Journal of Gastrointestinal Surgery

, Volume 18, Issue 4, pp 690–700 | Cite as

Impact of Surgeon and Hospital Volume on Mortality, Length of Stay, and Cost of Pancreaticoduodenectomy

  • Laura M. EnomotoEmail author
  • Niraj J. Gusani
  • Peter W. Dillon
  • Christopher S. Hollenbeak
Original Article



Improved mortality rates following pancreaticoduodenectomy by high-volume surgeons and hospitals have been well documented, but less is known about the impact of such volumes on length of stay and cost. This study uses data from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) to examine the effect of surgeon and hospital volume on mortality, length of stay, and cost following pancreaticoduodenectomy while controlling for patient-specific factors.


Data included 3,137 pancreaticoduodenectomies from the NIS performed between 2004 and 2008. Using logistic regression, the relationship between surgeon volume, hospital volume, and postoperative mortality, length of stay, and cost was estimated while accounting for patient factors.


After controlling for patient characteristics, patients of high-volume surgeons at high-volume hospitals had a significantly lower risk of mortality compared to low-volume surgeons at low-volume hospitals (OR 0.32, p < 0.001). Patients of high-volume surgeons at high-volume hospitals also had a five day shorter length of stay (p < 0.001), as well as significantly lower costs (US$12,275, p < 0.001).


The results of this study, which simultaneously accounted for surgeon volume, hospital volume, and potential confounding patient characteristics, suggest that both surgeon and hospital volume have a significant effect on outcomes following pancreaticoduodenectomy, affecting not only mortality rates but also lengths of stay and costs.


Volume Pancreaticoduodenectomy Mortality Length of stay Cost 


Authors' Contributions

Drs. Enomoto and Hollenbeak had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Conflict of Interest



  1. 1.
    Birkmeyer JD, Stukel TA, Siewers AE, et al.: Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117-2127.PubMedCrossRefGoogle Scholar
  2. 2.
    Birkmeyer JD, Siewers AE, Finlayson EV, et al.: Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128-1137.PubMedCrossRefGoogle Scholar
  3. 3.
    Begg CB, Cramer LD, Hoskins WJ, Brennan MF: Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998;280:1747-1751.PubMedCrossRefGoogle Scholar
  4. 4.
    Al-Refaie WB, Muluneh B, Zhong W, et al.: Who receives their complex cancer surgery at low-volume hospitals? J Am Coll Surg 2012;214:81-87.PubMedCrossRefGoogle Scholar
  5. 5.
    Fong Y, Gonen M, Rubin D, et al.: Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg 2005;242:540-544; discussion 544-547.PubMedCentralPubMedGoogle Scholar
  6. 6.
    Eppsteiner RW, Csikesz NG, McPhee JT, et al.: Surgeon volume impacts hospital mortality for pancreatic resection. Ann Surg 2009;249:635-640.PubMedCrossRefGoogle Scholar
  7. 7.
    Stitzenberg KB, Meropol NJ: Trends in centralization of cancer surgery. Ann Surg Oncol 2010;17:2824-2831.PubMedCrossRefGoogle Scholar
  8. 8.
    Epstein AJ, Gray BH, Schlesinger M: Racial and ethnic differences in the use of high-volume hospitals and surgeons. Arch Surg 2010;145:179-186.PubMedCrossRefGoogle Scholar
  9. 9.
    Liu JH, Zingmond DS, McGory ML, et al.: Disparities in the utilization of high-volume hospitals for complex surgery. JAMA 2006;296:1973-1980.PubMedCrossRefGoogle Scholar
  10. 10.
    Janssen-Heijnen ML, Maas HA, Houterman S, et al.: Comorbidity in older surgical cancer patients: influence on patient care and outcome. Eur J Cancer 2007;43:2179-2193.PubMedCrossRefGoogle Scholar
  11. 11.
    HCUP Nationwide Inpatient Sample (NIS). InRockville, MD: Agency for Healthcare Research and Quality, 2004 - 2008.Google Scholar
  12. 12.
    Birkmeyer JD, Finlayson EV, Birkmeyer CM: Volume standards for high-risk surgical procedures: potential benefits of the Leapfrog initiative. Surgery 2001;130:415-422.PubMedCrossRefGoogle Scholar
  13. 13.
    Quan H, Sundararajan V, Halfon P, et al.: Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005;43:1130-1139.PubMedCrossRefGoogle Scholar
  14. 14.
    Shwartz M, Young DW, Siegrist R: The ratio of costs to charges: how good a basis for estimating costs? Inquiry 1995;32:476-481.PubMedGoogle Scholar
  15. 15.
    Schmidt CM, Turrini O, Parikh P, et al.: Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. Arch Surg 2010;145:634-640.PubMedCrossRefGoogle Scholar
  16. 16.
    Ho V, Aloia T: Hospital volume, surgeon volume, and patient costs for cancer surgery. Med Care 2008;46:718-725.PubMedCrossRefGoogle Scholar
  17. 17.
    Teh SH, Diggs BS, Deveney CW, Sheppard BC: Patient and hospital characteristics on the variance of perioperative outcomes for pancreatic resection in the United States: a plea for outcome-based and not volume-based referral guidelines. Arch Surg 2009;144:713-721.PubMedCrossRefGoogle Scholar
  18. 18.
    Glasgow RE, Mulvihill SJ: Hospital volume influences outcome in patients undergoing pancreatic resection for cancer. West J Med 1996;165:294-300.PubMedCentralPubMedGoogle Scholar
  19. 19.
    Milstein A, Galvin RS, Delbanco SF, et al.: Improving the safety of health care: the leapfrog initiative. Eff Clin Pract 2000;3:313-316.PubMedGoogle Scholar
  20. 20.
    Finks JF, Osborne NH, Birkmeyer JD: Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011;364:2128-2137.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Gasper WJ, Glidden DV, Jin C, et al.: Has recognition of the relationship between mortality rates and hospital volume for major cancer surgery in California made a difference?: A follow-up analysis of another decade. Ann Surg 2009;250:472-483.PubMedGoogle Scholar
  22. 22.
    Kennedy TJ, Cassera MA, Wolf R, et al.: Surgeon volume versus morbidity and cost in patients undergoing pancreaticoduodenectomy in an academic community medical center. J Gastrointest Surg 2010;14:1990-1996.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2013

Authors and Affiliations

  • Laura M. Enomoto
    • 1
    Email author
  • Niraj J. Gusani
    • 1
    • 2
  • Peter W. Dillon
    • 1
  • Christopher S. Hollenbeak
    • 1
    • 2
  1. 1.Department of SurgeryPenn State Milton S. Hershey Medical CenterHersheyUSA
  2. 2.Department of Public Health SciencesPenn State College of MedicineHersheyUSA

Personalised recommendations