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1.
Langenbecks Arch Surg ; 409(1): 211, 2024 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-38985363

RESUMO

PURPOSE: Whether hospital volume affects outcome of patients undergoing hepatobiliary surgery, and whether the centralization of such procedures is justified remains to be investigated. The aim of this study was to analyze the outcome of liver surgery in Italy in relationship of hospital volume. METHODS: This is a nationwide retrospective observational study conducted on data collected by the National Italian Registry "Piano Nazionale Esiti" (PNE) 2023 that included all liver procedures performed in 2022. Outcome measure were case volume and 30-day mortality. Hospitals were classified as very high-volume (H-Vol), intermediate-volume (I-Vol), low-volume (L-Vol) and very low-volume (VL-VoL). A review on centralization process and outcome measures was added. RESULTS: 6,126 liver resections for liver tumors were performed in 327 hospitals in 2022. The 30-day mortality was 2.2%. There were 14 H-Vol, 19 I-Vol, 31 L-Vol and 263 VL-Vol hospitals with 30-day mortality of 1.7%, 2.2%, 2.6% and 3.6% respectively (P < 0.001); 220 centers (83%) performed less than 10 resections, and 78 (29%) centers only 1 resection in 2022. By considering the geographical macro-areas, the median count of liver resection performed in northern Italy exceeded those in central and southern Italy (57% vs. 23% vs. 20%, respectively). CONCLUSIONS: High-volume has been confirmed to be associated to better outcome after hepatobiliary surgical procedures. Further studies are required to detail the factors associated with mortality. The centralization process should be redesigned and oversight.


Assuntos
Hepatectomia , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Neoplasias Hepáticas , Humanos , Hepatectomia/mortalidade , Itália , Estudos Retrospectivos , Masculino , Feminino , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/mortalidade , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Idoso , Pessoa de Meia-Idade , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Sistema de Registros , Mortalidade Hospitalar , Resultado do Tratamento
2.
Br J Oral Maxillofac Surg ; 62(6): 539-541, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38834494

RESUMO

The traditional model of centralisation of care, whilst having many advantages, also requires adaptation and upscaling to meet the requirements of both regional areas and the increasing urban sprawl. However, to ensure comparable outcomes with current major centres, this transition, when required, must be delivered in a safe and effective manner. Our project, which utilised the British Association of Oral and Maxillofacial Surgeons (BAOMS) recently published outcome data from the Quality and Outcomes in Oral and Maxillofacial Surgery (QOMS) project to benchmark data prospectively collected from a small-volume, emerging centre in Northern Queensland, was the first of its kind in terms of validation studies. As expected, the small volume of our centre impacted the ability to derive powerful statistical models and comparators, an intrinsic limitation for small-volume centres whilst they are developing services. However, during this evolution project, the use of comparison metrics allowed for the detection of alert and alarm levels, which are invaluable to ensure patient safety and quality of outcome.Our paper demonstrated that, irrespective of size or volume, the utilisation of quality assurance metrics (national or international) provides for the safe and transparent upscaling of head and neck services in emerging, regional, and small-volume centres.


Assuntos
Benchmarking , Humanos , Procedimentos de Cirurgia Plástica/estatística & dados numéricos , Procedimentos de Cirurgia Plástica/normas , Queensland , Austrália , Avaliação de Resultados em Cuidados de Saúde , Neoplasias de Cabeça e Pescoço/cirurgia , Reino Unido , Garantia da Qualidade dos Cuidados de Saúde , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/normas
3.
PLoS One ; 19(6): e0303586, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38875301

RESUMO

INTRODUCTION: Literature regarding the impact of esophagectomy approach on hospitalizations costs and short-term outcomes is limited. Moreover, few have examined how institutional MIS experience affects costs. We thus examined utilization trends, costs, and short-term outcomes of open and minimally invasive (MIS) esophagectomy as well as assessing the relationship between institutional MIS volume and hospitalization costs. METHODS: All adults undergoing elective esophagectomy were identified from the 2016-2020 Nationwide Readmissions Database. Multiple regression models were used to assess approach with costs, in-hospital mortality, and major complications. Additionally, annual hospital MIS esophagectomy volume was modeled as a restricted cubic spline against costs. Institutions performing > 16 cases/year corresponding with the inflection point were categorized as high-volume hospitals (HVH). We subsequently examined the association of HVH status with costs, in-hospital mortality, and major complications in patients undergoing minimally invasive esophagectomy. RESULTS: Of an estimated 29,116 patients meeting inclusion, 10,876 (37.4%) underwent MIS esophagectomy. MIS approaches were associated with $10,600 in increased incremental costs (95% CI 8,800-12,500), but lower odds of in-hospital mortality (AOR 0.76; 95% CI 0.61-0.96) or major complications (AOR 0.68; 95% CI 0.60, 0.77). Moreover, HVH status was associated with decreased adjusted costs, as well as lower odds of postoperative complications for patients undergoing MIS operations. CONCLUSION: In this nationwide study, MIS esophagectomy was associated with increased hospitalization costs, but improved short-term outcomes. In MIS operations, cost differences were mitigated by volume, as HVH status was linked with decreased costs in the setting of decreased odds of complications. Centralization of care to HVH centers should be considered as MIS approaches are increasingly utilized.


