Surgeon volume and elective resection for colon cancer: an analysis of outcomes and use of laparoscopy.

BACKGROUND: Surgeon volume may be an important predictor of quality and cost outcomes. We evaluated the association between surgeon volume and quality and cost of surgical care in patients with colon cancer. STUDY DESIGN: We performed a retrospective study of patients who underwent resection for colon cancer, using data from the University HealthSystem Consortium from 2008 to 2011. Outcomes evaluated included use of laparoscopy, ICU admission, postoperative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized according to high (HVS), medium (MVS), and low (LVS) average annual volumes. RESULTS: A total of 17,749 patients were included in this study. The average age of the cohort was 65 years and 51% of patients were female. After adjustment for potential confounders, compared with LVS, HVS and MVS were more likely to use laparoscopy (HVS, odds ratio [OR] 1.27, 95% CI 1.15, 1.39; MVS, OR 1.16 95% CI 1.65, 1.26). Postoperative complications were significantly lower in patients operated on by HVS than LVS (OR 0.77 95% CI 0.76, 0.91). The HVS patients were less likely to require reoperation than those in the LVS group (OR 0.70, 95% CI 0.53, 0.92) Total direct costs were $927 (95% CI -$1,567 to -$287) lower in the HVS group compared with the LVS group. CONCLUSIONS: Higher quality, lower cost care was achieved by HVS in patients undergoing surgery for colon cancer. An assessment of differences in processes of care by surgeon volume may help further define the mechanism for this observed association.

Centre volume and resource consumption in liver transplantation.

BACKGROUND: Using SRTR/UNOS data, it has previously been shown that increased liver transplant centre volume improves graft and patient survival. In the current era of health care reform and pay for performance, the effects of centre volume on quality, utilization and cost are unknown. METHODS: Using the UHC database (2009-2010), 63 liver transplant centres were identified that were organized into tertiles based on annual centre case volume and stratified by severity of illness (SOI). Utilization endpoints included hospital and intensive care unit (ICU) length of stay (LOS), cost and in-hospital mortality. RESULTS: In all, 5130 transplants were identified. Mortality was improved at high volume centres (HVC) vs. low volume centres (LVC), 2.9 vs. 3.4%, respectively. HVC had a lower median LOS than LVC (9 vs. 10 days, P < 0.0001), shorter median ICU stay than LVC and medium volume centres (MVC) (2 vs. 3 and 3 days, respectively, P < 0.0001) and lower direct costs than LVC and MVC ($90,946 vs. $98,055 and $101,014, respectively, P < 0.0001); this effect persisted when adjusted for severity of illness. CONCLUSIONS: This UHC-based cohort shows that increased centre volume results in improved long-term post-liver transplant outcomes and more efficient use of hospital resources thereby lowering the cost. A better understanding of these mechanisms can lead to informed decisions and optimization of the pay for performance model in liver transplantation.