Condition-dependent responses of fish to motorboats.

Anthropogenic noise is a pollutant of global concern that has been shown to have a wide range of detrimental effects on multiple taxa. However, most noise studies to-date consider only overall population means, ignoring the potential for intraspecific variation in responses. Here, we used field experiments on Australia's Great Barrier Reef to assess condition-dependent responses of blue-green damselfish (Chromis viridis) to real motorboats. Despite finding no effect of motorboats on a physiological measure (opercular beat rate; OBR), we found a condition-dependent effect on anti-predator behaviour. In ambient conditions, startle responses to a looming stimulus were equivalent for relatively poor- and good-condition fish, but when motorboats were passing, poorer-condition fish startled at significantly shorter distances to the looming stimulus than better-condition fish. This greater susceptibility to motorboats in poorer-condition fish may be the result of generally more elevated stress levels, as poorer-condition fish had a higher pre-testing OBR than those in better condition. Considering intraspecific variation in responses is important to avoid misrepresenting potential effects of anthropogenic noise and to ensure the best management and mitigation of this pervasive pollutant.

Fishes in a changing world: learning from the past to promote sustainability of fish populations.

Populations of fishes provide valuable services for billions of people, but face diverse and interacting threats that jeopardize their sustainability. Human population growth and intensifying resource use for food, water, energy and goods are compromising fish populations through a variety of mechanisms, including overfishing, habitat degradation and declines in water quality. The important challenges raised by these issues have been recognized and have led to considerable advances over past decades in managing and mitigating threats to fishes worldwide. In this review, we identify the major threats faced by fish populations alongside recent advances that are helping to address these issues. There are very significant efforts worldwide directed towards ensuring a sustainable future for the world's fishes and fisheries and those who rely on them. Although considerable challenges remain, by drawing attention to successful mitigation of threats to fish and fisheries we hope to provide the encouragement and direction that will allow these challenges to be overcome in the future.

Parathyroidectomy in Maryland: effects of an endocrine center.

BACKGROUND: Surgery for hyperparathyroidism is associated with high cure rates and low morbidity and mortality when performed by experienced surgeons. We wanted to determine whether referral of patients with hyperparathyroidism to an endocrine surgery center has an impact on patient outcomes and costs. METHODS: Data from 901 patients who underwent parathyroidectomy recorded in the Maryland inpatient discharge database between 1990 and 1994 at 52 hospitals were compared with 169 consecutive patients who underwent surgical exploration by one surgeon (R.U.) at the Johns Hopkins Hospital. RESULTS: Although in 47 of 52 hospitals fewer than 10 parathyroidectomies were performed each year, in these hospitals four of five related deaths occurred before patient discharge. The percentage of parathyroidectomies in Maryland performed by one endocrine surgeon has increased from 8% in 1990 to 21% in 1994 and is associated with a 97% cure rate and no mortality. Moreover, while hospital length of stay (LOS) in the state has decreased from 7 to 3.1 days, LOS for the high-volume provider has declined to a mean of 1.3 days. CONCLUSIONS: Patients with hyperparathyroidism are increasingly referred to an endocrine surgery center, which results in a high cure rate, low morbidity, no mortality, and a shorter LOS. Improved surgical outcomes and lower costs depend on an experienced surgeon and argue for the referral of these patients to endocrine surgery centers.

Clinical pathway implementation improves outcomes for complex biliary surgery.