Assuntos
Procedimentos Cirúrgicos Eletivos , Esofagectomia , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos , Esofagectomia/economia , Esofagectomia/mortalidade , Humanos , Estados Unidos , Masculino , Feminino , Pessoa de Meia-Idade , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Idoso , Procedimentos Cirúrgicos Eletivos/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/economia , Custos Hospitalares , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Resultado do Tratamento , Hospitais com Baixo Volume de Atendimentos/economia
4.
Circ Cardiovasc Interv ; 17(6): e013466, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38889251

RESUMO

BACKGROUND: Procedure volumes are associated with outcomes for many cardiovascular procedures, leading to guidelines on minimum volume thresholds for certain procedures; however, the volume-outcome relationship with left atrial appendage occlusion is poorly understood. As such, we sought to determine the relationship between hospital and physician volume and WATCHMAN left atrial appendage occlusion procedural success overall and with the new generation WATCHMAN FLX device. METHODS: We performed an analysis of WATCHMAN procedures (January 2019 to October 2021) from the National Cardiovascular Data Registry LAAO Registry. Three-level hierarchical generalized linear models were used to assess the adjusted relationship between procedure volume and procedural success (device released with peridevice leak <5 mm, no in-hospital major adverse events). RESULTS: Among 87 480 patients (76.2±8.0 years; 58.8% men; mean CHA2DS2-VASc score, 4.8±1.5) from 693 hospitals, the procedural success rate was 94.2%. With hospital volume Q4 (greatest volume) as the reference, the likelihood of procedural success was significantly less among Q1 (odds ratio [OR], 0.66 [CI, 0.57-0.77]) and Q2 (OR, 0.78 [CI, 0.69-0.90]) but not Q3 (OR, 0.95 [CI, 0.84-1.07]). With physician volume Q4 (greatest volume) as the reference, the likelihood of procedural success was significantly less among Q1 (OR, 0.72 [CI, 0.63-0.82]), Q2 (OR, 0.79 [CI, 0.71-0.89]), and Q3 (OR, 0.88 [CI, 0.79-0.97]). Among WATCHMAN FLX procedures, there was attenuation of the volume-outcome relationships, with statistically significant but modest absolute differences of only ≈1% across volume quartiles. CONCLUSIONS: In this contemporary national analysis, greater hospital and physician WATCHMAN volumes were associated with increased procedure success. The WATCHMAN FLX transition was associated with increased procedural success and less heterogeneity in outcomes across volume quartiles. These findings indicate the importance of understanding the volume-outcome relationship for individual left atrial appendage occlusion devices.


Assuntos
Apêndice Atrial , Fibrilação Atrial , Cateterismo Cardíaco , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Sistema de Registros , Humanos , Apêndice Atrial/fisiopatologia , Feminino , Masculino , Idoso , Resultado do Tratamento , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Fibrilação Atrial/cirurgia , Idoso de 80 Anos ou mais , Estados Unidos , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Fatores de Risco , Medição de Risco , Fatores de Tempo , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Função do Átrio Esquerdo
6.
World Neurosurg ; 187: e289-e301, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38642832

RESUMO

BACKGROUND: Studies examining the relationship among hospital case volume, socioeconomic determinants of health, and patient outcomes are lacking. We sought to evaluate these associations in the surgical management of intracranial meningiomas. METHODS: We queried the National Inpatient Sample (NIS) database for patients who underwent craniotomy for the resection of meningioma in 2013. We categorized hospitals into high-volume centers (HVCs) or low-volume centers (LVCs). We compared outcomes in 2016 to assess the potential impact of the Affordable Care Act on health care equity. Primary outcome measures included hospital mortality, length of stay, complications, and disposition. RESULTS: A total of 10,270 encounters were studied (LVC, n = 5730 [55.8%]; HVC, n = 4340 [44.2%]). Of LVC patients, 62.9% identified as white compared with 70.2% at HVCs (P < 0.01). A higher percentage of patients at LVCs came from the lower 2 quartiles of median household income than did patients at HVCs (49.9% vs. 44.2%; P < 0.001). Higher mortality (1.3% vs. 0.9%; P = 0.041) was found in LVCs. Multivariable regression analysis showed that LVCs were significantly associated with increased complication (odds ratio, 1.36; 95% confidence interval, 1.30-1.426, P<0.001) and longer hospital length of stay (odds ratio, -0.05; 95% confidence interval, -0.92 to -0.45; P <0.001). There was a higher proportion of white patients at HVCs in 2016 compared with 2013 (67.9% vs. 72.3%). More patients from top income quartiles (24.2% vs. 40.5%) were treated at HVCs in 2016 compared with 2013. CONCLUSIONS: This study found notable racial and socioeconomic disparities in LVCs as well as access to HVCs over time. Disparities in meningioma treatment may be persistent and require further study.


