivariable analysis, teaching status was associated with decreased risk of mortality (OR 0.82, p = 0.0003) and increased likelihood of discharge home (OR 1.21, p < 0.0001). In subgroup analysis, within the highest hospital quartile by caseload, higher mortality rates and lower routine discharges were again seen at non-teaching hospitals (NTHs) (p = 0.0002 and p = 0.0016, respectively).
THs are performing more brain tumor surgeries over time with lower rates of inpatient mortality and perioperative complications even after controlling for hospital case volume. These results suggest a shift in neuro-oncology practice patterns favoring THs to optimize patient outcomes especially at the highest volume centers.
KeywordsBrain tumor Surgical neuro-oncology Craniotomy Academic centers Hospital teaching status Decreased morbidity and mortality
Compliance with ethical standards
Conflict of interest
This study was not funded by any source and all authors declare no conflict of interest.
All procedures performed in the study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments. Institutional Review Board (IRB) approval for the study was not necessary because all patient data with identifying information is stripped from the NIS repository.
- 5.Smith ER, Butler WE, Barker FG 2nd (2004) Craniotomy for resection of pediatric brain tumors in the United States, 1988 to 2000: effects of provider caseloads and progressive centralization and specialization of care. Neurosurgery 54:553–563. https://doi.org/10.1227/01.neu.0000108421.69822.67; discussion 563–555 CrossRefPubMedGoogle Scholar
- 6.Norderhaug I, Krogstad U, Ingebrigtsen T, Soreide O, Wiseth R, Myhre HO (2007) The Influence of Hospital or Physician Volume on Quality of Health Care. Oslo, NorwayGoogle Scholar
- 10.Moore BJ, White S, Washington R, Coenen N, Elixhauser A (2017) Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: The AHRQ Elixhauser Comorbidity Index. Med Care 55:698–705. https://doi.org/10.1097/MLR.0000000000000735 CrossRefPubMedGoogle Scholar
- 17.Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD (2011) "July effect": impact of the academic year-end changeover on patient outcomes: a systematic review. Ann Intern Med 155:309–315. https://doi.org/10.7326/0003-4819-155-5-201109060-00354 CrossRefPubMedGoogle Scholar
- 18.Khuri SF, Najjar SF, Daley J, Krasnicka B, Hossain M, Henderson WG, Aust JB, Bass B, Bishop MJ, Demakis J, DePalma R, Fabri PJ, Fink A, Gibbs J, Grover F, Hammermeister K, McDonald G, Neumayer L, Roswell RH, Spencer J, Turnage RH, Program VANSQI (2001) Comparison of surgical outcomes between teaching and nonteaching hospitals in the Department of Veterans Affairs. Ann Surg 234:370–382. https://doi.org/10.1097/00000658-200109000-00011; discussion 382–373 CrossRefPubMedPubMedCentralGoogle Scholar
- 20.Hyder O, Sachs T, Ejaz A, Spolverato G, Pawlik TM (2013) Impact of hospital teaching status on length of stay and mortality among patients undergoing complex hepatopancreaticobiliary surgery in the USA. J Gastrointest Surg 17:2114–2122. https://doi.org/10.1007/s11605-013-2349-4 CrossRefPubMedPubMedCentralGoogle Scholar
- 21.Hayanga AJ, Mukherjee D, Chang D, Kaiser H, Lee T, Gearhart S, Ahuja N, Freischlag J (2010) Teaching hospital status and operative mortality in the United States: tipping point in the volume-outcome relationship following colon resections? Arch Surg 145:346–350. https://doi.org/10.1001/archsurg.2010.24 CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Ihse I (2003) The volume-outcome relationship in cancer surgery: a hard sell. Ann Surg 238:777–781. https://doi.org/10.1097/01.sla.0000098616.19622.af CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Brown DA, Himes BT, Major BT, Mundell BF, Kumar R, Kall B, Meyer FB, Link MJ, Pollock BE, Atkinson JD, Van Gompel JJ, Marsh WR, Lanzino G, Bydon M, Parney IF (2018) Cranial Tumor Surgical Outcomes at a High-Volume Academic Referral Center. Mayo Clin Proc 93:16–24. https://doi.org/10.1016/j.mayocp.2017.08.023 CrossRefPubMedGoogle Scholar
- 29.Kalakoti P, Missios S, Menger R, Kukreja S, Konar S, Nanda A (2015) Association of risk factors with unfavorable outcomes after resection of adult benign intradural spine tumors and the effect of hospital volume on outcomes: an analysis of 18, 297 patients across 774 US hospitals using the National Inpatient Sample (2002–2011). Neurosurg Focus 39:E4. https://doi.org/10.3171/2015.5.FOCUS15157 CrossRefPubMedGoogle Scholar
- 30.Barker FG 2nd, Klibanski A, Swearingen B (2003) Transsphenoidal surgery for pituitary tumors in the United States, 1996–2000: mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab 88:4709–4719. https://doi.org/10.1210/jc.2003-030461 CrossRefPubMedGoogle Scholar
- 32.Kurian KM, Jenkinson MD, Brennan PM, Grant R, Jefferies S, Rooney AG, Bulbeck H, Erridge SC, Mills S, McBain C, McCabe MG, Price SJ, Marino S, Moyes E, Qian W, Waldman A, Vaqas B, Keatley D, Burchill P, Watts C (2018) Brain tumor research in the United Kingdom: current perspective and future challenges. A strategy document from the NCRI Brain Tumor CSG. Neurooncol Pract 5:10–17. https://doi.org/10.1093/nop/npx022 CrossRefPubMedGoogle Scholar