Association of Surgeon Case Numbers of Pancreaticoduodenectomies vs Related Procedures With Patient Outcomes to Inform Volume-Based Credentialing | Gastroenterology | JAMA Network Open | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 18.204.227.34. Please contact the publisher to request reinstatement.
1.
Pradarelli  JC, Campbell  DA  Jr, Dimick  JB.  Hospital credentialing and privileging of surgeons: a potential safety blind spot.   JAMA. 2015;313(13):1313-1314. doi:10.1001/jama.2015.1943 PubMedGoogle ScholarCrossref
2.
Birkmeyer  JD, Stukel  TA, Siewers  AE, Goodney  PP, Wennberg  DE, Lucas  FL.  Surgeon volume and operative mortality in the United States.   N Engl J Med. 2003;349(22):2117-2127. doi:10.1056/NEJMsa035205 PubMedGoogle ScholarCrossref
3.
Macedo  FIB, Jayanthi  P, Mowzoon  M, Yakoub  D, Dudeja  V, Merchant  N.  The impact of surgeon volume on outcomes after pancreaticoduodenectomy: a meta-analysis.   J Gastrointest Surg. 2017;21(10):1723-1731. doi:10.1007/s11605-017-3498-7 PubMedGoogle ScholarCrossref
4.
Mathur  A, Luberice  K, Ross  S, Choung  E, Rosemurgy  A.  Pancreaticoduodenectomy at high-volume centers: surgeon volume goes beyond the Leapfrog criteria.   Ann Surg. 2015;262(2):e37-e39. doi:10.1097/SLA.0000000000001330 PubMedGoogle ScholarCrossref
5.
Pecorelli  N, Balzano  G, Capretti  G, Zerbi  A, Di Carlo  V, Braga  M.  Effect of surgeon volume on outcome following pancreaticoduodenectomy in a high-volume hospital.   J Gastrointest Surg. 2012;16(3):518-523. doi:10.1007/s11605-011-1777-2 PubMedGoogle ScholarCrossref
6.
TheLeapfrogGroup. Inpatient surgery: surgical volume. Accessed March 25, 2019. https://www.leapfroggroup.org/ratings-reports/surgical-volume
7.
Urbach  DR.  Pledging to eliminate low-volume surgery.   N Engl J Med. 2015;373(15):1388-1390. doi:10.1056/NEJMp1508472 PubMedGoogle ScholarCrossref
8.
Shih  T, Cole  AI, Al-Attar  PM,  et al.  Reliability of surgeon-specific reporting of complications after colectomy.   Ann Surg. 2015;261(5):920-925. doi:10.1097/SLA.0000000000001032 PubMedGoogle ScholarCrossref
9.
Jacobs  RC, Groth  S, Farjah  F, Wilson  MA, Petersen  LA, Massarweh  NN.  Potential impact of “take the volume pledge” on access and outcomes for gastrointestinal cancer surgery.   Ann Surg. 2019;270(6):1079-1089. doi:10.1097/SLA.0000000000002796PubMedGoogle ScholarCrossref
10.
Modrall  JG, Minter  RM, Minhajuddin  A,  et al.  The surgeon volume-outcome relationship: not yet ready for policy.   Ann Surg. 2018;267(5):863-867. doi:10.1097/SLA.0000000000002334 PubMedGoogle ScholarCrossref
11.
Iezzoni  LI, Daley  J, Heeren  T,  et al.  Identifying complications of care using administrative data.   Med Care. 1994;32(7):700-715. doi:10.1097/00005650-199407000-00004 PubMedGoogle ScholarCrossref
12.
Elixhauser  A, Steiner  C, Harris  DR, Coffey  RM.  Comorbidity measures for use with administrative data.   Med Care. 1998;36(1):8-27. doi:10.1097/00005650-199801000-00004 PubMedGoogle ScholarCrossref
13.
American Board of Medical Specialties. Focused practice designation. Accessed May 14, 2019. https://www.abms.org/board-certification/focused-practice-designation/
14.
Vonlanthen  R, Lodge  P, Barkun  JS,  et al.  Toward a consensus on centralization in surgery.   Ann Surg. 2018;268(5):712-724. doi:10.1097/SLA.0000000000002965 PubMedGoogle ScholarCrossref
15.
Shahian  DM, Edwards  FH, Jacobs  JP,  et al.  Public reporting of cardiac surgery performance: part 1—history, rationale, consequences.   Ann Thorac Surg. 2011;92(3)(suppl):S2-S11. doi:10.1016/j.athoracsur.2011.06.100 PubMedGoogle ScholarCrossref
16.
Shahian  DM, Edwards  FH, Jacobs  JP,  et al.  Public reporting of cardiac surgery performance: part 2—implementation.   Ann Thorac Surg. 2011;92(3)(suppl):S12-S23. doi:10.1016/j.athoracsur.2011.06.101 PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Surgery
    April 29, 2020

    Association of Surgeon Case Numbers of Pancreaticoduodenectomies vs Related Procedures With Patient Outcomes to Inform Volume-Based Credentialing

    Author Affiliations
    • 1Department of Surgery, University of Michigan, Ann Arbor
    • 2Center for Healthcare Outcomes and Policy, School of Medicine, University of Michigan, Ann Arbor
    JAMA Netw Open. 2020;3(4):e203850. doi:10.1001/jamanetworkopen.2020.3850
    Key Points español 中文 (chinese)

    Question  Is surgeon experience with related procedures associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone?

    Findings  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.

    Meaning  These findings suggest that related procedure volumes may be used to inform surgeon-specific, volume-based credentialing standards.

    Abstract

    Importance  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.

    Objective  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.

    Results  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.

    ×