Search

A minimum volume threshold of at least six procedures per annum per surgeon has been set in UK and European guidelines for adrenal surgery. The aim of this study was to investigate outcomes for adrenal surgery in England relative to annual surgeon and hospital trust volume.Data were extracted from the Hospital Episodes Statistics database for England. A 6-year period (January 2013 to December 2018 inclusive) for all adult admissions for unilateral adrenal surgery was used. The primary outcome measure was an emergency readmission within 30 days of discharge following surgery. Procedures were categorized as open or minimally invasive surgery for analysis. Multilevel modelling was used to adjust for hierarchy and potential confounders.Data for 4189 adrenalectomies were identified. Only one third of surgeons (who operated on just over a half of all patients) performed at least six procedures in the year prior to the index procedure. For open surgery, emergency readmission rates fell significantly from 15.2 to 6.4 per cent for surgeons and from 13.2 to 6.1 per cent for trusts between the lowest- and highest-volume categories. Significant, but less dramatic falls were also seen for minimally invasive surgery.A volume-outcome effect was identified for adrenal surgery in England. Minimum volume thresholds should be set, although these may need to be more ambitious than the current threshold if outcomes are to be optimized.Surgery for disease of the adrenal gland can be complex. In many cases the skill and experience of the surgeon and the wider surgical team is thought to be important in determining the success of the procedure. The relative rarity of adrenal surgery means that there is little evidence to support this view. This study looked at outcomes for all 4189 patients who underwent adrenal surgery in England over a 6-year period. There was evidence that outcomes were better for patents when the surgeon and hospital trust had performed a larger number of adrenal surgery procedures in the year prior to the procedure. This was, however, dependent on which patient outcomes were studied and the type of procedure. These findings will inform the ongoing debate as to whether adrenal surgery in England should only be performed in regional centres by experienced teams.Surgery for disease of the adrenal gland can be complex. In many cases the skill and experience of the surgeon and the wider surgical team is thought to be important in determining the success of the procedure. The relative rarity of adrenal surgery means that there is little evidence to support this view. This study looked at outcomes for all 4189 patients who underwent adrenal surgery in England over a 6-year period. There was evidence that outcomes were better for patents when the surgeon and hospital trust had performed a larger number of adrenal surgery procedures in the year prior to the procedure. This was, however, dependent on which patient outcomes were studied and the type of procedure. These findings will inform the ongoing debate as to whether adrenal surgery in England should only be performed in regional centres by experienced teams.

Background The impact of surgical volume on outcomes in Hirschsprung’s disease (HD) remains uninvestigated. We aimed to determine whether higher surgeon and hospital-level HD operative volumes are associated with improved surgical outcomes following primary surgery for neonatal HD. Materials and methods Neonates who underwent either an ostomy or pull-through (PT) procedure for HD before 60 d of life and a PT procedure by age 1 y were identified in the Pediatric Health Information System (PHIS). Index admissions from January 2000 to September 2012 across 41 tertiary childrens hospitals were included. Surgeon and hospital-level HD operative volume were defined as the average annual number of PT procedures performed for HD in the 2 y preceding each included case. We examined the relationship between operative volumes and all-cause readmission, readmission for Hirschsprung’s associated enterocolitis (HAEC), and rates of reoperation within 30 d and 2 y. Results A total of 1268 infants were included. There were 218 patients (17.2%) readmitted to the hospital within 30 d and 540 (42.6%) within 2 y. A total of 119 patients (9.4%) had HAEC-related readmission within 30 d, and 271 (21.4%) had HAEC-related readmission within 2 y. A total of 57 patients (4.5%) had a reoperation within 30 d and 129 (10.2%) within 2 y. In risk-adjusted analyses, there were no significant associations between either surgeon or hospital HD operative volumes and readmission/reoperation rates within 30 d or 2 y. Conclusions Neither surgeon nor hospital PT volumes were significantly associated with readmission or reoperation rates for infants with Hirschsprung’s disease. Future work is needed to evaluate whether operative volumes are associated with functional outcomes following PT for HD.

