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:BACKGROUND:Outcomes for pancreatic resection have been studied extensively due to the high morbidity and mortality rates, with high-volume centers achieving superior outcomes. Ongoing investigations include healthcare costs, given the national focus on reducing expenditures. Therefore, we sought to evaluate the relationships between pancreatic surgery costs with perioperative outcomes and volume status. METHODS:We performed a retrospective analysis of 27,653 patients who underwent elective pancreatic resections from October 2013 to June 2017 using the Vizient database. Costs were calculated from charges using cost-charge ratios and adjusted for geographic variation. Generalized linear modeling adjusting for demographic, clinical, and operation characteristics was performed to assess the relationships between cost and length of stay, complications, in-hospital mortality, readmissions, and hospital volume. High-volume centers were defined as hospitals performing???19 operations annually. RESULTS:The unadjusted mean cost for pancreatic resection and corresponding hospitalization was $20,352. There were no differences in mean costs for pancreatectomies performed at high- and low-volume centers [-?$1175, 95% confidence interval (CI) -?$3254 to $904, p?=?0.27]. In subgroup analysis comparing adjusted mean costs at high- and low-volume centers, there was no difference among patients without an adverse outcome (-?$99, 95% CI -?$1612 to 1414, p?=?0.90), one or more adverse outcomes (-?$1586, 95% CI -?$4771 to 1599, p?=?0.33), or one or more complications (-?$2835, 95% CI -?$7588 to 1919, p?=?0.24). CONCLUSIONS:While high-volume hospitals have fewer adverse outcomes, there is no relationship between surgical volume and costs, which suggests that, in itself, surgical volume is not an indicator of improved healthcare efficiency reflected by lower costs. Patient referral to high-volume centers may not reduce overall healthcare expenditures for pancreatic operations.

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.

Similar Datasets

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