BACKGROUND: Complex biliary surgery is associated with significant morbidity, prolonged hospital stay, and high cost. Clinical pathway implementation has the potential to standardize treatment and improve outcomes. Therefore the aim of this analysis was to determine whether clinical pathway implementation and/or feedback of outcome data would alter hospital stay, charges, and mortality rates for complex biliary surgery at an academic medical center METHODS: Pre- and postoperative length of stay, hospital charges, and mortality rates were monitored for 36 months before (period 1) and for 2 18-month periods (periods 2 and 3) after implementation of a clinical pathway for hepaticojejunostomy. Outcome data were provided to the surgeons 18 months after pathway implementation to determine whether further clinical practice improvement was possible. RESULTS: From 1991 to 1997, 339 patients underwent hepaticojejunostomy at The Johns Hopkins Hospital for malignant and benign biliary obstruction. Total length of stay was 13.3 +/- 0.9 days for period 1 compared with 12.5 +/- 0.8 days for period 2 (not significant) and 10.1 +/- 0.3 days for period 3 (P < .01 vs period 1; P < .03 vs period 2). Hospital charges averaged $24,446 during period 1 compared with $23,338 during period 2 and $20,240 during period 3 (P < .01 vs periods 1 and 2). Hospital mortality rate was 4.5% during period 1 compared with 0.7% during periods 2 and 3 (P < .05). CONCLUSIONS: These data suggest that implementation of a clinical pathway for hepaticojejunostomy reduces hospital mortality rates and that feedback of outcome data to surgeons results in further clinical practice improvement. Thus clinical pathway implementation and feedback are effective methods to control costs at an academic medical center.

Effect of academic affiliation and obstetric volume on clinical outcome and cost of childbirth.

OBJECTIVE: To determine whether the academic affiliation and obstetric volume of the delivering hospital has an impact on clinical and economic outcomes. METHODS: We performed a cross-sectional analysis of data for all births in the State of Maryland during 1996. Acute hospital discharge data were obtained from the publicly available Maryland Health Services Cost Review Commission database. Institutions were classified as community hospitals, community teaching hospitals, and academic medical centers. Principal outcome variables included cesarean birth and complication rates, total hospital charges, and length of stay. RESULTS: A total of 63,143 cases were identified for analysis. The cesarean delivery rate was lower among academic medical centers, compared with community teaching hospitals and community hospitals (18.4% compared with 24.3% and 21.2%, respectively). After adjustment for patient case-mix, the adjusted odds ratio (OR) for cesarean birth was 0.66 at academic medical centers and 1.23 at community teaching hospitals compared with community hospitals (P <.01). Rates of episiotomy and serious complications were lower at academic medical centers compared with community hospitals. Adjusted total hospital charges were lower and length of stay was shorter for community hospitals compared with academic medical centers ($2937 compared with $3564 and 2.2 days compared with 2.5 days, respectively). CONCLUSION: Hospital academic affiliation was an important predictor of clinical outcomes. Better clinical outcomes were found primarily among patients at academic medical centers, although these institutions demonstrated moderately higher resource utilization, compared with community hospitals.

Complex gastrointestinal surgery: impact of provider experience on clinical and economic outcomes.