Assuntos
Disparidades em Assistência à Saúde , Hospitais com Alto Volume de Atendimentos , Neoplasias Meníngeas , Meningioma , Fatores Socioeconômicos , Humanos , Meningioma/cirurgia , Feminino , Masculino , Pessoa de Meia-Idade , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Neoplasias Meníngeas/cirurgia , Neoplasias Meníngeas/etnologia , Idoso , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Estados Unidos , Tempo de Internação/estatística & dados numéricos , Adulto , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos
7.
World Neurosurg ; 187: e494-e500, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38677643

RESUMO

BACKGROUND: High volume (HV) has been associated with improved outcomes in various neurosurgical procedures. The objective of this study was to explore the regional distribution of HV spine centers for cervical spine fusion and compare characteristics and outcomes for patients treated at HV centers versus lower volume centers. METHODS: The National Inpatient Sample database 2016-2020 was queried for patients undergoing cervical spine fusion for degenerative pathology. HV was defined as case-loads greater than 2 standard deviations above the mean. Patient characteristics, procedures, and outcomes were compared. RESULTS: Of 3895 hospitals performing cervical spine fusion for degenerative pathology, 28 (0.76%) were HV. The Mid-Atlantic and West South Central regions had the highest number of HV hospitals. HV hospitals were more likely to perform open anterior fusion surgeries (P < 0.01). Patients treated at HV hospitals were less likely to have severe symptomatology or comorbidities (P < 0.01 for all). When controlling for severity and demographics on multivariate analysis, HV centers had higher odds of length of stay ≤1 day, favorable discharge, and decreased total charges. CONCLUSIONS: Patients who underwent cervical spine fusion surgery at HV hospitals were less complex and had increased odds of length of stay ≤1, favorable discharge, and total charges in the lower 25th percentile than patients treated at non-HV hospitals. Physician comfort, patient selection, institutional infrastructure, and geographic characteristics likely play a role.


Assuntos
Vértebras Cervicais , Hospitais com Alto Volume de Atendimentos , Fusão Vertebral , Humanos , Fusão Vertebral/métodos , Feminino , Masculino , Vértebras Cervicais/cirurgia , Pessoa de Meia-Idade , Idoso , Resultado do Tratamento , Tempo de Internação/estatística & dados numéricos , Adulto , Estados Unidos , Bases de Dados Factuais , Hospitais com Baixo Volume de Atendimentos
8.
J Surg Oncol ; 129(8): 1449-1455, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38685721

RESUMO

BACKGROUND: Although correlation between center volume and survival has been reported for several complex cancers, it remains unknown if this is true for colorectal neuroendocrine carcinomas (CRNECs). We hypothesized that higher center annual volume of colorectal neuroendocrine neoplasm resections would be associated with overall survival (OS) for patients with CRNECs. METHODS: Patients in the National Cancer Database diagnosed with stages I-III CRNEC between 2006 and 2018 and who underwent surgical resection were identified. The mean annual colorectal neuroendocrine neoplasm resection volume threshold associated with significantly worse mortality hazard was determined using restricted cubic splines. Kaplan-Meier (KM) method was used to compare OS, while Cox proportional hazards model was used for multivariable analysis. RESULTS: There were 694 patients with CRNEC who met inclusion criteria across 1229 centers. Based on the cubic spline, centers treating fewer than one colorectal neuroendocrine neoplasm patient every 3 years on average had worse outcomes. Centers below this threshold were classified as low-volume (LV) centers corresponding with 42% of centers and about 15% of the patient cohort. In unadjusted survival analysis, LV patients had a median OS of 14 months (95% confidence interval [CI]: 10-19) while those treated at HV centers had a median OS of 33 months (95% CI: 25-49). In multivariable analysis, resection at a LV center was associated with increased risk of mortality (1.42 [95% CI: 1.01-2.00], p = 0.04). CONCLUSION: CRNEC patients have a dire prognosis; however, treatment at an HV center may be associated with decreased risk of mortality.


Assuntos
Carcinoma Neuroendócrino , Neoplasias Colorretais , Humanos , Masculino , Feminino , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Idoso , Carcinoma Neuroendócrino/mortalidade , Carcinoma Neuroendócrino/patologia , Carcinoma Neuroendócrino/cirurgia , Pessoa de Meia-Idade , Taxa de Sobrevida , Estudos Retrospectivos , Prognóstico , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Seguimentos , Estados Unidos/epidemiologia , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos
9.
Gynecol Oncol ; 186: 144-153, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38688188

RESUMO

OBJECTIVE: Despite lacking clinical data, the Dutch government is considering increasing the minimum annual surgical volume per center from twenty to fifty cytoreductive surgeries (CRS) for advanced-stage ovarian cancer (OC). This study aims to evaluate whether this increase is warranted. METHODS: This population-based study included all CRS for FIGO-stage IIB-IVB OC registered in eighteen Dutch hospitals between 2019 and 2022. Short-term outcomes included result of CRS, length of stay, severe complications, 30-day mortality, time to adjuvant chemotherapy, and textbook outcome. Patients were stratified by annual volume: low-volume (nine hospitals, <25), medium-volume (four hospitals, 29-37), and high-volume (five hospitals, 54-84). Descriptive statistics and multilevel logistic regressions were used to assess the (case-mix adjusted) associations of surgical volume and outcomes. RESULTS: A total of 1646 interval CRS (iCRS) and 789 primary CRS (pCRS) were included. No associations were found between surgical volume and different outcomes in the iCRS cohort. In the pCRS cohort, high-volume was associated with increased complete CRS rates (aOR 1.9, 95%-CI 1.2-3.1, p = 0.010). Furthermore, high-volume was associated with increased severe complication rates (aOR 2.3, 1.1-4.6, 95%-CI 1.3-4.2, p = 0.022) and prolonged length of stay (aOR 2.3, 95%-CI 1.3-4.2, p = 0.005). 30-day mortality, time to adjuvant chemotherapy, and textbook outcome were not associated with surgical volume in the pCRS cohort. Subgroup analyses (FIGO-stage IIIC-IVB) showed similar results. Various case-mix factors significantly impacted outcomes, warranting case-mix adjustment. CONCLUSIONS: Our analyses do not support further centralization of iCRS for advanced-stage OC. High-volume was associated with higher complete pCRS, suggesting either a more accurate selection in these hospitals or a more aggressive approach. The higher completeness rates were at the expense of higher severe complications and prolonged admissions.


