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Sheetz KH, Nuliyalu U, Nathan H, Sonnenday CJ. Association of Surgeon Case Numbers of Pancreaticoduodenectomies vs Related Procedures With Patient Outcomes to Inform Volume-Based Credentialing. JAMA Netw Open. 2020;3(4):e203850. doi:10.1001/jamanetworkopen.2020.3850
Is surgeon experience with related procedures associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone?
In this proof-of-concept cohort study of 176 043 patients and 1028 surgeons, 54 surgeons (5.3%) met modest annual volume thresholds for pancreaticoduodenectomy. However, increasing related hepatopancreatobiliary case volume was associated with better outcomes for pancreaticoduodenectomy.
These findings suggest that related procedure volumes may be used to inform surgeon-specific, volume-based credentialing standards.
Despite growing interest from various surgical societies and patient safety organizations, concerns remain that volume-based credentialing standards are arbitrary and may fail to recognize a surgeon’s full scope of practice.
To evaluate whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone.
Design, Setting, and Participants
This proof-of-concept cohort study used the all-payer State Inpatient Databases from 6 geographically diverse states to identify all operations for surgeons who performed at least 1 pancreaticoduodenectomy from January 1, 2012, to December 31, 2014. Each surgeon’s mean annual volume for pancreaticoduodenectomies and related complex hepatopancreatobiliary (HPB) procedures was calculated. Outcomes for surgeons above and below a threshold of 12 pancreaticoduodenectomies per year were evaluated. Whether related HPB procedure volume was also associated with better outcomes for surgeons not meeting the procedure-specific threshold was also evaluated. Data were analyzed from March 2 through 20, 2019.
Main Outcomes and Measures
Thirty-day mortality and complications.
The study cohort included 176 043 patients, of whom 92 064 were female (52.3%), with a mean (SD) age of 59 (17) years. Within 270 hospitals, only 54 of 1028 surgeons (5.3%) met the mean pancreaticoduodenectomy volume threshold from 2012 to 2014. In-hospital mortality after pancreaticoduodenectomy was lower for surgeons who performed 12 or more procedures per year (1.8% [95% CI, 1.1%- 2.4%] vs 4.7% [95% CI, 4.0%-5.4%]; odds ratio, 0.32; 95% CI, 0.21-0.50). However, in-hospital mortality varied 7-fold among surgeons who did not meet the threshold (1.2% [95% CI, 0.8%-1.6%] to 8.4% [95% CI, 7.9%-8.9%]). Increasing HPB case volume was associated with better outcomes for pancreaticoduodenectomy in this group. For example, surgeons performing 2 or fewer pancreaticoduodenectomies annually would need to perform an additional 27 related HPB procedures to match the in-hospital mortality rate of surgeons performing 12 or more pancreaticoduodenectomies.
Conclusions and Relevance
In this proof-of-concept cohort study, few surgeons met even modest annual volume thresholds for pancreaticoduodenectomy. The findings suggest that inclusion of related procedure volumes may safely expand the cohort of surgeons credentialed to perform certain procedures under volume-based standards.
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