BACKGROUND: Commonly performed elective gastrointestinal surgical procedures are carried out with low morbidity and mortality in hospitals throughout the United States. Complex operative procedures on the alimentary tract are performed with a relatively low frequency and are associated with higher mortality. Volume and experience of the surgical provider team have been correlated with better clinical and economic outcomes for one complex gastrointestinal surgical procedure, pancreaticoduodenectomy. This study evaluated whether provider volume and experience were important factors influencing clinical and economic outcomes for a variety of complex gastrointestinal surgical procedures in one state. STUDY DESIGN: Complex high-risk gastrointestinal surgical procedures were defined as those with statewide in-hospital mortality of > or = 5%, frequency of greater than 200 per year in the state, and requiring special surgical skill and expertise. Six procedures met these criteria. Using publicly available discharge data, all patients discharged from Maryland hospitals from July 1989 to June 1997 with a primary procedure code for one of the six study procedures were selected. Hospitals were classified into one of six groups based on the average number of study procedures per year: 10 or less; 11 to 20; 21 to 50; 51 to 100; 101 to 200; and 201 or more procedures per year. A hospital was included if at least one procedure was performed there during the study period. No providers fell within the 51 to 100, and 101 to 200 groups, so all analyses were performed for the remaining four volume groups that were classified, respectively, as minimal (10 or fewer procedures), low (11 to 20 procedures), medium (21 to 50 procedures), and high-volume groups (201 or more procedures). Poisson regression was used to assess the relationship between in-hospital mortality and hospital volume after case-mix adjustment. Multiple linear regression models were used to assess differences in average length-of-stay and average total hospital charges among hospital volume groups. We further analyzed mortality, length-of-stay, and charges at the procedural level to understand these subgroups of complex gastrointestinal patients. We also examined the relationship between provider volume and outcomes for malignant versus benign diagnosis groups. RESULTS: Complex gastrointestinal surgical procedures were performed on 4,561 patients in Maryland from July 1989 through June 1997. The study population averaged 61.6 years of age, was 55% male, 71% Caucasian, and had predominantly Medicare as a payment source. After case-mix adjustment, patients who underwent complex gastrointestinal surgical procedures at the medium-, low-, and minimal-volume provider groups had a 2.1, 3.3, and 3.2 times greater risk of in-hospital death, respectively, than patients at the high-volume provider (p < 0.001 for all comparisons); longer lengths-of-stay, 16.1, 15.7, and 15.5 days at the low-, medium-, and minimal-volume groups, respectively, versus 14.0 days for the high-volume provider (p < 0.001 for all comparisons). Similarly, adjusted charges at the high-volume provider were, on average, 14% less than those of the low-volume group, which had the next lowest charges. Although mortality rates differed by procedure type, for each procedure, mortality increased as provider volume decreased, following the pattern found in the aggregate analysis. After case-mix adjustment, the risk of in-hospital death for patients with malignant diagnoses was significantly higher for the medium-, low-, and minimal-volume groups compared with patients at the high-volume provider, relative risk of 3.1, 4.0, and 4.2, respectively, (p < 0.001 for all comparisons). CONCLUSIONS: This study demonstrates that increased hospital experience is associated with a marked decrease in hospital mortality. The decreased mortality at the high-volume provider was also associated with shorter lengths-of-stay and lower hospital char

Should hepatic resections be performed at high-volume referral centers?

Recent studies have demonstrated the relationship between clinical outcomes of complex surgical procedures and provider volume. Hepatic resection is one such high-risk surgical procedure. The aim of this analysis was to determine whether mortality and cost of performing hepatic resection are related to surgical volume while also examining outcomes by extent of resection and diagnosis, variables seen with this procedure. Maryland discharge data were used to study surgical volume, length of stay, charges, and mortality for 606 liver resections performed at all acute-care hospitals between January 1990 and June 1996. One high-volume provider accounted for 43.6% of discharges, averaging 40.6 cases per year. In comparison, the remainder of resections were performed at 35 other hospitals, averaging 1.5 cases per year. Data were stratified into these high- and low-volume groups, and adjusted outcomes were compared. The mortality rate for all procedures in the low-volume group was 7.9% compared to 1.5% for the high-volume provider (P <0.01, relative risk = 5.2). No overall differences were observed between low- and high-volume providers in total hospital charges. When analyzing by procedure type and diagnosis, lower mortality was seen in the high-volume center for both minor and major resections, as well as resections for metastatic disease. It was concluded that hepatic resection can be performed more safely and at comparable cost at high-volume referral centers.

Toxicity of environmental lead and the influence of intestinal absorption in children.

Exposure to metals, particularly lead, remains a widespread issue that is associated with historical and current industrial practices. Whereas the toxic properties of metals are well described, exposure to metals per se is only one of many factors contributing to elevated blood metal concentrations and their consequent health effects in humans. The absorbed dose of metal is affected by geochemical, biochemical, and physiological parameters that influence the rate and extent of absorption. In children, the interplay among these factors can be of critical importance, especially when biochemical and physiological processes might not have matured to their normal adult status. Such immaturity represents an elevated risk to metal-exposed children because they might be more susceptible to enhanced absorption, especially via the oral route. This review brings together the more recent findings on the physiological mechanisms of metal absorption, especially lead, and examines several models that can be useful in assessing the potential for metal uptake in children.