Objective To investigate whether a volume–outcome relationship exists for elective abdominal aortic aneurysm (AAA) surgery conducted within the National Health Service (NHS) in England. Methods This was an analysis of administrative data. Data were extracted from the Hospital Episodes Statistics database for England from April 2011 to March 2019 for all adult admissions for elective infrarenal AAA surgery. Data were extracted for the NHS trust and surgeon undertaking the procedure, the surgical technique used (open or endovascular), the financial year of admission, length of hospital and critical care stay during the procedure and subsequent emergency re-admissions (primary outcome) and deaths within 30 days. Multilevel modelling was used to adjust for hierarchy and confounding. Results A dataset of 31 829 procedures (8867 open, 22 962 endovascular) was extracted. For open surgery, lower trust annual volume was associated with higher 30 day emergency re-admission rates and higher 30 day mortality. For open surgery, lower surgeon annual volume was associated with higher 30 day mortality and length of hospital stay greater than the median. For endovascular surgery, lower surgeon annual volume was associated with not having an overnight stay in critical care. None of the other volume–outcome relationships investigated was significant. Conclusion For elective infrarenal AAA surgery in the UK NHS, there was strong evidence of a volume–outcome relationship for open surgery. However, evidence for a volume–outcome relationship is dependent on the specific procedure undertaken and the outcome of interest.

OBJECTIVES Although rectal biopsy has long been established as the criterion standard for the diagnosis of Hirschsprung disease, little to no information exists regarding nationwide rates of rectal biopsy positivity or interinstitutional variability. We sought to determine the national rate of rectal biopsy positivity and factors contributing to institutional variability. METHODS A retrospective review of the Children's Hospital Association's (CHA) Pediatric Health Information System from 2009 to 2018 identified infants

Purpose of review Penile cancer is a rare disease with significant morbidity. Because of the low volume of cases, it has been suggested that its treatment should be centralized in order to improve outcomes through better management of both the primary tumor and distant disease. We reviewed and summarized the most relevant recent publications regarding centralization of penile cancer management. Recent findings Management of penile cancer in academic and supra-regional centers was associated with better survival outcomes. Moreover, reports from population-based studies showed more adherence to guidelines recommendations in academic centers with higher utilization of organ sparing treatments and invasive inguinal lymph node staging. Summary The optimal management of penile cancer remains a major therapeutic challenge. Patients with invasive tumors are less adequately managed in lower volume nonspecialized centers. The data convincingly support efforts to centralize penile cancer care and to promote the development of centers of expertise in order to achieve the best possible outcomes for each patient.

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 As the utilization of reverse total shoulder arthroplasty (RSA) grows, it is increasingly important to examine the relationship between hospital volume and RSA outcomes. We hypothesized that hospitals that perform a higher volume of RSAs would have improved outcomes. We also performed stratum-specific likelihood ratio (SSLR) analysis with the aim of delineating concrete definitions of hospital volume for RSA. METHODS The Nationwide Readmissions Database was queried for patients who had undergone elective RSA from 2011 to 2015. Annual hospital volume and 90-day outcome data were collected, including readmission, revision, complications, hospital length of stay (LOS), supramedian cost, and discharge disposition. SSLR analysis was performed to determine hospital volume cutoffs associated with increased risks for adverse events. Cutoffs generated through SSLR analysis were confirmed via binomial logistic regression. RESULTS The proportion of patients receiving care at high-volume centers increased from 2011 to 2015. SSLR analysis produced hospital volume cutoffs for each outcome, with higher-volume centers showing improved outcomes. The volume cutoffs associated with the best rates of 90-day outcomes ranged from 54 to 70 RSAs/year, whereas cost and resource utilization cutoffs were higher, with the best outcomes in hospitals performing >100 RSAs/year. SSLR analysis of 90-day readmission produced 3 hospital volume categories (1 to 16, 17 to 69, and ≥70 RSAs/year), each significantly different from each other. These were similar to the strata for 90-day revision (1 to 16, 17 to 53, and ≥54 RSAs/year) and 90-day complications (1 to 9, 10 to 68, and ≥69 RSAs/year). SSLR analysis produced 6 hospital volume categories for cost of care over the median value (1 to 5, 6 to 25, 26 to 47, 48 to 71, 72 to 105, and ≥106 RSAs/year), 5 categories for an extended LOS (1 to 10, 11 to 25, 26 to 59, 60 to 105, and ≥106 RSAs/year), and 4 categories for non-home discharge (1 to 31, 32 to 71, 72 to 105, and ≥106 RSAs/year). CONCLUSIONS We have defined hospital surgical volumes that maximize outcomes after RSA, likely related to surgical experience, ancillary staff familiarity, and protocolized pathways. This information may be used in future policy decisions to consolidate complex procedures, such as RSA, at high-volume destinations, or to encourage lower-volume institutions to strategize an approach to function as a higher-volume center. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Studies over the past decade have clearly demonstrated an association between high surgeon and hospital volume and improved outcomes for women undergoing gynecologic surgical procedures. In contrast to procedures associated with higher morbidity, the association between higher volume and improved outcomes is often modest for gynecologic surgeries. The lower magnitude of this association has limited actionable policy changes for gynecologic surgery. These data have been driving initiatives such as regionalization of care, targeted quality improvement at low volume centers and volume-based credentialing in gynecology.