Assuntos
Procedimentos Cirúrgicos de Citorredução , Hospitais com Alto Volume de Atendimentos , Estadiamento de Neoplasias , Neoplasias Ovarianas , Humanos , Feminino , Procedimentos Cirúrgicos de Citorredução/métodos , Procedimentos Cirúrgicos de Citorredução/estatística & dados numéricos , Países Baixos/epidemiologia , Neoplasias Ovarianas/cirurgia , Neoplasias Ovarianas/patologia , Neoplasias Ovarianas/tratamento farmacológico , Pessoa de Meia-Idade , Idoso , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Adulto , Tempo de Internação/estatística & dados numéricos , Quimioterapia Adjuvante/estatística & dados numéricos , Resultado do Tratamento , Carcinoma Epitelial do Ovário/cirurgia , Carcinoma Epitelial do Ovário/patologia , Carcinoma Epitelial do Ovário/mortalidade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia
10.
World J Surg ; 48(6): 1481-1491, 2024 06.
Artigo em Inglês | MEDLINE | ID: mdl-38610103

RESUMO

INTRODUCTION: New Zealand has a population of only 5.5 million meaning that for many surgical procedures the country qualifies as a "low-volume center." However, the health system is well developed and required to provide complex surgical procedures that benchmark internationally against comparable countries. This investigation was undertaken to review regional variation and volumes of complex resection and palliative upper gastrointestinal (UGI) surgical procedures within New Zealand. METHODS: Data pertaining to patients undergoing complex resectional UGI procedures (esophagectomy, gastrectomy, pancreatectomy, and hepatectomies) and palliative UGI procedures (esophageal stenting, enteroenterostomy, biliary enteric anastomosis, and liver ablation) in a New Zealand hospital between January 1, 2000 and December 31, 2019 were obtained from the National Minimum Dataset. RESULTS: New Zealand is a low-volume center for UGI surgery (229 hepatectomies, 250 gastrectomies, 126 pancreatectomies, and 74 esophagectomies annually). Over 80% of patients undergoing hepatic resection/ablation, gastrectomy, esophagectomy, and pancreatectomy are treated in one of the six national cancer centers (Auckland, Waikato, Mid-Central, Capital Coast, Canterbury, or Southern). There is evidence of the decreasing frequency of these procedures in small centers with increasing frequency in large centers suggesting that some regionalization is occurring. Palliative procedures were more widely performed. Indigenous Maori were less likely to be treated in a nationally designated cancer center than non-Maori. CONCLUSIONS: The challenge for New Zealand and similarly sized countries is to develop and implement a system that optimizes the skills and pathways that come from a frequent performance of complex surgery while maintaining system resilience and ensuring equitable access for all patients.


Assuntos
Acessibilidade aos Serviços de Saúde , Nova Zelândia , Humanos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Cuidados Paliativos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Masculino , Feminino , Hepatectomia/estatística & dados numéricos , Hepatectomia/métodos , Procedimentos Cirúrgicos do Sistema Biliar/estatística & dados numéricos , Gastrectomia/estatística & dados numéricos , Pancreatectomia/estatística & dados numéricos , Estudos Retrospectivos
11.
Arch Cardiovasc Dis ; 117(5): 321-331, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38670869

RESUMO

BACKGROUND: Transcatheter (TAVR) has supplanted surgical (SAVR) aortic valve replacement (AVR). AIM: To evaluate whether adoption of this technology has varied according to centre volume at the nationwide level. METHODS: From an administrative hospital-discharge database, we collected data on all AVRs performed in France between 2007 and 2019. Centres were divided into terciles based on the annual number of SAVRs performed in 2007-2009 ("before TAVR era"). RESULTS: A total of 192,773 AVRs (134,662 SAVRs and 58,111 TAVRs) were performed in 47 centres. The annual number of AVRs and TAVRs increased significantly and linearly in low-volume (<152 SAVRs/year; median 106, interquartile range [IQR] 75-129), middle-volume (152-219 SAVRs/year; median 197, IQR 172-212) and high-volume (>219 SAVRs/year; median 303, IQR 268-513) terciles, but to a greater degree in the latter (+14, +16 and +24 AVRs/centre/year and +16, +19 and +31 TAVRs/centre/year, respectively; PANCOVA<0.001). Charlson Comorbidity Index and in-hospital death rates declined from 2010 to 2019 in all terciles (all Ptrend<0.05). In 2017-2019, after adjusting for age, sex and Charlson Comorbidity Index, there was a trend toward lower death rates in the high-volume tercile (P=0.06) for SAVR, whereas death rates were similar for TAVR irrespective of tercile (P=0.27). Similar results were obtained when terciles were defined based on number of interventions performed in the last instead of the first 3years. Importantly, even centres in the lowest-volume tercile performed a relatively high number of interventions (150 TAVRs/year/centre). CONCLUSIONS: In a centralized public healthcare system, the total number of AVRs increased linearly between 2007 and 2019, mostly due to an increase in TAVR, irrespective of centre volume. Progressive declines in patient risk profiles and death rates were observed in all terciles; in 2017-2019 death rates were similar in all terciles, although lower in high-volume centres for SAVR.