Pheromone-induced reproductive inhibition in young female Peromyscus leucopus.

Soiled bedding and urine from adult female white-footed mice (Peromyscus leucopus) were tested for their capacity to inhibit reproduction of young females. Test animals were given either physical or airborne contact with soiled bedding from adult females, adult female urine, clean bedding, or water from 21 to 150 days of age. Results indicate that reproductive inhibition is due to an airborne pheromone emitted by the adult females as a component of their urine. In the second experiment, young female mice were exposed to an adult female for 0, 1, 3, 6, 12, 18, or 24 h/day from 21 to 150 days of age. Results from this experiment show that exposure to adult females of as little as 3 h/day was sufficient to cause reproductive inhibition to occur. This phenomenon has important implications in terms of both female-female reproductive competition and socially mediated population regulation.

Impact of race on the outcome of carotid endarterectomy: a population-based analysis of 9,842 recent elective procedures.

OBJECTIVE: To examine the influence of race and other potentially confounding variables on the outcome of carotid endarterectomy (CEA). SUMMARY: Previous studies have demonstrated that CEA is performed less frequently in black patients, although little attention has been focused on the influence of race on the outcome of surgery. METHODS: The Maryland Health Services Cost Review Commission database was reviewed to identify all elective CEA procedures performed in all nonfederal acute care hospitals in the state from 1990 through 1995 to examine the influence of race and other factors on the rates of in-hospital complications, in-hospital stroke, length of stay, and total hospital charges. RESULTS: Carotid endarterectomy was performed in 9,219 (94%) white and 623 (6%) black patients during this period. The in-hospital stroke rate was 1.7%-3. 1% among black patients and 1.6% among white patients. Black patients had a longer length of stay and higher mean hospital charges than white patients. Multivariate logistic regression analysis identified black race as an independent risk factor for in-hospital stroke. Performance of CEA by a high-volume surgeon was protective for the combined occurrence of in-hospital stroke or death, and whites were more than twice as likely to undergo surgery performed by high-volume surgeons. Conversely, undergoing surgery in a low-volume hospital was associated with in-hospital stroke, and blacks were four times as likely to use low-volume hospitals. CONCLUSIONS: Black patients who underwent elective CEA in Maryland from 1990 to 1995 had an increased incidence of in-hospital stroke, a longer hospital stay, and higher hospital charges than whites. Black race was identified as an independent risk factor for in-hospital stroke, although the reasons for this influence of race on outcome are undefined. The authors' observations also suggest the possibility of limited access to optimal surgical care among blacks, and this issue warrants further study.

The effects of regionalization on cost and outcome for one general high-risk surgical procedure.

PURPOSE: The effects of regionalization of tertiary care were studied by analyzing cost and outcome for pancreaticoduodenectomies in a state in which the majority of these high-risk procedures were performed in one hospital. METHODS: Using Maryland inpatient discharge data via a retrospective study, the authors compared cost and outcome data for a hospital with more than one half of the cases in the state to all other hospital providers as a group and with smaller groupings according to the volume of procedures performed. RESULTS: Hospital mortality, length of stay, and costs were significantly less at the high-volume regional medical center when compared with all other hospitals. Mortality and cost increased as volume decreased when hospitals were grouped according to volume. CONCLUSIONS: An academic medical center, functioning as a high-volume regional provider, can deliver tertiary care services with improved outcomes at lower costs than community hospitals.

Carotid endarterectomy--is intensive care unit care necessary?

