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Which Matters More, Surgeon Volume or Specialty?

Henry S. Park, BS; Sanziana A. Roman, MD; Julie Ann Sosa, MA, MD

Arch Surg. 2009;144(11):1060-1067.

Objective  To assess the effect of surgeon volume and specialty on clinical and economic outcomes after adrenalectomy.

Design  Population-based retrospective cohort analysis.

Setting  Healthcare Cost and Utilization Project Nationwide Inpatient Sample.

Participants  Adults (18 years) undergoing adrenalectomy in the United States (1999-2005). Patient demographic and clinical characteristics, surgeon specialty (general vs urologist), surgeon adrenalectomy volume, and hospital factors were assessed.

Main Outcome Measures  The ² test, analysis of variance, and multivariate linear and logistic regression were used to assess in-hospital complications, mean hospital length of stay (LOS), and total inpatient hospital costs.

Results  A total of 3144 adrenalectomies were included. Mean patient age was 53.7 years; 58.8% were women and 77.4% white. A higher proportion of general surgeons were high-volume surgeons compared with urologists (34.1% vs 18.2%, P < .001). Low-volume surgeons had more complications (18.2% vs 11.3%, P < .001) and their patients had longer LOS (5.5 vs 3.9 days, P < .001) than did high-volume surgeons; urologists had more complications (18.4% vs 15.2%, P = .03) and higher costs ($13 168 vs $11 732, P = .02) than did general surgeons. After adjustment for patient and provider characteristics in multivariate analyses, surgeon volume, but not specialty, was an independent predictor of complications (odds ratio = 1.5, P < .002) and LOS (1.0-day difference, P < .001). Hospital volume was associated only with LOS (0.8-day difference, P < .007). Surgeon volume, specialty, and hospital volume were not predictors of costs.

Conclusion  To optimize outcomes, patients with adrenal disease should be referred to surgeons based on adrenal volume and laparoscopic expertise irrespective of specialty practice.

Author Affiliations: Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.

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