Dataset Information

Measuring the Volume-Outcome Relation for Complex Hospital Surgery.

ABSTRACT:

Background

Prominent studies continue to measure the hospital volume-outcome relation using simple logistic or random-effects models. These regression models may not appropriately account for unobserved differences across hospitals (such as differences in organizational effectiveness) which could be mistaken for a volume outcome relation.

Objective

To explore alternative estimation methods for measuring the volume-outcome relation for six major cancer operations, and to determine which estimation method is most appropriate.

Methods

We analyzed patient-level hospital discharge data from three USA states and data from the American Hospital Association Annual Survey of Hospitals from 2000 to 2011. We studied six major cancer operations using three regression frameworks (logistic, fixed-effects, and random-effects) to determine the correlation between patient outcome (mortality) and hospital volume.

Results

For our data, logistic and random-effects models suggest a non-zero volume effect, whereas fixed-effects models do not. Model-specification tests support the fixed-effects or random-effects model, depending on the surgical procedure; the basic logistic model is always rejected. Esophagectomy and rectal resection do not exhibit significant volume effects, whereas colectomy, pancreatic resection, pneumonectomy, and pulmonary lobectomy do.

Conclusions

The statistical significance of the hospital volume-outcome relation depends critically on the regression model. A simple logistic model cannot control for unobserved differences across hospitals that may be mistaken for a volume effect. Even when one applies panel-data methods, one must carefully choose between fixed- and random-effects models.

SUBMITTER: Kim W

PROVIDER: S-EPMC4937076 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

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Publications

Measuring the Volume-Outcome Relation for Complex Hospital Surgery.

Kim Woohyeon W Wolff Stephen S Ho Vivian V

Applied health economics and health policy 20160801 4

<h4>Background</h4>Prominent studies continue to measure the hospital volume-outcome relation using simple logistic or random-effects models. These regression models may not appropriately account for unobserved differences across hospitals (such as differences in organizational effectiveness) which could be mistaken for a volume outcome relation.<h4>Objective</h4>To explore alternative estimation methods for measuring the volume-outcome relation for six major cancer operations, and to determine ...[more]

PMID: 27083171

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Project description:BackgroundMost studies showing a volume outcome effect in resection surgery for oesophago-gastric cancer were conducted before the centralisation of clinical services. This study evaluated the relation between hospital- and surgeon volume and different risk-adjusted outcomes after oesophago-gastric (OG) cancer surgery in England between 2011 and 2013.MethodsIn data from the National Oesophago-Gastric Cancer Audit from the UK, multivariable random-effects logistic regression models were used to quantify the effect of surgeon and hospital volume on three outcomes: 30-day and 90-day mortality and anastomotic leakage. The models included patient risk factors to adjust for differences in case-mix among hospitals and surgeons. The between-cluster heterogeneity was estimated with the median odds ratio (MOR).ResultsThe study included patients treated at 42 hospitals and 329 surgeons. The median (interquartile range) of the annual hospital and surgeon volumes were 110 patients (82 to 137) and 13 patients (8 to 19), respectively. The overall rates for 30-day and 90-day mortality were 2.3% and 4.4% respectively, and the anastomotic leakage was 6.3%. Higher hospital volume was associated with lower 30-day mortality (OR: 0.94; 95% CI: 0.91-0.98) and lower anastomotic leakage rates (OR: 0.96; 95% CI: 0.93-0.98) but not 90-day mortality. Higher surgeon volume was only associated with lower anastomotic leakage rates (OR: 0.81; 95% CI: 0.72-0.92). Hospital volume explained a part of the between-hospital variation in 30-day mortality whereas surgeon volume explained part of the between-hospital variation in anastomotic leakage.ConclusionsIn the setting of centralized O-G cancer surgery in England, we could still observe an effect of volume on short-term outcomes. However, the effect is inconsistent, depending on the type of outcome measure under consideration, and much smaller than in previous studies. Efforts to centralise O-G cancer services further should carefully address the effects of both hospital and surgeon volume on the range of outcome measures that are relevant to patients.

Project description:ImportanceEarly surgery for severe primary degenerative mitral regurgitation is recommended, provided optimal outcomes are achievable. Contemporary national data defining mitral valve surgery volume and outcomes are lacking.ObjectiveTo assess national 30-day and 1-year outcomes of mitral valve surgery and define the hospital- and surgeon-level volume-outcome association with mitral valve repair or replacement (MVRR) in patients with primary mitral regurgitation.Design, setting, and participantsThis multicenter cross-sectional observational study used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to identify patients undergoing isolated MVRR for primary mitral regurgitation in the United States. Operative data were collected from July 1, 2011, to December 31, 2016, and analyzed from March 1 to July 1, 2019, with data linked to the Centers for Medicare and Medicaid Services.Main outcomes and measuresThe primary outcome was 30-day in-hospital operative mortality after isolated MVRR for primary mitral regurgitation. Secondary outcomes were 30-day composite mortality plus morbidity (any occurrence of bleeding, stroke, prolonged ventilation, renal failure, or deep wound infection), rate of successful mitral valve repair of primary mitral regurgitation (residual mitral regurgitation of mild [1+] or better), and 1-year mortality, reoperation, and rehospitalization for heart failure.ResultsA total of 55 311 patients, 1094 hospitals, and 2410 surgeons were identified. Increasing hospital and surgeon volumes were associated with lower risk-adjusted 30-day mortality, lower 30-day composite mortality plus morbidity, and higher rate of successful repair. The lowest vs highest hospital volume quartile had higher 1-year risk-adjusted mortality (hazard ratio [HR], 1.61, 95% CI, 1.31-1.98), but not mitral reoperation (odds ratio [OR], 1.51; 95% CI, 0.81-2.78) or hospitalization for heart failure (HR, 1.25; 95% CI, 0.96-1.64). The surgeon-level 1-year volume-outcome associations were similar for mortality (HR, 1.60; 95% CI, 1.32-1.94) but not significant for mitral reoperation (HR, 1.14; 95% CI, 0.60-2.18) or hospitalization for heart failure (HR, 1.17; 95% CI, 0.91-1.50).Conclusions and relevanceNational hospital- and surgeon-level inverse volume-outcome associations were observed for 30-day and 1-year mortality after mitral valve surgery for primary mitral regurgitation. These findings may help to define access to experienced centers and surgeons for the management of primary mitral regurgitation.

Dataset Information

Measuring the Volume-Outcome Relation for Complex Hospital Surgery.

Background

Objective

Methods

Results

Conclusions

Publications

Measuring the Volume-Outcome Relation for Complex Hospital Surgery.

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