PURPOSE: The purpose of this study was to determine whether postoperative intensive care unit care is necessary for all patients undergoing carotid endarterectomy and whether a subgroup of patients at low-risk not requiring treatment in the intensive care unit could be identified. METHODS: Case control analysis of random numbers sample over the last decade of 50% of patients undergoing isolated carotid endarterectomy at a tertiary care hospital. One hundred twenty-nine patients undergoing carotid endarterectomy were identified. Preoperative risk factors, intraoperative course, intensive case unit interventions including vasoactive agents, myocardial ischemia/infarction, arrhythmias, bronchospasm, reintubation, neurologic events, and need for reoperation, were recorded. Timing of interventions, length of stay in intensive care unit, and postoperative course were all recorded. Financial impact was assessed. RESULTS: Among 129 patients only 31 patients did not require intensive care unit interventions. A multivariate linear regression analysis demonstrated a model in which a preoperative history of hypertension, myocardial infarction, arrhythmia, and chronic renal failure were 83% predictive of the need for an intensive care unit bed. Specifically, patients could be stratified into a low-risk group before the operation by less than four risk factors. Additionally, all patients requiring interventions or with adverse outcomes were identified by the eight postoperative hour. CONCLUSIONS: In preoperative scheduling of intensive care unit beds, patients with less than four risk factors can be stratified to monitoring beds and those with greater than or equal to four can be stratified to intervention beds. After 8 hours, if no interventions are necessary or adverse outcomes occur, then floor recovery is safe. Patients who satisfy this algorithm would save 50% of current intensive care unit charges.

Influence of age and hospital volume on the results of carotid endarterectomy: a statewide analysis of 9918 cases.

PURPOSE: This study evaluated the impact of patient age and hospital volume on the results of carotid endarterectomy (CEA) in contemporary practice. METHODS: The Maryland Health Services Cost Review Commission (MHSCRC) database was reviewed to identify all patients who underwent elective CEA as the primary procedure in all acute care hospitals in the state over the past 6 years. RESULTS: From January 1990 through December 1995, 9918 elective CEAs were performed in 48 hospitals at a total charge of $68.9 million. Postoperative death and neurologic complications occurred in 90 (0.9%) and 166 (1.7%) cases, including 0.8% and 1.7%, 0.9% and 1.6%, 0.9% and 1.8%, and 1.4% and 1.3% of patients < 65 years, 65 to 69 years, 70 to 79 years, and > or = 80 years old, respectively. The mean length of stay and hospital charges increased linearly with increasing age: 4.2 days/$6550, 4.4 days/$6834, 4.8 days/$7059, and 5.6 days (p < 0.0001 vs others)/$7756 (p < 0.005 vs 70 to 79 years and p < 0.0003 vs < 70 years old), respectively, for patients < 65, 65 to 69, 70 to 79, and > or = 80 years old. The mortality rate was 1.9% in low-volume hospitals, 1.1% in moderate-volume hospitals, and 0.8% in high-volume hospitals. The neurologic complication rate was significantly higher (6.1%; p < 0.0001) in low-volume when compared with moderate-volume (1.3%) and high-volume (1.8%) hospitals. CONCLUSIONS: CEA is a safe procedure in the majority of hospitals in contemporary practice, even among the very elderly, who may experience a longer length of stay and higher charges correlating with their documented greater medical complexity.

Results of elective abdominal aortic aneurysm repair in the 1990s: A population-based analysis of 2335 cases.

