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Background Many countries have centralized and dedicated trauma centres with high volumes of trauma patients. However, the volume-outcome relationship in severely injured patients (Injury Severity Score (ISS) > 15) remains unclear. The aim of this study was to determine the association between hospital volume and outcomes in Major Trauma Centres (MTCs). Methods A retrospective observational cohort study was conducted using the Trauma Audit and Research Network (TARN) consisting of all English Major Trauma Centres (MTCs). Severely injured patients (ISS > 15) admitted to a MTC between 2013 and 2016 were included. The effect of hospital volume on outcome was analysed with random effects logistic regression models with a random intercept for centre and was tested for nonlinearity. Primary outcome was in-hospital mortality. Results A total of 47,157 severely injured patients from 28 MTCs were included in this study. Hospital volume varied from 69 to 781 severely injured patients per year. There were small between-centre differences in mortality after adjusting for important demographic and injury severity characteristics (adjusted 95% odds ratio range: 0.99–1.01). Hospital volume was found to be linear and not associated with in-hospital mortality (adjusted odds ratio (aOR) 1.02 per 10 patients, 95% confidence interval (CI) 0.68–1.54, p = 0.92). Conclusions Despite the large variation in volume of the included MTCs, no relationship between hospital volume and outcome of severely injured patients was found. These results suggest that centres with similar structure and processes of care can achieve comparable outcomes in severely injured patients despite the number of severely injured patients they treat.

Background Published data in the last decade showed that a majority of adrenal operations are done by surgeons performing only one such case per year and based on the distribution of personal workloads ‘high-volume’ surgeons are defined as those doing 4 or more cases/year. Purpose This paper summarises literature data identified by a working group established by the European Society of Endocrine Surgeons (ESES). The findings were discussed during ESES-2019 conference and members agreed on a consensus statement. Results The annual of adrenal operations performed yearly in individual countries was reported to be 800/year in UK and over 1600/year in France. The learning curve of an individual surgeon undertaking laparoscopic, retroperitoneoscopic or robotic adrenalectomy is estimated to be 20–40 cases. Preoperative morbidity and length of stay are more favourable in high-volume centres. Conclusion The main recommendations are that adrenal surgery should continue only in centres performing at least 6 cases per year, surgery for adrenocortical cancer should be restricted to centres performing at least 12 adrenal operations per year, and an integrated multidisciplinary team should be established in all such centres. Clinical information regarding adrenalectomies should be recorded prospectively and contribution to the established EUROCRINE and ENSAT databases is strongly encouraged. Surgeons wishing to develop expertise in this field should seek mentorship and further training from established adrenal surgeons.

Objective: As open abdominal aortic aneurysm (AAA) repair (OAR) rates decline in the endovascular era, the endorsement of minimum volume thresholds for OAR is increasingly controversial, as this may affect credentialing and training. The purpose of this analysis was to identify an optimal centre volume threshold that is associated with the most significant mortality reduction after OAR, and to determine how this reflects contemporary practice. Methods: This was an observational study of OARs performed in 11 countries (2010 e 2016) within the International Consortium of Vascular Registry database (n 1⁄4 178 302). The primary endpoint was post- operative in hospital mortality. Two different methodologies (area under the receiving operating curve optimisation and Markov chain Monte Carlo procedure) were used to determine the optimal centre volume threshold associated with the most significant mortality improvement. Results: In total, 154 912 (86.9%) intact and 23 390 (13.1%) ruptured AAAs were analysed. The majority (63.1%; n 1⁄4 112 557) underwent endovascular repair (EVAR) (OAR 36.9%; n 1⁄4 65 745). A significant inverse relationship between increasing centre volume and lower peri-operative mortality after intact and ruptured OAR was evident (p < .001) but not with EVAR. An annual centre volume of between 13 and 16 procedures per year was associated with the most significant mortality reduction after intact OAR (adjusted predicted mortality < 13 procedures/year 4.6% [95% confidence interval 4.0% e 5.2%] vs. 13 procedures/year 3.1% [95% CI 2.8% e 3.5%]). With the increasing adoption of EVAR, the mean number of OARs per centre (intact þ ruptured) decreased significantly (2010 e 2013 1⁄4 35.7; 2014 e 2016 1⁄4 29.8; p < .001). Only 23% of centres (n 1⁄4 240/1 065) met the 13 procedures/year volume threshold, with significant variation between nations (Germany 11%; Denmark 100%). Conclusion: An annual centre volume of 13 e 16 OARs per year is the optimal threshold associated with the greatest mortality risk reduction after treatment of intact AAA. However, in the current endovascular era, achieving this threshold requires significant re-organisation of OAR practice delivery in many countries, and would affect provision of non-elective aortic services. Low volume centres continuing to offer OAR should aim to achieve mortality results equivalent to the high volume institution benchmark, using validated data from quality registries to track outcomes., peer-reviewed

