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Table 1.  
Distribution of Patient and Hospital Characteristics Among Adult Patients Undergoing Esophagomyotomy Stratified by Hospital Volume
Distribution of Patient and Hospital Characteristics Among Adult Patients Undergoing Esophagomyotomy Stratified by Hospital Volume
Table 2.  
Postoperative Complications, Length of Stay, and Hospital Charges Among Low-, Intermediate-, and High-Volume Hospitalsa
Postoperative Complications, Length of Stay, and Hospital Charges Among Low-, Intermediate-, and High-Volume Hospitalsa
1.
Begg  CB, Cramer  LD, Hoskins  WJ, Brennan  MF.  Impact of hospital volume on operative mortality for major cancer surgery.  JAMA. 1998;280(20):1747-1751.PubMedGoogle ScholarCrossref
2.
Finks  JF, Osborne  NH, Birkmeyer  JD.  Trends in hospital volume and operative mortality for high-risk surgery.  N Engl J Med. 2011;364(22):2128-2137.PubMedGoogle ScholarCrossref
3.
Munasinghe  A, Markar  SR, Mamidanna  R,  et al.  Is it time to centralize high-risk cancer care in the United States? Comparison of outcomes of esophagectomy between England and the United States.  Ann Surg. 2015;262(1):79-85.PubMedGoogle ScholarCrossref
4.
Schlottmann  F, Strassle  PD, Patti  MG.  Comparative analysis of perioperative outcomes and costs between laparoscopic and open antireflux surgery.  J Am Coll Surg. 2017;224(3):327-333.PubMedGoogle ScholarCrossref
5.
Schlottmann  F, Strassle  PD, Farrell  TM, Patti  MG.  Minimally invasive surgery should be the standard of care for paraesophageal hernia repair.  J Gastrointest Surg. 2017;21(5):778-784.PubMedGoogle ScholarCrossref
Research Letter
April 2018

Association of Surgical Volume With Perioperative Outcomes for Esophagomyotomy for Esophageal Achalasia

Author Affiliations
  • 1Department of Surgery, University of North Carolina, Chapel Hill
  • 2Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
  • 3Department of Medicine, University of North Carolina, Chapel Hill
JAMA Surg. 2018;153(4):383-386. doi:10.1001/jamasurg.2017.4923

The association of surgical volume with postoperative results has been studied primarily on demanding oncological surgical procedures. These studies have shown significant lower rates of postoperative morbidity and mortality in high-volume centers.1-3

Esophageal achalasia is a rare disease, and it is unknown if a surgeon’s volume affects the postoperative results. Therefore, we aimed to characterize the trend of utilization of esophagomyotomy stratified by surgical volume in the United States and to analyze the association of surgical volume with perioperative outcomes.

Methods

A retrospective population-based analysis was performed using the National (Nationwide) Inpatient Sample for the period January 1, 2000, through December 31, 2013. This study was approved by the University of North Carolina Institutional Review Board as exempt research, and patient informed consent was waived because the study used de-identified data. Data were collected from January 10, 2017, to February 1, 2017. Data analysis took place from February 2, 2017, to March 15, 2017.

Adult patients aged 18 years or older who were diagnosed with esophageal achalasia and who underwent esophagomyotomy were included. Hospital surgical volume was determined using the 30th and 60th percentile cut points for weighted discharges and was classified as low volume (<5 operations per year), intermediate volume (5-10 operations per year), or high volume (>10 operations per year).

The yearly incidence of esophagomyotomy, stratified across hospital volume, was calculated using Poisson regression. Patient demographics and outcomes were compared across surgical volume using χ2 and Wilcoxon or Mann-Whitney tests, where appropriate. Missing data were estimated using Markov Chain Monte Carlo multiple imputation. Main-effect multivariable analyses on the potential influence of surgical volume on patient outcomes were performed using logistic regression on the imputed data sets.

All analyses were performed using SAS software, version 9.4 (SAS Institute Inc). A 2-sided P < .05 was considered statistically significant.