Assuntos
Estenose da Valva Aórtica , Valva Aórtica , Bases de Dados Factuais , Implante de Prótese de Valva Cardíaca , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Substituição da Valva Aórtica Transcateter , Humanos , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , França/epidemiologia , Hospitais com Alto Volume de Atendimentos/tendências , Substituição da Valva Aórtica Transcateter/tendências , Substituição da Valva Aórtica Transcateter/mortalidade , Substituição da Valva Aórtica Transcateter/efeitos adversos , Feminino , Hospitais com Baixo Volume de Atendimentos/tendências , Masculino , Idoso , Resultado do Tratamento , Fatores de Tempo , Valva Aórtica/cirurgia , Valva Aórtica/fisiopatologia , Fatores de Risco , Idoso de 80 Anos ou mais , Implante de Prótese de Valva Cardíaca/mortalidade , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/tendências , Implante de Prótese de Valva Cardíaca/instrumentação , Padrões de Prática Médica/tendências , Medição de Risco , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Difusão de Inovações
12.
Eur J Vasc Endovasc Surg ; 68(1): 30-38, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38428671

RESUMO

OBJECTIVE: Registry data suggest that centralising abdominal aortic aneurysm (AAA) surgery decreases the mortality rate after AAA repair. However, the impact of higher elective volumes on ruptured AAA (rAAA) repair associated mortality rates remains uncertain. This study aimed to examine associations between intact AAA (iAAA) repair volume and post-operative rAAA death. METHODS: Using data from official national registries between 2015 - 2019, all iAAA and rAAA repairs were separately analysed across 10 public hospitals. The following were assessed: 30 day and 12 month mortality rate following open surgical repair (OSR) and endovascular aneurysm repair (EVAR). Associations between the 5 year hospital iAAA repair volumes (organised into tertiles) and rAAA associated mortality rate were analysed, regardless of treatment modality. Receiver operating characteristic (ROC) curves were generated to identify iAAA volume thresholds for decreasing the rAAA mortality rate. Subanalysis by treatment type was conducted. Threshold analysis was repeated with the Markov chain Monte Carlo (MCMC) procedure to confirm the findings. RESULTS: A total of 1 599 iAAAs (80.2% EVAR, 19.8% OSR) and 196 rAAAs (66.3% EVAR, 33.7% OSR) repairs were analysed. The median and interquartile range of the volume/hospital/year for all iAAA repairs were 39.2 (31.2, 47.4). The top volume iAAA tertile exhibited lower rAAA associated 30 day (odds ratio [OR] 0.374; p = .007) and 12 month (OR 0.264; p < .001) mortality rates. The ROC analysis revealed a threshold of 40 iAAA repairs/hospital/year (EVAR + OSR) for a reduced rAAA mortality rate. Middle volume hospitals for open iAAA repair had reduced 30 day (OR 0.267; p = .033) and 12 month (OR 0.223; p = .020) mortality rates, with a threshold of five OSR procedures/year. The MCMC procedure found similar thresholds. No significant association was found between elective EVAR volumes and ruptured EVAR mortality. CONCLUSION: Higher iAAA repair volumes correlated with a lower rAAA mortality rate, particularly for OSR. The recommended iAAA repair threshold is 40 procedures/year and five procedures/year for OSR. These findings support high elective volumes for improving the rAAA mortality rate, especially for OSR.


Assuntos
Aneurisma da Aorta Abdominal , Ruptura Aórtica , Procedimentos Cirúrgicos Eletivos , Procedimentos Endovasculares , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Sistema de Registros , Humanos , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/cirurgia , Ruptura Aórtica/mortalidade , Masculino , Feminino , Idoso , Procedimentos Cirúrgicos Eletivos/mortalidade , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Procedimentos Endovasculares/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Fatores de Risco , Idoso de 80 Anos ou mais , Implante de Prótese Vascular/mortalidade , Implante de Prótese Vascular/efeitos adversos , Medição de Risco , Resultado do Tratamento , Fatores de Tempo , Mortalidade Hospitalar , Estudos Retrospectivos
13.
J Vasc Surg ; 80(1): 53-63.e3, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38431064