Evidence on volume outcome associations for autologous stem cell transplantation (ASCT) in multiple myeloma (MM) is limited. We investigated ASCT utilization patterns and volume outcome associations in the German National Registry for Stem Cell Transplants (DRST). MM patients with an upfront ASCT between 1998 and 2014 registered in the DRST were included. ASCT utilization increased strongly from 6% to 17% between 1999 and 2013 with the largest increase for patients aged 60-64 years (8-34%). The mean number of ASCTs conducted in the hospitals per year varied (quintiles, Q1:0.0-8.2 to Q5:31.0-102.7). Center volume was not associated with survival after upfront ASCT (lowest vs. highest center volume, hazard ratios and 95% confidence intervals: 0.95 (0.76-1.18)

The last 20 years have witnessed a trend towards the centralization of colorectal surgery. Both surgeon and hospital volumes have a significant impact on both short-term and oncologic long-term outcomes. However, there is no consensus on volume thresholds, and differences between hospitals considered low- or high-volume are diminishing over time. In addition, public health policies have limited the centralization of colorectal surgery for cancer worldwide.

In the United States, there has been widespread recognition among health care quality improvement experts that a strong relationship exists between the volume of particular surgical cases performed and the outcomes experienced by patients electing to undergo such procedures (1,2).

This is a critical comment on the paper by Endo et al. on the volume-outcome relationship on survival and cost benefits in severe burn injury which addresses biases related to patient transfer and burn severity assessment.

Background. We sought to study the association between RPS case volume and outcomes. Although a relationship has been demonstrated between case volume and patient outcomes in some cancers, such a relationship has not been established for retroperitoneal sarcomas (RPSs). Study Design. The National Cancer Database (NCDB) was queried for patients undergoing treatment for primary RPS diagnosed between 2004 and 2013. Mean annual patient volume for RPS resection was calculated for all hospitals and divided into low volume (10 cases/year). Risk-adjusted regression analyses were performed to identify predictors of 30-day surgical mortality, R0 margin status, and overall survival (OS). Results. Our study population consisted of 5,407 patients with a median age of 61 years, of whom 47% were male and 3,803 (70%) underwent surgical resection. Absolute 30-day surgical mortality and R0 margin rate following surgery for low-, medium-, and high-volume institutions were 2.4%, 1.3%, and 0.5% (p=0.027) and 68%, 65%, and 82%, (p<0.001), respectively. Five-year overall survival rates for low, medium, and high-volume institutions were 56%, 57%, and 66%, respectively (p<0.001). Patients treated at low-volume institutions had a significantly higher risk of 30-day mortality (adjusted OR = 4.66, 95% CI 2.26–9.63) and long-term mortality (adjusted HR = 1.56, 95% CI 1.16–2.11) compared to high-volume institutions. Conclusion. We demonstrate the existence of a hospital sarcoma service line volume-oncologic outcome relationship for RPS at the national level and provide benchmark data for cancer care delivery systems and policy makers.

