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Original Investigation
April 2017

Defining a Hospital Volume Threshold for Minimally Invasive Pancreaticoduodenectomy in the United States

Author Affiliations
  • 1Department of Surgery, Duke University Medical Center, Durham, North Carolina
  • 2Department of Biostatistics, Duke University, Durham, North Carolina
  • 3Duke Clinical Research Institute, Durham, North Carolina
JAMA Surg. 2017;152(4):336-342. doi:10.1001/jamasurg.2016.4753
Key Points

Question  What is the minimum number of minimally invasive pancreaticoduodenectomy (MIPD) cases performed by a hospital that is associated with the lowest risk for complications?

Findings  In this review of 865 cases of MIPD, we found that increasing hospital procedural volume of MIPD is associated with improved outcomes up to 22 cases per year.

Meaning  The identified threshold of 22 cases per year may serve as a foundation for protocols aimed at safer implementation of MIPD at the national level and may have implications for surgical education and training.

Abstract

Importance  There is increasing interest in expanding use of minimally invasive pancreaticoduodenectomy (MIPD). This procedure is complex, with data suggesting a significant association between hospital volume and outcomes.

Objective  To determine whether there is an MIPD hospital volume threshold for which patient outcomes could be optimized.

Design, Setting, and Participants  Adult patients undergoing MIPD were identified from the Healthcare Cost and Utilization Project National Inpatient Sample from 2000 to 2012. Multivariable models with restricted cubic splines were used to identify a hospital volume threshold by plotting annual hospital volume against the adjusted odds of postoperative complications. The current analysis was conducted on August 16, 2016.

Main Outcomes and Measures  Incidence of any complication.

Results  Of the 865 patients who underwent MIPD, 474 (55%) were male and the median patient age was 67 years (interquartile range, 59-74 years). Among the patients, 747 (86%) had cancer and 91 (11%) had benign conditions/pancreatitis. Overall, 410 patients (47%) had postoperative complications and 31 (4%) died in-hospital. After adjustment for demographic and clinical characteristics, increasing hospital volume was associated with reduced complications (overall association P < .001); the likelihood of experiencing a complication declined as hospital volume increased up to 22 cases per year (95% CI, 21-23). Median hospital volume was 6 cases per year (range, 1-60). Most patients (n = 717; 83%) underwent the procedure at low-volume (≤22 cases per year) hospitals. After adjustment for patient mix, undergoing MIPD at low- vs high-volume hospitals was significantly associated with increased odds for postoperative complications (odds ratio, 1.74; 95% CI, 1.03-2.94; P = .04).

Conclusions and Relevance  Hospital volume is significantly associated with improved outcomes from MIPD, with a threshold of 22 cases per year. Most patients undergo MIPD at low-volume hospitals. Protocols outlining minimum procedural volume thresholds should be considered to facilitate safer dissemination of MIPD.

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