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A Plea for Outcome-Based and Not Volume-Based Referral Guidelines

Swee H. Teh, MD; Brian S. Diggs, PhD; Clifford W. Deveney, MD; Brett C. Sheppard, MD

Arch Surg. 2009;144(8):713-721.

Hypothesis  There is an effect of patient and hospital characteristics on perioperative outcomes for pancreatic resection in the United States.

Design  Retrospective cohort study.

Setting  Academic research.

Patients  Patient data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project from January 1988 to January 2003.

Main Outcome Measures  In-hospital mortality, perioperative complications, and mortality following a major complication.

Results  A total of 103 222 patients underwent major pancreatic surgery. The annual number of pancreatic resections increased 15.0% during the 16-year study period. Resection for benign pancreatic disease increased 26.8%. Overall in-hospital mortality, perioperative complications, and mortality following a major complication were 6.5%, 35.6%, and 15.6%, respectively. Multivariate analysis demonstrated that significant independent predictors for these 3 perioperative outcomes were advancing age, male sex, medical comorbidity, and hospital volume for each type of pancreatic resection. The in-hospital mortality for pancreatoduodenectomy increases with age and ranges from 1.7% to 13.8% (P < .001). After adjusting for other confounders, the odds of in-hospital mortality for pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy in those 65 years or older were 4.78-fold, 3.84-fold, and 2.60-fold, respectively, lower in the high-volume hospitals compared with those in the lower-volume hospitals.

Conclusions  Perioperative complications derived from this population-based study were higher than those reported in many case series. A significant disparity was noted in perioperative outcomes among surgical centers across the United States. An outcome-based referral guideline may have an immediate effect on improving the quality of care in patients who undergo pancreatic resection for benign and malignant disease.

Author Affiliations: Department of Surgery, Oregon Health & Science University, Portland.

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Patient and Hospital Characteristics on the Variance of Perioperative Outcomes for Pancreatic Resection in the United States—Invited Critique
Michael B. Farnell
Arch Surg. 2009;144(8):721.
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