Background Most studies showing a volume outcome effect in resection surgery for oesophago-gastric cancer were conducted before the centralisation of clinical services. This study evaluated the relation between hospital- and surgeon volume and different risk-adjusted outcomes after oesophago-gastric (OG) cancer surgery in England between 2011 and 2013. Methods In data from the National Oesophago-Gastric Cancer Audit from the UK, multivariable random-effects logistic regression models were used to quantify the effect of surgeon and hospital volume on three outcomes: 30-day and 90-day mortality and anastomotic leakage. The models included patient risk factors to adjust for differences in case-mix among hospitals and surgeons. The between-cluster heterogeneity was estimated with the median odds ratio (MOR). Results The study included patients treated at 42 hospitals and 329 surgeons. The median (interquartile range) of the annual hospital and surgeon volumes were 110 patients (82 to 137) and 13 patients (8 to 19), respectively. The overall rates for 30-day and 90-day mortality were 2.3% and 4.4% respectively, and the anastomotic leakage was 6.3%. Higher hospital volume was associated with lower 30-day mortality (OR: 0.94; 95% CI: 0.91–0.98) and lower anastomotic leakage rates (OR: 0.96; 95% CI: 0.93–0.98) but not 90-day mortality. Higher surgeon volume was only associated with lower anastomotic leakage rates (OR: 0.81; 95% CI: 0.72–0.92). Hospital volume explained a part of the between-hospital variation in 30-day mortality whereas surgeon volume explained part of the between-hospital variation in anastomotic leakage. Conclusions In the setting of centralized O-G cancer surgery in England, we could still observe an effect of volume on short-term outcomes. However, the effect is inconsistent, depending on the type of outcome measure under consideration, and much smaller than in previous studies. Efforts to centralise O-G cancer services further should carefully address the effects of both hospital and surgeon volume on the range of outcome measures that are relevant to patients.

Background The aim of this study was to evaluate institutional volume-outcome relationships in extracorporeal membrane oxygenation (ECMO) with subanalyses of ECMO in patients with a primary diagnosis of respiratory failure. Methods All institutions with adult ECMO discharges in the Nationwide Inpatient Sample from 2002 to 2011 were evaluated. International Classification of Diseases (ninth revision) codes were used to identify ECMO-treated patients, indications, and concurrent procedures. Patients who were treated with ECMO after cardiotomy were excluded. Annual institutional and national volume of ECMO hospitalizations varied widely, hence the number of ECMO cases performed at an institution was calculated for each year independently. Institutions were grouped into high-, medium-, and low-volume terciles by year. Statistical analysis included hierarchical, multivariable logistic regression. Results The in-hospital mortality rates for ECMO admissions at low-, medium-, and high-volume ECMO centers were 48% (n = 467), 60% (n = 285), and 57% (n = 445), respectively ( p = 0.001). In post hoc pairwise comparisons, patients in low-volume hospitals were more likely to survive to discharge compared with patients in medium-volume ( p = 0.001) and high-volume ( p = 0.005) hospitals. There was no significant difference in survival between medium-volume and high-volume hospitals ( p = 0.81). In a subanalysis of patients with respiratory failure, low-volume ECMO centers maintained the lowest rates of in-hospital mortality (47%), versus 61% in medium-volume institutions ( p = 0.045) and 56% in high-volume institutions ( p = 0.15). Multivariable logistical regression produced similar results in the entire study sample and in patients with respiratory failure. Conclusions ECMO outcomes in the Nationwide Inpatient Sample do not follow a traditional volume-outcome relationship, and these results suggest that, in properly selected patients, ECMO can be performed with acceptable results in U.S. centers that do not perform a high volume of ECMO.

Esophageal cancer incidence is rapidly increasing in the western countries. Adenocarcinoma has recently become the most frequent subtype because of the changes in lifestyle. As observed for other types of surgery, even for esophageal surgery better results have been observed in centers with high volume of activity. Countries with formal policies of centralization, as Great Britain and The Netherlands, have got lower mortality and longer survival than those obtained before the centralization program introduction and of those countries without centralization programs. However, concerns about accessibility to high volume hospitals for lower level social strata have emerged in different countries. In Italy most of the esophagectomies for cancer are performed in very low volume centers with limited experience. High volume centers with >20 cases/year are few but, even if managing patients with more severe comorbidities have got a lower mortality and a shorter length of stay. The Aim of this paper is to identify the organizational, structural and volume requirements for accreditation of a center as an esophageal surgery center. Special attention must be given to a multidisciplinary approach involving different highly skilled specialists with the creation of a multidisciplinary team and individualized diagnostic and therapeutic pathways.