OBJECTIVES To investigate volume-outcome relationships in robot-assisted radical prostatectomy (RARP) for cancer using data from the Hospital Episodes Statistics (HES) database for England. MATERIALS AND METHODS Data for all adult, elective RPs for cancer during the period January 2013-December 2018 (inclusive) were extracted from the HES database. The HES database records data on all National Health Service (NHS) hospital admissions in England. Data were extracted for the NHS trust and surgeon undertaking the procedure, the surgical technique used (laparoscopic, open or robot-assisted), hospital length of stay (LOS), emergency readmissions, and deaths. Multilevel modelling was used to adjust for hierarchy and covariates. RESULTS Data were available for 35 629 RPs (27 945 RARPs). The proportion of procedures conducted as RARPs increased from 53.2% in 2013 to 92.6% in 2018. For RARP, there was a significant relationship between 90-day emergency hospital readmission (primary outcome) and trust volume (odds ratio [OR] for volume decrease of 10 procedures: 0.99, 95% confidence interval [CI] 0.99-1.00; P = 0.037) and surgeon volume (OR for volume decrease of 10 procedures: 0.99, 95% CI 0.99-1.00; P = 0.013) in the previous year. From lowest to highest volume category there was a decline in the adjusted proportion of patients readmitted as an emergency at 90 days from 10.6% (0-49 procedures) to 7.0% (≥300 procedures) for trusts and from 9.4% (0-9 procedures) to 8.3% (≥100 procedures) for surgeons. LOS was also significantly associated with surgeon and trust volume, although 1-year mortality was associated with neither. CONCLUSIONS There is evidence of a volume-outcome relationship for RARP in England and minimising low-volume RARP will improve patient outcomes. Nevertheless, the observed effect size was relatively modest, and stakeholders should be realistic when evaluating the likely impact of further centralisation at a population level.

Objectives To investigate volume-outcome relationships in nephrectomy and cystectomy for cancer. Materials and methods Data were extracted from the UK Hospital Episodes Statistics database, which records data on all National Health Service (NHS) hospital admissions in the England. Data were included for a 5-year period (April 2013-March 2018 inclusive) and data on emergency and paediatric admissions were excluded. Data were extracted on the NHS trust and surgeon undertaking the procedure, the surgical technique used (open, laparoscopic or robot-assisted) and length of hospital stay during the procedure. This dataset was supplemented by data on mortality from the UK Office for National Statistics. A number of volume thresholds and volume measures were investigated. Multilevel modelling was used to adjust for hierarchy and confounding factors. Results Data were available for 18 107 nephrectomy and 6762 cystectomy procedures for cancer. There was little evidence of trust or surgeon volume influencing readmission rates or mortality. There was some evidence of shorter length of hospital stay for high-volume surgeons, although the volume measure and threshold used were important. Conclusions We found little evidence that further centralization of nephrectomy or cystectomy for cancer surgery will improve the patient outcomes investigated. It may be that length of stay can be optimized though training and support for lower-volume centres, rather than further centralization.

