TABLE 5.6

California Hospital Pancreatectomy Volume and Outcomes, 1990-1994

Hospital Volume (no. of cases)

No. of Hospitals

Length of Hospital Stay (days)

Total Charges ($)

Patients Discharged to Home (%)

Crude Mortality (%)

Risk-Adjusted Mortality Rate (%)

1 to 5

210

22.7

87,857

74.3

14.1

14.1

6 to 10

53

22.7

76,593

80.0

10.4

9.6

11 to 20

20

22.9

78,003

81.8

8.9

8.7

21 to 30

9

20.2

70,959

92.1

5.7

6.9

31 to 50

4

23.9

111,497

87.1

8.2

8.3

>50

2

20.5

71,585

95.1

3.5

3.5

Mean

 

22.3

83,479

82.1

9.9

9.9

 

SOURCE: Glasgow and Mulvihill, 1996.

TABLE 5.7

Volume-Outcome Effect for Pancreatectomy in New York State, 1984-1991

Hospital Volume (no. of surgeries over 7 years)

No. of Hospitals

Percentage of Total Patients

Mean Length of Stay (days)

Standardized Mortality (%)

<10

124

24

35

18.9

10-50

57

54

32

11.8

51-80

1

3

22

12.9

>81

2

19

27

5.5

 

SOURCE: Lieberman et al., 1995.

Employing a similar method, Lieberman et al. (1995) used hospital discharge abstracts to identify 1,972 patients having pancreatic resection in New York State between 1984 and 1991. Table 5.7 clearly shows the same higher-volume-better survival relationship, with mortality rates three times as high (18.9 versus 5.5 percent) in the low-(fewer than 10 cases) compared to the high-volume hospitals (more than 81 cases), after adjusting for patient characteristics (age, sex, race, number of secondary diagnoses), admission status, transfer status, year of surgery, and payer status. About one-quarter (24 percent) of patients were cared for in hospitals seeing fewer than 10 cases per year. The effect on outcomes of the volume of surgeries performed by physicians was also assessed and was not found to be a predictor of in-hospital mortality.

The volume-outcome association is also evident in a National Cancer Data Base (NCDB) study of 8,917 cases of pancreatic cancer in 1983-1985, and 8,025 cases in 1990 from 978 hospitals (25 percent teaching institutions) (Janes et al., 1996). The 1990 unadjusted operative mortality among patients receiving potentially curative cancer surgery was 7.7 percent in hospitals where fewer than 5 patients were seen per year and 4.2 percent in hospitals where 20 or more patients per year were treated. The trend of better outcomes with higher volumes was evident at each stage of disease. Teaching and community comprehensive hospitals had lower operative mortality (4.7 and 4.6 percent, respectively), whereas community hospitals and hospitals without



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