RESUMO

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) at high-volume hospitals has previously been associated with lower perioperative mortality, but the impact of annual surgeon volume on outcomes following TEVAR for BTAI remains unknown. METHODS: We analyzed Vascular Quality Initiative (VQI) data from patients with BTAI that underwent TEVAR between 2013 and 2023. Annual surgeon volumes were computed as the number of TEVARs (for any pathology) performed over a 1-year period preceding each procedure and were further categorized into quintiles. Surgeons in the first volume quintile were categorized as low volume (LV), the highest quintile as high volume (HV), and the middle three quintiles as medium volume (MV). TEVAR procedures performed by surgeons with less than 1-year enrollment in the VQI were excluded. Using multilevel logistic regression models, we evaluated associations between surgeon volume and perioperative outcomes, accounting for annual center volumes and adjusting for potential confounders, including aortic injury grade and severity of coexisting injuries. Multilevel models accounted for the nested clustering of patients and surgeons within the same center. Sensitivity analysis excluding patients with grade IV BTAI was performed. RESULTS: We studied 1321 patients who underwent TEVAR for BTAI (28% by LV surgeons [0-1 procedures per year], 52% by MV surgeons [2-8 procedures per year], 20% by HV surgeons [≥9 procedures per year]). With higher surgeon volume, TEVAR was delayed more (in <4 hours: LV: 68%, MV: 54%, HV: 46%; P < .001; elective (>24 hours): LV: 5.1%; MV: 8.9%: HV: 14%), heparin administered more (LV: 80%, MV: 81%, HV: 87%; P = .007), perioperative mortality appears lower (LV: 11%, MV: 7.3%, HV: 6.5%; P = .095), and ischemic/hemorrhagic stroke was lower (LV: 6.5%, MV: 3.6%, HV: 1.5%; P = .006). After adjustment, compared with LV surgeons, higher volume surgeons had lower odds of perioperative mortality (MV: 0.49; 95% confidence interval [CI], 0.25-0.97; P = .039; HV: 0.45; 95% CI, 0.16-1.22; P = .12; MV/HV: 0.50; 95% CI, 0.26-0.96; P = .038) and ischemic/hemorrhagic stroke (MV: 0.38; 95% CI, 0.18-0.81; P = .011; HV: 0.16; 95% CI, 0.04-0.61; P = .008). Sensitivity analysis found lower adjusted odds for perioperative mortality (although not significant) and ischemic/hemorrhagic stroke for higher volume surgeons. CONCLUSIONS: In patients undergoing TEVAR for BTAI, higher surgeon volume is independently associated with lower perioperative mortality and postoperative stroke, regardless of hospital volume. Future studies could elucidate if TEVAR for non-ruptured BTAI might be delayed and allow stabilization, heparinization, and involvement of a higher TEVAR volume surgeon.


Assuntos
Aorta Torácica , Implante de Prótese Vascular , Competência Clínica , Procedimentos Endovasculares , Hospitais com Alto Volume de Atendimentos , Cirurgiões , Lesões do Sistema Vascular , Ferimentos não Penetrantes , Humanos , Aorta Torácica/cirurgia , Aorta Torácica/lesões , Aorta Torácica/diagnóstico por imagem , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Ferimentos não Penetrantes/cirurgia , Ferimentos não Penetrantes/mortalidade , Masculino , Feminino , Lesões do Sistema Vascular/cirurgia , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/diagnóstico por imagem , Pessoa de Meia-Idade , Resultado do Tratamento , Estudos Retrospectivos , Fatores de Tempo , Fatores de Risco , Adulto , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Medição de Risco , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Traumatismos Torácicos/cirurgia , Traumatismos Torácicos/mortalidade , Hospitais com Baixo Volume de Atendimentos , Estados Unidos , Bases de Dados Factuais , Idoso , Correção Endovascular de Aneurisma
14.
Am J Surg ; 234: 112-116, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38553337

RESUMO

INTRODUCTION: We aimed to examine impact of trauma center (TC) surgical stabilization of rib fracture (SSRF) volume on outcomes of patients undergoing SSRF. METHODS: Blunt rib fracture patients who underwent SSRF were included from ACS-TQIP2017-2021. TCs were stratified according to tertiles of SSRF volume:low (LV), middle, and high (HV). Outcomes were time to SSRF, respiratory complications, prolonged ventilator use, mortality. RESULTS: 16,872 patients were identified (LV:5470,HV:5836). Mean age was 56 years, 74% were male, median thorax-AIS was 3. HV centers had a lower proportion of patients with flail chest (HV41% vs LV50%), pulmonary contusion (HV44% vs LV52%) and had shorter time to SSRF(HV58 vs LV76 â€‹h), less respiratory complications (HV3.2% vs LV4.5%), prolonged ventilator use (HV15% vs LV26%), mortality (HV2% vs LV2.6%) (all p â€‹< â€‹0.05). On multivariable regression analysis, HV centers were independently associated with reduced time to SSRF(ߠ​= â€‹-18.77,95%CI â€‹= â€‹-21.30to-16.25), respiratory complications (OR â€‹= â€‹0.67,95%CI â€‹= â€‹0.49-0.94), prolonged ventilator use (OR â€‹= â€‹0.49,95%CI â€‹= â€‹0.41-0.59), but not mortality. CONCLUSIONS: HV SSRF centers have improved outcomes, however, there are variations in threshold for SSRF and indications must be standardized. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Therapeutic/Care Management.


Assuntos
Fraturas das Costelas , Centros de Traumatologia , Humanos , Fraturas das Costelas/cirurgia , Fraturas das Costelas/mortalidade , Masculino , Pessoa de Meia-Idade , Feminino , Ferimentos não Penetrantes/cirurgia , Ferimentos não Penetrantes/mortalidade , Estudos Retrospectivos , Idoso , Adulto , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Resultado do Tratamento , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Tórax Fundido/cirurgia
15.
Jpn J Clin Oncol ; 54(6): 716-721, 2024 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-38411262

RESUMO

OBJECTIVES: We sought clinical characteristics, survival outcomes, and prognostic factors for overall survival of retroperitoneal sarcoma in Japan. METHODS: A Japanese hospital-based cancer registry database with a pivotal 10-year follow-up was used to identify and enroll patients, registered from 106 institutions, diagnosed with retroperitoneal sarcoma in 2008-2009. Treating hospitals were divided by hospital care volume; high-volume hospitals and low-volume hospitals were defined as ≥ 4 and < 4 cases/year, respectively. RESULTS: A total of 91 men and 97 women were included, with a median age of 64 years. The most common histological type was liposarcoma in 101 patients, followed by leiomyosarcoma in 38 patients. The 5-year and 10-year overall survival rates were 44.1 and 28.3%. The majority of patients (n = 152, 80.9%) were treated at low-volume hospitals. High-volume hospital patients had higher 10-year overall survival rates than low-volume hospital patients (51.2% vs 23.2%, P = 0.026). Multivariate analysis revealed age over 60 years, treatment in low-volume hospitals and chemotherapy were independent predictors of unfavorable survival while treatment with surgery was an independent predictor of favorable survival. CONCLUSIONS: The possibility of surgical removal was suggested to be the most important prognostic factor for retroperitoneal sarcoma. Better survival was shown in patients treated at high-volume hospitals in our series.