As surgical mortality decreases and endovascular utilization increases, it is unknown whether volume-outcome relationships exist in thoracic aortic dissection repair. We characterized volume-outcome relationships for surgical and endovascular management of thoracic aortic dissection.Patients aged more than 18 years undergoing repair of thoracic aortic dissection in the United States between 2010 and 2014 were identified in seven all-payer state inpatient administrative databases. Patients were divided into groups based on type of repair: surgical repair of type A dissection (TAAD), surgical repair of type B dissection (TBAD), and endovascular repair (TEVAR). Hierarchical logistic regression models evaluated the association between hospital volume and in-hospital mortality.Overall in-hospital mortality rate was 13.4% (890 of 6650), highest after TAAD (463 of 2918, 15.9%), followed by TBAD (270 of 1934, 14.0%) and TEVAR (157 of 1798, 8.7%). Volume-outcome relationships for adjusted in-hospital mortality were demonstrated for TAAD and TBAD (P-trend.001), but not TEVAR (P-trend = .11). Adjusted in-hospital mortality differed most for TAAD (fewer than 3 cases per year: 21%, 95% confidence interval, 18% to 24%; vs 11 or more cases per year: 12%, 95% confidence interval, 8% to 16%; P.001) and TBAD (fewer than 2 cases per year: 18%, 95% confidence interval, 15% to 22%; vs 11 or more cases per year: 9%, 95% confidence interval, 5% to 12%; P.001), whereas TEVAR did not differ between quartiles. Adjusted mortality was lower at centers with 26 or more overall annual thoracic dissection repairs, compared with any of the three lower-volume quartiles (P.001).This study demonstrated lower mortality at high-volume hospitals for overall repair of aortic dissection, persisting separately for surgical repair of TAAD and TBAD, but not TEVAR. As endovascular technology advances and practice patterns consequently change, analyses should focus on understanding the balance between procedural volume, mortality, and access to care for thoracic aortic dissection.

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.

We previously reported a significant volume–outcome relationship in mortality rates after gastrectomies for gastric cancer patients in Texas (1999–2001). We aimed to identify whether changes in the volume distribution of gastrectomies occurred, whether volume–outcome relationships persisted, and potential changes in the factors influencing volume–outcome relationships. We performed a population-based study using the Texas Inpatient Public Use Data File between 2010 and 2015. Hospitals were classified as high-volume centers (HVCs, > 15 cases per year), intermediate-volume centers (IVCs, 3–15 cases per year), and low-volume centers (LVCs

BACKGROUND Although volume-outcome relationships have been explored for various procedures and interventions, limited information is available concerning the effect of hospital and physician volume on heart failure mortality. Most importantly, little is known about whether there are optimal hospital and physician volume thresholds to reduce heart failure mortality. OBJECTIVES We used nationwide population-based data to identify the optimal hospital and physician volume thresholds to achieve optimum mortality and to examine the relative and combined effects of the volume thresholds on heart failure mortality. METHODS We analyzed all 20,178 heart failure patients admitted in 2012 through Taiwan's National Health Insurance Research Database. Restricted cubic splines and multilevel logistic regression were used to identify whether there are optimal hospital and physician volume thresholds and to assess the relative and combined relationships of the volume thresholds to 30-day mortality, adjusted for patient, physician, and hospital characteristics. RESULTS Hospital and physician volume thresholds of 40 cases and 15 cases a year, respectively, were identified, under which there was an increased risk of 30-day mortality. Patients treated by physicians with previous annual volumes