Results

A total of 7488 patients were included. During the study period, 5278 patients (70.5%) underwent esophagomyotomy in high-volume hospitals, 1349 (18.0%) in intermediate-volume hospitals, and 861 (11.5%) in low-volume hospitals. Use of the laparoscopic approach was significantly different among the 3 groups, with 360 patients (36.0%) using it in low-volume hospitals, 567 (42.0%) in intermediate-volume hospitals, and 2631 (49.9%) in high-volume hospitals (P < .001). Demographic and patient characteristics, stratified by hospital volume, are described in Table 1.

Between January 1, 2000, and December 31, 2013, the percentage of procedures occurring at high-volume hospitals increased from 70.5% to 82.5%, whereas the percentage of procedures at low-volume hospitals decreased from 13.9% to 7.8% and at intermediate-volume hospitals from 15.6% to 9.7%.

Compared with high-volume hospitals, low- and intermediate-volume hospitals had a significantly higher incidence of complications. Specifically, patients at low- and intermediate-volume hospitals had higher rates of postoperative bleeding, cardiac failure, renal failure, and respiratory failure. In addition, high-volume hospitals were associated with shorter length of hospital stay (Table 2).

After adjusting for patient and hospital characteristics, we found that patients receiving care at low-volume hospitals (odds ratio [OR], 1.37) were still more likely to have postoperative complications, compared with patients at high-volume hospitals. Patients at low- and intermediate-volume hospitals were more likely to have postoperative respiratory failure. Patients at low-volume hospitals had a median (interquartile range) length of stay of 3 (2-6) days or stayed 1.27 days longer than did patients at high-volume centers, and patients at intermediate-volume hospitals also had a median (interquartile range) length of stay of 3 (2-6) days or stayed 0.63 days longer (Table 2).

Discussion

During the study period, most surgical treatments for esophageal achalasia in the United States were performed in high-volume centers. Patients receiving care at high-volume hospitals had a lower incidence of postoperative respiratory complications and shorter length of hospital stay. In addition, high surgical volume was associated with higher rates of minimally invasive surgery. Laparoscopic surgery, in fact, has proven to be associated with significantly better postoperative outcomes and lower costs in patients with other benign esophageal disorders.4,5

Even though it is hard to legislate, volume standards should be implemented for a rare disease such as esophageal achalasia and centers of excellence should be designated for its treatment. These recommendations might benefit both patients and the US health care system.

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Article Information

Corresponding Author: Francisco Schlottmann, MD, Department of Surgery, University of North Carolina at Chapel Hill, 4030 Burnett Womack Bldg, 101 Manning Dr, CB 7081, Chapel Hill, NC 27599-7081 (fschlottmann@hotmail.com).

Published Online: December 20, 2017. doi:10.1001/jamasurg.2017.4923

Accepted for Publication: July 23, 2017.

Author Contributions: Dr Schlottmann had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Schlottmann, Patti.

Statistical analysis: Schlottmann, Strassle.

Administrative, technical, or material support: Strassle.

Study supervision: Schlottmann, Patti.

Conflict of Interest Disclosures: None reported.

References
1.
Begg  CB, Cramer  LD, Hoskins  WJ, Brennan  MF.  Impact of hospital volume on operative mortality for major cancer surgery.  JAMA. 1998;280(20):1747-1751.PubMedGoogle ScholarCrossref
2.
Finks  JF, Osborne  NH, Birkmeyer  JD.  Trends in hospital volume and operative mortality for high-risk surgery.  N Engl J Med. 2011;364(22):2128-2137.PubMedGoogle ScholarCrossref
3.
Munasinghe  A, Markar  SR, Mamidanna  R,  et al.  Is it time to centralize high-risk cancer care in the United States? Comparison of outcomes of esophagectomy between England and the United States.  Ann Surg. 2015;262(1):79-85.PubMedGoogle ScholarCrossref
4.
Schlottmann  F, Strassle  PD, Patti  MG.  Comparative analysis of perioperative outcomes and costs between laparoscopic and open antireflux surgery.  J Am Coll Surg. 2017;224(3):327-333.PubMedGoogle ScholarCrossref
5.
Schlottmann  F, Strassle  PD, Farrell  TM, Patti  MG.  Minimally invasive surgery should be the standard of care for paraesophageal hernia repair.  J Gastrointest Surg. 2017;21(5):778-784.PubMedGoogle ScholarCrossref
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