September 16, 1998
Some surgeries for cancer are safer, easier on the patient -- and less costly -- when performed at medical centers that do the lion's share of them in any region, according to the results of a Johns Hopkins study, The Importance of Hospital Volume in the Overall Management of Pancreatic Cancer. "Even after accounting for age, race, gender and coexisting ailments, the results were startling," says Toby Gordon, Sc.D., one of the study's authors and Hopkins associate professor of surgery.
For the study, published in the September 1998 issue of The Annals of Surgery, researchers examined outcomes for all 1,236 pancreatic cancer patients who underwent surgical removal of all or part of the pancreas, palliative bypasses and stent procedures at 48 Maryland acute care hospitals between 1990 and 1995. The investigators looked at in-hospital mortality, hospital length of stay and total hospital costs of the operations, which are routinely used to slow down the course of disease or alleviate pain.
To assess the influence of patient volume and surgical experience on outcomes, the investigators grouped the hospitals into three categories based on numbers of procedures. Only one center -- Johns Hopkins -- met the study's criterion for a high-volume provider (20 or more operations per year). Seven other hospitals performing five to 19 procedures annually were classified as medium-volume providers, while the 40 hospitals doing fewer than five each year were considered low-volume providers.
Patients undergoing pancreatic resections in the low-volume hospitals were 19.3 times more likely to die than patients in the high-volume hospital. There was an 8.0 times greater chance of dying in the medium-volume medical centers. Patients undergoing bypass surgeries had a 2.7 times greater risk of death at the low-volume providers and a 1.9 times greater risk at medium-volume providers compared with the high-volume provider. Patients who got stents had 4.3 and 4.8 times greater risk of in-hospital death at low- and medium-volume centers, respectively, compared to the high-volume center.
Differences in how long patients required hospitalization after surgery were similarly dramatic among the hospital groups. The mean length of hospital stay for patients undergoing resections at the high-volume hospital was 16.3, versus 19.4 days at the low-volume providers. For bypass operations, patients in the high-volume center stayed an average of 14.3 days compared to 16.3 days for patients in the low-volume centers. Stent procedures resulted in hospital stays of 4.6 days at the high-volume hospital while the same procedures done in the low-volume centers required stays of 6.7 days.
"Clearly, this study underscores the importance and value of surgical experience in obtaining the best results for patients," says Gordon. "Our study further suggests that the greater surgical expertise at the high-volume center also results in greater cost efficiencies."
The other authors of the study are J.A. Sosa, M.D.; H.M. Bowman, M.S.; E.B. Bass, M.D, M.P.H.; C.J. Yeo, M.D.; K.D. Lillemoe, M.D.; H.A. Pitt, M.D.; J.M.Tielsch, Ph.D.; and J.L. Cameron, M.D.