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Original Investigation
May 17, 2017

Association of Very Low-Volume Practice With Vascular Surgery Outcomes in New York

Author Affiliations
  • 1Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
  • 2Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
JAMA Surg. Published online May 17, 2017. doi:10.1001/jamasurg.2017.1100
Key Points

Question  Does the practice of 1 or fewer procedures per year exist in vascular surgery in New York, and what is its effect on surgical outcomes?

Findings  In this cohort study using inpatient hospital data from 2000 to 2014, the practice of very low-volume surgeons performing open abdominal aortic aneurysm repair and carotid endarterectomy has declined in New York but continued to exist. Very low-volume practice was associated with worse clinical outcomes as well as increased health care resource use.

Meaning  Future efforts are needed to address this practice pattern to ensure high-quality care for all patients.


Importance  Little research has focused on very low-volume surgery, especially in the context of decreasing vascular surgery volume with the adoption of endovascular procedures.

Objective  To investigate the existence and outcomes of open abdominal aortic aneurysm repair (OAR) and carotid endarterectomy (CEA) performed by very low-volume surgeons in New York.

Design, Settings, and Participants  This cohort study examined inpatient data of patients undergoing elective OAR or CEA from 2000 to 2014 from all New York hospitals.

Exposures  Surgeons who performed 1 or less designated procedure per year on average were considered very low volume, as opposed to higher-volume surgeons.

Main Outcomes and Measures  Temporal trends of the existence of very low-volume practice were evaluated. Hierarchical logistic regression was used to compare in-hospital outcomes and health care resource use between patients treated by very low-volume surgeons and higher-volume surgeons for both OAR and CEA, adjusting for patient, surgeon, and hospital characteristics.

Results  There were 8781 OAR procedures and 68 896 CEA procedures included in the study. The mean (SD) patient age was 71.7 (8.4) years for OAR and 71.5 (9.1) years for CEA. A total of 614 surgeons performed OAR and 1071 performed CEA in New York during the study period. Of these, 318 (51.8%) and 512 (47.8%), respectively, were very low-volume surgeons. Very low-volume surgeons were less likely to be vascular surgeons. The number and proportion of very low-volume surgeons decreased over years. Compared with patients treated by higher-volume surgeons, those treated by very low-volume surgeons were more likely to have higher in-hospital mortality (odds ratio [OR], 2.09; 95% CI, 1.41-3.08) following OAR and higher risks of postoperative myocardial infarction (OR, 1.83; 95% CI, 1.03-3.26) and stroke (OR, 1.78; 95% CI, 1.21-2.62) following CEA. Patients treated by very low-volume surgeons also had greater health care resource use following both surgeries, including prolonged length of stay (OR, 1.37; 95% CI, 1.11-1.70) following OAR as well as higher charges (OR, 1.28; 95% CI, 1.01-1.62) and increased 30-day readmission (OR, 1.30; 95% CI 1.04-1.62) following CEA.

Conclusions and Relevance  The OAR and CEA procedures performed by very low-volume surgeons resulted in worse postoperative outcomes and greater lengths of stay. Although the percentage of very low-volume surgeons declined from 2000 to 2014, it remains concerning, given ready access to higher-volume surgeons. Future research is needed to understand the existence of this practice pattern in other surgical fields. Efforts to eliminate this practice pattern are warranted to ensure high-quality care for all patients.