Context Radical prostatectomy (RP) is one of the most complex urological procedures performed. Higher surgical volume has been found previously to be associated with better patient outcomes and reduced costs to the health care system. This has resulted in some regionalization of care toward high-volume facilities and providers; however, the preponderance of RPs is still performed at low-volume institutions. Objective To provide an updated systematic review of the association of hospital and surgeon volume on patient and system outcomes after RP, including robot-assisted RP. Evidence acquisition A systematic review of literature was undertaken, searching PubMed (1959–2016) for original articles. Selection criteria included RP, hospital and/or surgeon volumes as predictor variables, categorization of hospital and/or surgeon volumes, and measurable end points. Evidence synthesis Overall 49 publications fulfilled the inclusion criteria. Most of the studies demonstrated that higher-volume surgeries are associated with better outcomes including reduced mortality, morbidity, postoperative complications, length of stay, readmission, and cost-associated factors. The volume–outcome relationship is maintained in robotic surgery. Eleven studies assessed hospital and surgeon volume simultaneously, and findings reflect that neither is an independent predictor variable affecting outcomes. The studies varied in how volume cutoffs were categorized as well as how the volume–outcome relationship was methodologically evaluated. Conclusions Contemporary evidence continues to support the relationship between high-volume surgeries with improved RP outcomes. Recent studies demonstrate that the volume–outcome relationship applies to robot-assisted RP and may be applied for potential cost savings in health care. An increase in the number of international studies suggests reproducibility of the association. Although regionalization of surgical care remains a contentious issue, there is an increasing body of evidence that short-term outcomes are improved at high-volume centers for RP. Patient summary This systematic review of the latest literature found that higher surgical volume was associated with improved outcomes for radical prostatectomy.

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

Increasing hospital or surgeon volume is associated with improved outcomes among patients with pancreatic cancer. Promotion of regionalized care is based on this volume-outcome association. However, other research has exposed nuances and complexities inherent to this association that should be considered when promoting regionalized care models. We herein provide a critical review of the literature on the volume-outcome association and a discussion of areas of ongoing controversy. A PubMed literature search was conducted for the years 1995–2020. Peer reviewed original research studies were selected for critical review based on study design, potential to draw meaningful conclusions from the data, and discussion of current knowledge gaps. Based on the cumulative published literature, hospital/surgeon volume and patient mortality are inversely related. However, it remains unclear whether volume is a proxy for other more causative variables inherent in high-volume centers. Interpretation of the volume-outcome association is made more difficult to interpret due to the large variation in the definition of high volume, difficulty in isolating the individual impact of surgeon versus hospital volume, challenges in quantifying health system processes related to volume, and the fact that some low-volume centers consistently achieve excellent clinical results. Implementation of true regionalized care models has been rare, likely reflecting both health system and patient level challenges. The volume-outcome association has been consistently demonstrated to be important to the care of patients with pancreas cancer. The underlying mechanism of this association to explain the overall benefit is likely multifactorial. Better understanding of what drives the volume-outcome association may increase access to optimized care for a broader range of hospital systems and patients.

Zahlreiche Studien zeigten den Einfluss des „hospital- und surgeon-volume“ auf die Komplikationsraten von Schilddrusenoperationen. Diese Studie uberpruft diesen Zusammenhang bei Operationen benigner Schilddrusenerkrankungen sowohl fur subtotale als auch fur totale Lappenresektionen. Weiterhin ist bislang unklar, welcher Schwellenwert fur das klinikbezogene Fallvolumen ermittelt werden kann, ab dem das Komplikationsrisiko unter dem Bundesdurchschnitt liegt. Datengrundlage waren bundesweite Routinedaten von AOK-Versicherten mit Schilddrusen-OP in den Jahren 2014-2016. Permanente Stimmlippenlahmungen (SLL), revisionsbedurftige Blutungen bzw. Wundinfektionen wurden anhand von Indikatoren erfasst. Der Effekt des Fallvolumens auf die Indikatoren sowie der Fallzahlschwellenwert wurden mittels logistischer Regression bestimmt. Permanente SLL wurden bei 1,3 % und revisionsbedurftige Blutungen bzw. Wundinfektionen bei 1,6 % bzw. 0,3 % der Eingriffe beobachtet. Gegenuber Krankenhausern mit >450 Eingriffen pro Jahr war das Risiko fur permanente SLL in Krankenhausern mit weniger als 201, 101 bzw. 51 Eingriffen signifikant erhoht (OR [95%-KI]: 1,5 [1,1–2,1]; 1,5 [1,1–2,1]; 1,8 [1,3–2,5]). Der Schwellenwert zum Erreichen des Risikos fur eine permanente SLL unter dem Bundesdurchschnitt (1,3 %) betrug 265 Eingriffe pro Jahr (95 %-KI: 110–420). Fur revisionsbedurftige Blutungen bzw. Wundinfektion wurden keine Zusammenhange festgestellt. Die vorliegende Studie zeigte, dass mit steigendem Fallvolumen das Risiko einer postoperativen permanenten SLL sank. Das breite Konfidenzintervall des Schwellenwertes erschwert eine eindeutige Fallzahlempfehlung. Damit das Risiko fur eine permanente SLL nicht mit hoher Wahrscheinlichkeit uber dem Bundesdurschnitt liegt sollte das jahrliche Fallvolumen zumindest 110 Eingriffe erreichen.