Assuntos
Sistema de Registros , Neoplasias Retroperitoneais , Sarcoma , Humanos , Masculino , Neoplasias Retroperitoneais/mortalidade , Neoplasias Retroperitoneais/patologia , Neoplasias Retroperitoneais/terapia , Neoplasias Retroperitoneais/epidemiologia , Neoplasias Retroperitoneais/cirurgia , Feminino , Pessoa de Meia-Idade , Japão/epidemiologia , Idoso , Sarcoma/terapia , Sarcoma/patologia , Sarcoma/epidemiologia , Sarcoma/mortalidade , Seguimentos , Adulto , Prognóstico , Taxa de Sobrevida , Idoso de 80 Anos ou mais , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Lipossarcoma/patologia , Lipossarcoma/terapia , Lipossarcoma/epidemiologia , Lipossarcoma/mortalidade , Leiomiossarcoma/patologia , Leiomiossarcoma/epidemiologia , Leiomiossarcoma/terapia , Leiomiossarcoma/mortalidade , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos
16.
Int J Surg ; 110(5): 3021-3029, 2024 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-38353697

RESUMO

BACKGROUND: Postoperative mortality plays an important role in evaluating the surgical safety of esophagectomy. Although postoperative mortality after esophagectomy is partly influenced by the yearly hospital surgical case volume (hospital volume), this association remains unclear. METHODS: Studies assessing the association between hospital volume and postoperative mortality in patients who underwent esophagectomy for esophageal cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random effects model. The dose-response association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with PROSPERO. RESULTS: Fifty-six studies including 385 469 participants were included. A higher-volume hospital significantly reduced the risk of postesophagectomy mortality by 53% compared with their lower-volume counterparts (odds ratio, 0.47; 95% CI: 0.42-0.53). Similar results were found in subgroup analyses. Volume-outcome analysis suggested that postesophagectomy mortality rates remained roughly stable after the hospital volume reached a plateau of 45 esophagectomies per year. CONCLUSIONS: Higher-volume hospitals had significantly lower postesophagectomy mortality rates in patients with esophageal cancer, with a threshold of 45 esophagectomies per year for a high-volume hospital. This remarkable negative correlation showed the benefit of a better safety in centralization of esophagectomy to a high-volume hospital.


Assuntos
Neoplasias Esofágicas , Esofagectomia , Hospitais com Alto Volume de Atendimentos , Humanos , Esofagectomia/mortalidade , Esofagectomia/efeitos adversos , Neoplasias Esofágicas/cirurgia , Neoplasias Esofágicas/mortalidade , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Mortalidade Hospitalar , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/epidemiologia
17.
Transplant Proc ; 56(3): 640-646, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38355370

RESUMO

INTRODUCTION: Liver transplantation (LT) is a complex and demanding procedure associated with significant perioperative challenges and risks. Concerns have arisen regarding LT outcomes in low-volume centers. We implemented an integrated training and surgical team network to address these concerns within the Catholic Medical Center (CMC) network. This study presents a comprehensive review of our 9-year LT experience within the CMC medical network. METHOD: A retrospective study of LT procedures conducted between January 2013 and August 2021 in 6 CMC-affiliated hospitals was performed. One center was categorized as a high-volume center, conducting over 60 cases annually, and the remaining 5 were considered small-volume centers. The primary endpoints assessed were 1-year and 5-year survival rates. RESULTS: A total of 793 LTs were performed during the study period. The high-volume center performed 411 living donor LT (LDLT) cases and 127 deceased donor LT (DDLT) cases. Also, 146 LDLT cases and 109 DDLT cases were performed in 5 small-volume centers. One-year and 5-year patient survival for LDLT recipients was 88.3% and 78.8% in the high-volume center and 85.6% and 80.6% in the low-volume center. Five-year survival was not significantly different in small-volume centers (P = .903). For DDLT recipients, 1-year and 5-year patient survival was 80.3% and 70.6% in the high-volume center and 76.1% and 67.6% in the low-volume center. In DDLT cases, 5-year survival was not significantly different in small-volume centers (P = .445). CONCLUSION: In conclusion, comparable outcomes for liver transplantation can be obtained in a small-volume center with a high level of integrated training systems and networks.