OBJECTIVE: The safety and efficacy of conventional abdominal aortic aneurysm (AAA) repair are undergoing increased examination in parallel with the development of less invasive repair methods. Because most published studies of elective AAA repair report operations performed in tertiary referral institutions and thus may not reflect the outcome in the surgical community at large, the current population-based study was undertaken to document the results obtained across a broad spectrum of clinical practice in a defined geographic area and to examine the factors that influence the outcomes. METHODS: The Maryland Health Services Cost Review Commission database was used to identify all the elective AAA repairs that were performed in all the nonfederal acute care hospitals in the state from 1990 to 1995. RESULTS: Elective AAA repair was performed on 2335 patients (mean age, 70.4 years) in 46 of the 52 (88%) nonfederal acute care hospitals in the state, including seven high-volume (>100 cases), nine moderate-volume (50 to 99 cases), and 30 low-volume (<50 cases) institutions. The in-hospital mortality rate was 3.5% and increased significantly with advancing age: less than 65 years, 2.2%; 65 to 69 years, 2.5%; 70 to 79 years, 3.5%; and more than 80 years, 7.3% (P =.002). Mortality rates were higher for women (4.5% vs 3.2%; P =.17), for blacks (6.7% vs 3.2%; P =.046), and for patients with renal failure (11.8% vs 3. 4%; P =.11) but not for patients with hypertension, diabetes, heart disease, and pulmonary disease. The operative mortality rate was inversely correlated with hospital volume (4.3% in low-volume hospitals, 4.2% in moderate-volume hospitals, and 2.5% in high-volume hospitals; P =.08), although no differences were noted in the mean ages or comorbidity levels of patients who underwent operations in these three hospital populations. The operative mortality rate was inversely correlated with the experience of the individual surgeon: one case, 9.9%; two to nine cases, 4.9%; 10 to 49 cases, 2.8%; 50 to 99 cases, 2.9%; and more than 100 cases, 3.8% (P =.01). Multivariate analysis results identified patient age (P =. 002), low hospital volume (P =.039), and very low surgeon volume (P =.01) as independent predictors of operative mortality. The mean length of stay and mean hospital charges were 10.6 days and $17,589 and decreased with increasing surgeon volume: one case, 22.7 days/$32,800; two to nine cases, 10.6 days/$18,509; 10 to 49 cases, 10.0 days/$16,611; 50 to 99 cases, 10.9 days/$17,843; and more than 100 cases, 9.6 days/$16,682 (P <.0001/P <.0001). CONCLUSION: Elective AAA repair is a safe procedure in contemporary practice in Maryland. Operative risk is increased among the elderly and when operations are performed by surgeons with very low volumes or in low-volume hospitals. Hospital lengths of stay were shorter and charges were lower when elective AAA repair was performed by surgeons with higher volumes.

William Stewart Halsted: letters to a young female admirer.

OBJECTIVE: To present the first new information in the past 25 years concerning the life of Dr. William Stewart Halsted. This paper reports on recently discovered personal correspondence of Dr. Halsted, beginning at age 66, to a young lady, Elizabeth Blanchard Randall, 40 years his junior. SUMMARY BACKGROUND DATA: Dr. William Stewart Halsted is generally considered the most important and influential surgeon that this country has produced. During his Hopkins days in Baltimore (1886-1922) he was rather reclusive, and little is known of his personal life. He was married but had no children. Several biographies written by Halsted's contemporaries constitute the bulk of what is known about Halsted's personal life. METHODS: All extant letters from Dr. Halsted to Miss Randall were reviewed. Archival materials were consulted to understand the context for this friendship. The correspondence between Halsted and Randall took place during a 3-year period, although their acquaintance was probably long-standing. RESULTS: The letters reveal Dr. Halsted and Miss Randall's great and warm affection for each other, despite their 40-year age difference. The letters have a playful nature absent in Halsted's other correspondence. This relationship has not been previously noted. CONCLUSIONS: Late in Halsted's life, he developed a warm and affectionate relationship with a young lady 40 years his junior, as revealed in Halsted's correspondence. Halsted's warm, personal, and playful letters are in stark contrast to his biographers' portrayals of him as a more serious and reclusive person.

The use of intravenous digital subtraction angiography in the evaluation of tetralogy of Fallot.

Sixteen patients with tetralogy of Fallot were studied with intravenous digital subtraction angiography (DSA). Of these, 11 were males and five were females, ranging in age from 26 months to 54 years, with a mean age of 22 years at the time of the initial study. Twenty-two DSA studies were performed in the 16 patients, in seven patients preoperatively, in 12 patients postoperatively, and in three patients both pre- and postoperatively. In the seven patients studied preoperatively, all DSA studies were considered technically adequate as corroborative evidence in the diagnosis of tetralogy of Fallot. All associated cardiac abnormalities were adequately demonstrated. The 16 postoperative studies on 12 patients were performed to evaluate the adequacy of the surgery and/or postoperative complications. These studies were judged as technically satisfactory. The authors utilized intravenous DSA in the pre- and postoperative evaluation of 16 patients with tetralogy of Fallot and found that reliable angiographic information was provided and that this technique may serve as a useful adjunct with other noninvasive and invasive tests in the preoperative and postoperative evaluation of these patients.