International audience; OBJECTIVEThe purpose of this study was to systematically review the research on volume and outcome relationships in critical care.METHODSFrom January 1, 2001, to April 30, 2014, MEDLINE and EMBASE were searched for studies assessing the relationship between admission volume and clinical outcomes in critical illness. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies. Of 127 studies reviewed, 46 met inclusion criteria, covering seven clinical conditions. Two investigators independently reviewed each article using a standardized form to abstract information on key study characteristics and results.RESULTSOverall, 29 of the studies (63%) reported a statistically significant association between higher admission volume and improved outcomes. The magnitude of the association (mortality OR between the lowest vs highest stratum of volume centers), as well as the thresholds used to characterize high volume, varied across clinical conditions. Critically ill patients with cardiovascular (n = 7, OR = 1.49 [1.11-2.00]), respiratory (n = 12, OR = 1.20 [1.04-1.38]), severe sepsis (n = 4, OR = 1.17 [1.03-1.33]), hepato-GI (n = 3, OR = 1.30 [1.08-1.78]), neurologic (n = 3, OR = 1.38 [1.22-1.57]), and postoperative admission diagnoses (n = 3, OR = 2.95 [1.05-8.30]) were more likely to benefit from admission to higher-volume centers compared with lower-volume centers. Studies that controlled for ICU or hospital organizational factors were less likely to find a significant volume-outcome relationship than studies that did not control for these factors.CONCLUSIONSCritically ill patients generally benefit from care in high-volume centers, with more substantial benefits in selected high-risk conditions. This relationship may in part be mediated by specific ICU and hospital organizational factors.Volume-outcome relationships are well established in many surgical conditions and high-risk procedures in health care.1 Under these relationships, higher numbers of procedures are thought to lead to better patient outcomes through the development of procedural skill.2 Such observations lend conceptual support to the development of regionalized systems of surgical care, in which patients are selectively referred to high-volume providers.3 Selective referral has substantially improved the quality of care for patients in need of these planned high-risk procedures, with improved outcomes over time due in large part to concentration of care.2Given the current shortage of ICU physicians and the overall complexity of critical illness, critical care is also an attractive target for regionalization. However, unlike in many surgical conditions, the volume-outcome relationship in critical illness is still incompletely characterized.4 In the absence of a well-defined volume-outcome relationship, regionalization of critical care may increase costs while delaying definitive therapy for extremely sick patients in need of rapid diagnosis and treatment. Moreover, regionalization is only one potential strategy for region-wide organization of critical care.5 Without a greater understanding of the mechanism of the volume-outcome relationship, which may in part be determined by organizational factors that are correlated with volume, we may miss out on opportunities to improve outcomes for small-volume providers without large-scale reorganization of care.The goal of this study was to perform a systematic review of literature to assess the volume-outcome relationship among critically ill adult patients. In addition to providing summary information, we sought to understand organizational factors that may be potential mechanisms for this effect by analyzing the differences between positive and negative studies.

Mortality and morbidity are both increased during revision hip surgery. Higher hospital procedure volumes have been associated with lower rates of mortality and/or complications according to some reports - the "practice makes perfect" hypothesis.The aim of the study was to test "practice makes perfect; hypothesis with regards to revision hip surgery at our low volume hospital.This is a retrospective study of all the patients who underwent revision hip arthroplasty under the care of the senior author between February 2002 and January 2006. Data was collected about the 30-day and one-year mortality, post-operative complications like deep vein thrombosis (DVT), pulmonary embolism (PE), superficial or deep wound infections, dislocations, and the Oxford hip score.The rate of revision hip surgery carried out in our hospital was 6.25 per year. There was no 30-day mortality, stroke within 3 months, dislocations within one year, re-admission within one month, one-year mortality and deep infections within one year. The final outcome after revision hip surgery, based on Oxford questionnaire, showed that 72% had an excellent outcome and 8% had poor outcome.Volume and outcome relationship may not contribute towards the final outcome when individual surgeons and hospitals are considered. Good general hospital care can greatly affect the health outcome for a particular procedure. Strategies aimed at improving the general hospital care may benefit the patients as much as volume based regionalization.