Assuntos
Transplante de Fígado , Transplante de Fígado/mortalidade , Humanos , Estudos Retrospectivos , Masculino , Feminino , Pessoa de Meia-Idade , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Adulto , Resultado do Tratamento
18.
Gynecol Oncol ; 181: 141-154, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-38163384

RESUMO

OBJECTIVE: This systematic review aimed to investigate what are the most relevant social determinants of health (SDH), how they are measured, how they interact among themselves and what is their impact on the outcomes of cervical cancer patients. METHODS: Search was performed in PubMed, Scopus, Web of Science, Embase, Cochrane, and Google Scholar databases from January 2001 to September 2022. The protocol was registered at PROSPERO (CRD42022346854). We followed the PICOS strategy: Population- Patients treated for cervical cancer in the United States; Intervention - Any SDH; Comparison- None; Outcome measures- Cancer treatment outcomes related to the survival of the patients; Types of studies- Observational studies. Two reviewers extracted the data following the PRISMA guidelines. Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies was used for risk of bias (ROB) assessment. RESULTS: Twenty-four studies were included (22 had low and 2 had moderate ROB). Most manuscripts analyzed data from public registries (83.3%) and only one SDH (54.17%). The SDH category of Neighborhood was not included in any study. Although the SDH were measured differently across the studies, not being married, receiving treatment at a low-volume hospital, and having public insurance (Medicaid or Medicare) or not being insured was associated with shorter survival of cervical cancer patients in most studies. CONCLUSIONS: There is a deficit in the number of studies comprehensively assessing the impact of SDH on cervical cancer treatment-related outcomes. Marital status, hospital volume and health insurance status are potential predictors of worse outcome.


Assuntos
Neoplasias do Colo do Útero , Feminino , Humanos , Idoso , Estados Unidos/epidemiologia , Neoplasias do Colo do Útero/terapia , Determinantes Sociais da Saúde , Estudos Transversais , Medicare , Hospitais com Baixo Volume de Atendimentos
19.
J Heart Lung Transplant ; 43(5): 787-796, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38199514

RESUMO

BACKGROUND: To date, no pediatric studies have highlighted the impact of center's ventricular assist device (VAD) volumes on post implant outcomes. METHODS: Children (age <19) enrolled in Pedimacs undergoing initial left ventricular assist device implantation from 2012 to 2020 were included. Center volume was analyzed as a continuous and categorical variable. For categorical analysis, center volumes were divided as: low volume (1-15 implants), medium volume (15-30 implants), and high volume (>30 implants) during our study period. Patient characteristics and outcomes were compared by center's VAD volumes. RESULTS: Of 44 centers, 16 (36.4%) were low, 11 (25%) were medium, and 17 (38.6%) were high-volume centers. Children at high-volume centers were least likely intubated, sedated, or paralyzed, and most likely ambulating preimplant (p < 0.05 for all). Center's VAD volumes were not a significant risk factor for mortality post implant when treated as a continuous or a categorical variable (p > 0.05). Compared to low volume, children at high-volume centers had fewer early neurological events. Compared to medium volume, those at high-volume centers had fewer late bleeding events (p < 0.05 for all). There were no significant differences in survival after an adverse event by hospital volumes (p > 0.05). CONCLUSIONS: Although hospital volume does not affect post-VAD implant mortality, pediatric centers with higher VAD volumes have fewer patients intubated, sedated, paralyzed pre implant, and have lower adverse events. Failure to rescue was not significantly different between low, medium, and high-volume VAD centers.


Assuntos
Insuficiência Cardíaca , Coração Auxiliar , Hospitais com Alto Volume de Atendimentos , Humanos , Masculino , Criança , Feminino , Pré-Escolar , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/cirurgia , Adolescente , Estudos Retrospectivos , Estados Unidos/epidemiologia , Resultado do Tratamento , Lactente , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Bases de Dados Factuais , Taxa de Sobrevida/tendências
20.
Ann Thorac Surg ; 117(6): 1187-1193, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38290594

RESUMO

BACKGROUND: Lower institutional volume has been associated with inferior pediatric cardiac surgery outcomes. This study explored the variation in mortality rates among low-, mid-, and high-volume hospitals performing pediatric cardiac surgery in the United States. METHODS: The Kids' Inpatient Database was explored for the years 2016 and 2019. Hospitals performing only off-bypass coarctation and ventricular septal defect repair were omitted. The hospitals were divided into 3 groups by their annual case volume. Multivariable logistic regression models were fit to obtain risk-adjusted in-hospital mortality rates. RESULTS: A total of 25,749 operations performed by 235 hospitals were included in the study. The risk-adjusted mortality rate for the entire sample was 1.9%. There were 140 hospitals in the low-volume group, 64 hospitals in the mid-volume group, and 31 in the high-volume group. All groups had low-mortality (mortality <1.9%) and high-mortality (mortality >1.9%) hospitals. Among low-volume hospitals, 53% were low-mortality (n = 74) and 47% were high-mortality (n = 66) hospitals. Among mid-volume hospitals, 58% were low-mortality (n = 37) and 42% were high-mortality (n = 27) hospitals. Among high-volume hospitals, 68% were low-mortality (n = 21) and 32% were high-mortality (n = 10) hospitals. There was no statistically significant difference in risk-adjusted in-hospital mortality when comparing low-, mid-, and high-volume centers for 7 Society of Thoracic Surgeons benchmark procedures. CONCLUSIONS: This national, real-world, risk-adjusted volume outcome analysis highlights that volume alone may not be the sole arbiter to predict quality of pediatric cardiac surgery outcomes. Using case volume alone as a surrogate for quality may unfairly asperse high-performing, low-volume programs.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Mortalidade Hospitalar , Humanos , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Mortalidade Hospitalar/tendências , Masculino , Feminino , Estados Unidos , Lactente , Criança , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Pré-Escolar , Cardiopatias Congênitas/cirurgia , Cardiopatias Congênitas/mortalidade , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Estudos Retrospectivos , Recém-Nascido , Hospitais Pediátricos/estatística & dados numéricos
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