The importance of surgeon experience for clinical and economic outcomes from thyroidectomy.

OBJECTIVE: To determine whether individual surgeon experience is associated with improved short-term clinical and economic outcomes for patients with benign and malignant thyroid disease who underwent thyroid procedures in Maryland between 1991 and 1996. SUMMARY BACKGROUND DATA: There is a prevailing belief that surgeon experience affects patient outcomes in endocrine surgery, but there is a paucity of objective evidence outside of clinical series published by experienced surgeons that supports this view. METHODS: A cross-sectional analysis of all patients who underwent thyroidectomy in Maryland between 1991 and 1996 was conducted using a computerized statewide hospital discharge data base. Surgeons were categorized by volume of thyroidectomies over the 6-year study period: A (1 to 9 cases), B (10 to 29 cases), C (30 to 100 cases), and D (>100 cases). Multivariate regression was used to assess the relation between surgeon caseload and in-hospital complications, length of stay, and total hospital charges, adjusting for case mix and hospital volume. RESULTS: The highest-volume surgeons (group D) performed the greatest proportion of total thyroidectomies among the 5860 discharges, and they were more likely to operate on patients with cancer. After adjusting for case mix and hospital volume, highest-volume surgeons had the shortest length of stay (1.4 days vs. 1.7 days for groups B and C and 1.9 days for group A) and the lowest complication rate (5.1 % vs. 6.1% for groups B and C and 8.6% for group A). Length of stay and complications were more determined by surgeon experience than hospital volume, which had no consistent association with outcomes. CONCLUSIONS: Individual surgeon experience is significantly associated with complication rates and length of stay for thyroidectomy.

Statewide regionalization of pancreaticoduodenectomy and its effect on in-hospital mortality.

OBJECTIVE: This study examined a statewide trend in Maryland toward regionalization of pancreaticoduodenectomy over a 12-year period and its effect on statewide in-hospital mortality rates for this procedure. SUMMARY BACKGROUND DATA: Previous studies have demonstrated that the best outcomes are achieved in centers performing large numbers of pancreaticoduodenectomies, which suggests that regionalization could lower the overall in-hospital mortality rate for this procedure. METHODS: Maryland state hospital discharge data were used to select records of patients undergoing a pancreaticoduodenectomy between 1984 and 1995. Hospitals were classified into high-volume and low-volume provider groups. Trends in surgical volume and mortality rates were examined by provider group and for the entire state. Regression analyses were used to examine whether hospital share of pancreaticoduodenectomies was a significant predictor of the in-hospital mortality rate, adjusting for study year and patient characteristics. The portion of the decline in the statewide in-hospital mortality rate for this procedure attributable to the high-volume provider's increasing share was determined. RESULTS: A total of 795 pancreaticoduodenectomies were performed in Maryland at 43 hospitals from 1984 to 1995 (Maryland residents only). During this period, one institution increased its yearly share of pancreaticoduodenectomies from 20.7% to 58.5%, and the statewide in-hospital mortality rate for the procedure decreased from 17.2% to 4.9%. After adjustment for patient characteristics and study year, hospital share remained a significant predictor of mortality. An estimated 61% of the decline in the statewide in-hospital mortality rate for the procedure was attributable to the increase in share of discharges at the high-volume provider. CONCLUSIONS: A trend toward regionalization of pancreaticoduodenectomy over a 12-year period in Maryland was associated with a significant decrease in the statewide in-hospital mortality rate for this procedure, demonstrating the effectiveness of regionalization for high-risk surgery.