The existence of a relationship between surgeon volume and patient outcome has been reported for different complex surgical operations. This relationship has also been confirmed for patients undergoing Roux-en-Y gastric bypass (RYGB) in the Longitudinal Assessment of Bariatric Surgery (LABS) study. Despite multiple studies demonstrating volume-outcome relationships, fewer studies investigate the causes of this relationship.The purpose of the present study is to understand possible explanations for the volume-outcome relationship in LABS.LABS includes a 10-center, prospective study examining 30-day outcomes after bariatric surgery. The relationship between surgeon annual RYGB volume and incidence of a composite endpoint (CE) has been published previously. Technical aspects of RYGB surgery were compared between high and low volume surgeons. The previously published model was adjusted for select technical factors.High-volume surgeons (100 RYGBs/yr) were more likely to perform a linear stapled gastrojejunostomy, use fibrin sealant, and place a drain at the gastrojejunostomy compared with low-volume surgeons (25 RYGBs/yr), and less likely to perform an intraoperative leak test. After adjusting for the newly identified technical factors, the relative risk of CE was .93 per 10 RYGB/yr increase in volume, compared with .90 for clinical risk adjustment alone.High-volume surgeons exhibited certain differences in technique compared with low-volume surgeons. After adjusting for these differences, the strength of the volume-outcome relationship previously found was reduced only slightly, suggesting that other factors are also involved.

This study examined the effect of surgeons’ volume on outcomes in lung surgery: lobectomies and wedge resections. Additionally, the effect of video-assisted thoracoscopic surgery (VATS) on cost, utilization, and adverse events was analyzed. The Premier Hospital Database was the data source for this analysis. Eligible patients were those of any age undergoing lobectomy or wedge resection using VATS for cancer treatment. Volume was represented by the aggregate experience level of the surgeon in a six-month window before each surgery. A positive volume-outcome relationship was found with some notable features. The relationship is stronger for cost and utilization outcomes than for adverse events; for thoracic surgeons as opposed to other surgeons; for VATS lobectomies rather than VATS wedge resections. While there was a reduction in cost and resource utilization with greater experience in VATS, these outcomes were not associated with greater experience in open procedures.

[1] Moons P. The importance of methodological rigour in quality-of-life studies. Eur J Cardiothorac Surg 2010;37(1):246—7. [2] Dick F, Hinder D, Immer FF, Hirzel C, Do DD, Carrel TP, Schmidli J. Outcome and quality of life after surgical and endovascular treatment of descending aortic lesions. Ann Thorac Surg 2008;85(5):1605—12. [3] Immer FF, Lippeck C, Barmettler H, Berdat PA, Eckstein FS, Kipfer B, Saner H, Schmidli J, Carrel TP. Improvement of quality of life after surgery on the thoracic aorta: effect of antegrade cerebral perfusion and short duration of deep hypothermic circulatory arrest. Circulation 2004;110(11 Suppl. 1):II250—5. [4] Ware JE, Kosinski M, Keller SD. The SF-36 Physical and Mental Health Summary Scales: a manual for users of Version 1, 2nd Edition, Lincoln, RI: QualityMetric Incorporated; 2001. [5] Bullinger M, Kirchberger I. SF-36. Fragebogen zum Gesundheitszustand. Handanweisung. Gottingen: Hogrefe; 1998.

Since the first volume-outcome relationships in the medical care were reported by Luft in 1979,1 there has been a persistent and sometimes emotional debate about whether certain sorts of complex, elective care should be restricted to high-volume medical centers. Over the past 2 decades, numerous studies have shown that higher hospital volume is associated with lower postoperative mortality and morbidity rates after a great number of different surgical procedures.2–12 These include both high-risk operations and less complex procedures. There are also reports on improved survival after cancer surgery done in high-volume specialty centers as compared with low- and medium-volume units.13–16 Still, the referral pattern has remained practically unchanged in most countries, and few if any signs of regionalization of complex procedures have been seen. In The Netherlands, 40% to 46% of pancreaticoduodenectomies continue to be done in low-volume units,7 and such operations are practiced in 50% of Swedish hospitals, most of which do less than three operations annually.17 Although relations between volume and outcome have long been recognized efforts to concentrate, selective procedures in high-volume hospitals are only now beginning to gain momentum. What explains the hesitation?

