Readmission After Pancreaticoduodenectomy: The Influence of the Volume Effect Beyond Mortality.

BACKGROUND: As increased focus is placed on quality of care in surgery, readmission is an increasingly important metric by which hospital and surgeon quality is measured. For complex pancreatic surgery, we hypothesized that increased pancreaticoduodenectomy (PD) volume may mitigate readmission rates. METHODS: The University Healthsystems Consortium database was queried for all patients (n = 9805) undergoing PD from 2009 to 2011. Hospitals were stratified into quintiles based on number of cases performed annually. Univariate and multivariate logistic regression analyses were performed to identify factors associated with 30-day readmission. RESULTS: The 30-day readmission rate for patients undergoing PD was 19.1 %. Stratified by volume, hospitals performing the highest two quintiles of PDs annually (≥56 cases) had a significantly lower unadjusted readmission rate than those hospitals performing the lowest quintile (n ≤ 23 cases; 16.7 and 18.0 % vs. 20.9 %, p < 0.05). On univariate analysis, readmitted patients tended to have higher severity of illness (p < 0.01) and longer index admission (10 vs. 9 days, p < 0.01). Age and insurance status had no significant association with readmission. Multivariate analysis demonstrated that higher severity of illness (odds ratio [OR] 1.36, 95 % confidence interval [CI] 1.04-1.77, p = 0.02), discharge to rehab (OR 1.41, 95 % CI 1.19-1.66, p < 0.001), and surgery at the lowest volume hospitals (OR 1.28, 95 % CI 1.08-1.51, p = 0.004) were factors independently associated with readmission. CONCLUSIONS: Lower hospital volume is a significant risk factor for readmission after PD. To minimize the excess resource utilization that accompanies readmission, patients undergoing complex oncologic pancreatic surgery should be directed to hospitals most experienced in caring for this patient population.

Factors related to readmission after major elective surgery.

BACKGROUND: Hospital readmissions have received increased scrutiny as a marker for excessive resource utilization and also quality care. AIM: To identify the rate of and risk factors for hospital readmission after major surgery at academic medical centers. METHODS: Using the University Health Consortium Clinical Database, 30-day readmission rates in all adult patients undergoing colectomy (n = 103,129), lung resection (n = 73,558), gastric bypass (n = 62,010) or abdominal aortic surgery (n = 17,997) from 2009 to 2012 were identified. Logistic regression was performed to examine risks for readmission. RESULTS: Overall readmission rates ranged from 8.9 % after gastric bypass to 15.8 % after colectomy. Black race was associated with increased likelihood for readmission after three of the four procedures with odds ratios ranging from 1.13 after colectomy to 1.44 after gastric bypass. For all procedures, moderate, severe, or extreme severity of illness (SOI) and need for transitional care were associated with increased odds for hospital readmission. Lower center volume was an independent predictor of readmission after gastric bypass surgery and aortic surgery. CONCLUSION: Readmission rates after major elective surgery are high across national academic centers. Center volume, SOI, and need for transitional care after discharge are factors associated with readmission and may be used to identify patients at high risk of readmission and hospital utilization after major surgery.

Resident Operative Experience in Hepatopancreatobiliary Surgery: Exposing the Divide.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires an experience in hepatopancreatobiliary (HPB) surgery as part of general surgery residency training. The composition of this experience, however, is unclear. We set out to evaluate current trends in the HPB experience of US general surgery residents. METHODS: National ACGME operative case logs from 1990 to 2016 were examined with a focus on the HPB operative domains. Time-trend analysis was performed using ANOVA and linear regression analysis. RESULTS: Median biliary, liver, and pancreatic operative volumes increased by 30%, 33%, and 27% over the 27-year study period (all p < 0.05). Both core and advanced HPB cases increased, but the rate of increase for core was four times greater than that of advanced. However, when cholecystectomy was excluded, this trend reversed such that HPB core operations decreased by 11 cases over the study period. Further analysis demonstrated that laparoscopic cholecystectomy comprised 90% of all biliary cases and 77% of all HPB cases for graduates in 2016. Finally, operative volume variability-the difference in case numbers between high and low volume residents-increased by 16%, 21%, and 73% for the biliary, liver, and pancreatic domains, respectively (all p < 0.05). CONCLUSIONS: Despite increases in overall HPB operative volume, the HPB experience is changing for today's surgical trainees. Moreover, the HPB experience is comprised largely of a single operation-the cholecystectomy. Awareness of these trends is important for surgical educators to facilitate adequate exposure to HPB surgery among general surgery residents.