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High Hospital Volume Is Associated with Better Outcomes for Breast Cancer Surgery: Analysis of 233,247 Patients

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The relationship between hospital volume and outcomes needs to be further elucidated for low-risk procedures such as surgical therapy of localized breast cancer. The objective of this investigation was to assess the relationship between hospital volume and outcomes for breast cancer surgery.


A total of 233,247 patients who underwent breast-conserving therapy (BCT) and breast-ablative therapy (BAT) for localized breast cancer were extracted from 13 years (1988–2000) of the Nationwide Inpatient Samples. Hospital volume was classified as low (<30 cases/year), intermediate (≥ 30 to <70cases/year), and high (≥ 70 cases/year). Multiple linear and logistic regression analyses were used to assess the risk-adjusted association between hospital volume and outcomes.


In risk-adjusted analyses, patients operated on at low-volume hospitals were 3.04 (p = 0.03) times more likely to die after BCT compared with patients operated on at high-volume hospitals. Similarly, low-volume hospitals had a significantly higher likelihood of postoperative complications (odds ratio [OR] = 1.73, p = 0.01 for BCT; OR = 1.44, p < 0.001 for BAT) compared with high-volume hospitals. Compared with low-volume hospitals, length of hospital stay was significantly shorter and nonroutine patient discharge significantly lower for high-volume providers for both BCT and BAT (all p < 0.001). Patients were also significantly less likely to undergo BCT if operated on in a low- or intermediate-volume hospital compared with a high-volume provider (p < 0.001).


High-volume hospitals had significantly lower nonroutine patient discharge, postoperative morbidity and mortality, shorter length of hospital stay, and higher likelihood of performing BCT. Referral of patients with localized breast cancer to high-volume hospitals may be justified.

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The authors thank the Swiss National Foundation, Bern, Switzerland; Krebsliga beider Basel, Basel, Switzerland; Freiwillige Akademische Gesellschaft, Basel, Switzerland; and Fondazione Gustav e Ruth Jacob, Aranno, Switzerland, for their financial support of Dr. Guller’s research fellowship at the Duke University Medical Center. The authors thank the Division of Orthopedic Surgery, Duke University Medical Center, Durham, North Carolina, purchasing the Nationwide Inpatient Samples 1988–2000.

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Correspondence to Ulrich Guller M.D., MHS.



Postoperative In-Hospital Morbidity

A. Mechanical wound complications:

Delayed wound healing: 998.83

Postoperative hematoma: 998.12

Disruption of operative wound: 998.3

Persistent postoperative fistula: 998.6

Emphysema resulting from procedure: 998.81

B. Infections:

Postoperative skin abscess: 998.59

Postoperative septic wound complications: 998.59

Postoperative skin infection: 998.59

Postoperative infected seroma: 998.51

C. Complications during procedure:

Accidental puncture or laceration, complicating surgery: 998.2

Foreign body accidentally left during procedure: 998.4

Bleeding complicating procedure: 998.11

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Guller, U., Safford, S., Pietrobon, R. et al. High Hospital Volume Is Associated with Better Outcomes for Breast Cancer Surgery: Analysis of 233,247 Patients . World J. Surg. 29, 994–999 (2005).

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