Background Prominent studies continue to measure the hospital volume-outcome relation using simple logistic or random-effects models. These regression models may not appropriately account for unobserved differences across hospitals (such as differences in organizational effectiveness) which could be mistaken for a volume outcome relation. Objective To explore alternative estimation methods for measuring the volume-outcome relation for six major cancer operations, and to determine which estimation method is most appropriate. Methods We analyzed patient-level hospital discharge data from three USA states and data from the American Hospital Association Annual Survey of Hospitals from 2000 to 2011. We studied six major cancer operations using three regression frameworks (logistic, fixed-effects, and random-effects) to determine the correlation between patient outcome (mortality) and hospital volume. Results For our data, logistic and random-effects models suggest a non-zero volume effect, whereas fixed-effects models do not. Model-specification tests support the fixed-effects or random-effects model, depending on the surgical procedure; the basic logistic model is always rejected. Esophagectomy and rectal resection do not exhibit significant volume effects, whereas colectomy, pancreatic resection, pneumonectomy, and pulmonary lobectomy do. Conclusions The statistical significance of the hospital volume-outcome relation depends critically on the regression model. A simple logistic model cannot control for unobserved differences across hospitals that may be mistaken for a volume effect. Even when one applies panel-data methods, one must carefully choose between fixed- and random-effects models. Electronic supplementary material The online version of this article (doi:10.1007/s40258-016-0241-6) contains supplementary material, which is available to authorized users.

Objectives Our aim was to analyse the relation between hospital volume and peri-operative mortality in abdominal aortic aneurysm surgery. Design Systematic review. Method The Medline, Embase and Cochrane databases were searched to identify all population based studies reporting on the volume outcome relationship published between 1966 and 2006. Two independent observers performed methodological quality assessment and data extraction. Outcome was 30-day or in-hospital mortality in relation to hospital volume. Results Twenty-four articles were included. Overall peri-operative mortality ranged from 2.3 to 9.9%. The cut-off values for a high- or low-volume hospital appeared to range from 8 to 50 operations annually. The peri-operative mortality in low volume hospitals (LVH) ranged from 3.0 to 13.8% (median 6.2%) and from 1.8 to 7.4% in high volume hospitals (HVH) (median 4.3%). In 14 studies a significantly lower mortality was found in HVH as opposed to LVH; in 10 articles no such difference between HVH and LVH could be proved. Conclusion We found some evidence for a relation between the volume of AAA surgery and peri-operative mortality. There seems to be a nonsignificant trend in favour of high volume hospitals. However we could not derive an unequivocal volume threshold for safely performing AAA surgery.

Many studies have shown an association between both surgeon and hospital operative procedure volumes and outcomes, particularly operative mortality. It is also recognized that volume is only one of a number of factors, including 1) surgeon training and experience, and 2) hospital resources, organization, and processes of care, which can also influence outcomes. The Surgical Oncology Program at Cancer Care Ontario has included hospital volumes in a set of standards for the conduct of major pancreatic cancer surgery, along with recommendations for surgeon training and hospital resources, organization, support services, and processes of care to encourage regionalization of major HPB surgery. Cooperation with these recommendations was encouraged by the public reporting of mortality data and by an educational program directed at both surgeons and senior administrators in Ontario hospitals with the support of the provincial health ministry. The provincial mortality rate from major pancreatic cancer surgery has decreased by more than 50% since the introduction of this program.

Background To identify the radiation volume effect and significant dosimetric parameters for temporal lobe injury (TLI) and determine the radiation dose tolerance of the temporal lobe (TL) in nasopharyngeal carcinoma (NPC) patients treated with intensity modulated radiation therapy (IMRT). Methods Twenty NPC patients with magnetic resonance imaging (MRI)-diagnosed unilateral TLI were reviewed. Dose-volume data was retrospectively analyzed. Results Paired samples t-tests showed all dosimetric parameters significantly correlated with TLI, except the TL volume (TLV) and V75 (the TLV that received ≥75 Gy, P = 0.73 and 0.22, respectively). Receiver operating characteristic (ROC) curves showed V10 and V20 (P = 0.552 and 0.11, respectively) were the only non-significant predictors from V10 to V70 for TLI. D0.5cc (dose to 0.5 ml of the TLV) was an independent predictor for TLI (P 0.5cc was 0.843 (P Conclusions A D0.5cc of 69 Gy may be the dose tolerance of the TL. The risk of TLI was highly dependent on high dose ‘hot spots’ in the TL; physicians should be cautious of such ‘hot spots’ in the TL during IMRT treatment plan optimization, review and approval.