Volume Matters: Examining the Management of Necrotizing Pancreatitis in the United States
Ikemsinachi C Nzenwa1, Vahe S Panossian1, Michael P DeWane1
1Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA.
Objective:
To examine the impact of hospital volume on mortality and health care utilization in patients admitted with necrotizing pancreatitis (NP).
Background:
Over 20% of patients with acute pancreatitis develop NP, which has been associated with higher rates of procedural intervention, morbidity, and mortality.
Methods:
Adult patients admitted with NP were identified in the 2016 to 2019 Nationwide Readmissions Database. Hospital volume cutoffs were defined by tertiles of total NP admissions per year [low-volume (<9 admissions/year); medium-volume (9 to 25 admissions/year); high-volume (≥26 admissions/year)]. Subgroup analyses were performed for patients with NP undergoing procedural intervention. The primary outcome was in-hospital mortality. Multivariable logistic regression models determined the association between clinical outcomes and hospital volume.
Results:
A total of 25,483 patients were identified, 14.3% of whom underwent procedural intervention, with the highest rate of intervention occurring in high-volume hospitals. The most common interventions offered at low-volume and medium-volume hospitals were open necrosectomy and percutaneous drainage. In contrast, high-volume hospitals had increased rates of minimally invasive surgery and endoscopic management. High-volume centers had the highest mortality rate among all patients (7.3% vs 6.6% vs 5.5%, P < 0.001) but the lowest among the intervention-only cohort (7.5% vs 10.4% vs 12.0%, P < 0.001). After adjusting for confounders, high-volume centers had lower odds of mortality in all patients (odds ratio: 0.78, 95% CI: 0.65 to 0.93) and in the intervention-only cohort (odds ratio: 0.64, 95% CI: 0.42 to 0.96). High-volume hospitals were also associated with a shorter hospital stay and lower health care costs.
Conclusions:
Management of NP at high-volume hospitals was associated with improved survival and decreased health care utilization. As interventional techniques advance, following evidence-based guidelines and implementing clear referral pathways will optimize outcomes for both patients and hospital systems.
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