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Defining a Hospital Volume Threshold for Minimally Invasive Pancreaticoduodenectomy in the United States
Mohamed Abdelgadir Adam1, Samantha Thomas2, Linda Youngwirth1
1Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Importance:
There is increasing interest in expanding use of minimally invasive pancreaticoduodenectomy (MIPD). This procedure is complex, with data suggesting a significant association between hospital volume and outcomes.
Objective:
To determine whether there is an MIPD hospital volume threshold for which patient outcomes could be optimized.
Design, Setting, And Participants:
Adult patients undergoing MIPD were identified from the Healthcare Cost and Utilization Project National Inpatient Sample from 2000 to 2012. Multivariable models with restricted cubic splines were used to identify a hospital volume threshold by plotting annual hospital volume against the adjusted odds of postoperative complications. The current analysis was conducted on August 16, 2016.
Main Outcomes And Measures:
Incidence of any complication.
Results:
Of the 865 patients who underwent MIPD, 474 (55%) were male and the median patient age was 67 years (interquartile range, 59-74 years). Among the patients, 747 (86%) had cancer and 91 (11%) had benign conditions/pancreatitis. Overall, 410 patients (47%) had postoperative complications and 31 (4%) died in-hospital. After adjustment for demographic and clinical characteristics, increasing hospital volume was associated with reduced complications (overall association P < .001); the likelihood of experiencing a complication declined as hospital volume increased up to 22 cases per year (95% CI, 21-23). Median hospital volume was 6 cases per year (range, 1-60). Most patients (n = 717; 83%) underwent the procedure at low-volume (≤22 cases per year) hospitals. After adjustment for patient mix, undergoing MIPD at low- vs high-volume hospitals was significantly associated with increased odds for postoperative complications (odds ratio, 1.74; 95% CI, 1.03-2.94; P = .04).
Conclusions And Relevance:
Hospital volume is significantly associated with improved outcomes from MIPD, with a threshold of 22 cases per year. Most patients undergo MIPD at low-volume hospitals. Protocols outlining minimum procedural volume thresholds should be considered to facilitate safer dissemination of MIPD.
Insights
Minimally invasive pancreaticoduodenectomy (MIPD) outcomes improve with higher hospital volume, with an optimal threshold of 22 cases annually. Most MIPD procedures occur at lower-volume hospitals, increasing complication risks.
Area of Science:
- Surgical Oncology
- Gastroenterology
- Health Services Research
Background:
- Minimally invasive pancreaticoduodenectomy (MIPD) is gaining traction, but its complexity necessitates evaluating the impact of hospital volume on patient outcomes.
- Existing data suggest a significant correlation between the number of procedures a hospital performs and patient safety and success rates.
Purpose of the Study:
- To identify a specific hospital volume threshold for minimally invasive pancreaticoduodenectomy (MIPD) that optimizes patient outcomes.
- To analyze the relationship between annual hospital volume and the incidence of postoperative complications following MIPD.
Main Methods:
- Retrospective analysis of adult patients undergoing MIPD using the Healthcare Cost and Utilization Project National Inpatient Sample (2000-2012).
- Multivariable models with restricted cubic splines were employed to determine the hospital volume threshold associated with reduced postoperative complications.
- Statistical analysis adjusted for patient demographics and clinical characteristics.
Main Results:
- A total of 865 patients underwent MIPD; 47% experienced postoperative complications, and 4% died in-hospital.
- Increasing hospital volume was significantly associated with reduced complications (P < .001), with an optimal threshold identified at 22 cases per year.
- Patients undergoing MIPD at low-volume hospitals (≤22 cases/year) had significantly higher odds of postoperative complications (OR, 1.74; P = .04) compared to high-volume hospitals.
Conclusions:
- Hospital volume is a critical factor in achieving better outcomes for minimally invasive pancreaticoduodenectomy (MIPD), with a threshold of 22 cases annually showing significant benefit.
- The majority of MIPD procedures are performed at hospitals with lower annual volumes, potentially exposing more patients to increased risks.
- Implementing protocols that define minimum procedural volume thresholds for MIPD could enhance patient safety and guide the wider adoption of this complex surgical approach.