Introduction The aim of this study is to investigate firstly, the rate of recurrence following primary repair of a congenital diaphragmatic hernia (CDH) and secondly, the rate of recurrence following revisional surgical repair. The primary outcome is rate of recurrence. Secondary outcomes are to establish whether recurrence is related to surgeon, surgeon volume, side of defect, the use of a patch, or a thoracopscopic approach Methods All repairs performed in an English regional center over 22 years were recorded. Possible explanatory variables were whether the repair was itself of a recurrence, the surgeon's identity, the surgeon's volume of prior repairs, the side of the defect, the use of a patch. Results 198 repairs were performed; 170 primary repairs and 28 of recurrences. Failure occurred significantly more commonly among recurrences (32%) than primary repairs (11%), p = 0.005. Failure of the primary repair was significantly more common where a patch was used 8/34 (23%) rather than a sutured repair 10/136 (7%), p = 0.006, or where a thoracoscopic technique was used 4/13 (31%) rather than laparotomy 14/157 (9%) p = 0.01. Failure of the primary repair was unrelated to the identity of the surgeon (Χ2 = 5, p = 0.9) or the volume of prior repairs (t = 0.3, p = 0.6). However, failure of repair of a recurrence was significantly related to the surgeon's volume of prior repairs (t = 2.3, p = 0.01) and the identity of the surgeon (Χ2 = 17, p = 0.014), but not the use of a patch (Χ2 = 1.6, p = 0.2). Conclusions Repair of a recurrence of a CDH has a higher probability of failure than the original repair and is related to both the identity of the surgeon and the prior volume of experience. There is a volume outcome relationship for the repair of recurrence, but not the primary repair of CDH. Our study suggests the repair of recurrence of CDH should be restricted to surgeons with proven outcomes for this procedure.

Background In the past, for a number of abdominal surgical interventions a correlation between treatment volume of a hospital and the patient's outcome was shown in national and international studies. Methods Based on a systematic literature search we analyzed the absolute and risk-adjusted in-house lethality as well as the rate of complications and the failure to rescue after abdominal surgery in Germany. The hospitals were grouped in quintiles according to the volume of treatment. Results 11 studies including more than 2 million patients were identified and surgeries for the treatment of 9 disease conditions were studied. The meta-analysis shows a significantly lower absolute and risk-adjusted in-house mortality for surgery in hospitals with high treatment volumes compared to low volume hospitals. In the context of subgroup analysis, this effect is demonstrated especially for complex surgical procedures. The failure to rescue in patients suffering from sepsis is significantly lower in high volume centers compared to low volume centers. Conclusion This systematic review and meta-analysis shows on more than 2 million patients that there is a volume-outcome relationship for the surgical treatment of abdominal diseases in Germany across various organ systems, which is particularly true for complex interventions.

Despite the well-established relationship between volume and outcomes, patients continue to have procedures performed at low-volume hospitals. The factors patients use to make the complex decision of where to have hepatopancreaticobiliary (HPB) surgery remain poorly characterized. A novel survey instrument was administered to all patients who had undergone HPB surgery at two university-affiliated community hospitals. 76 patients participated in the study (89% response rate). The majority of patients were unaware of the volume-outcome relationship (58.8%). No demographic factors differed between patients who were or were not aware except for patient research. Physician factors were the most important selection category (64.4%). Only 28.9% of patients were willing to travel more than two hours to have an operation performed at a hospital with a high volume/improved quality. Despite many voices calling for regionalization, patient decision-making factors should be considered before any realistic implementation.

In Italy, the establishment of breast units, starting from 2015, based on the requirements of the European Society of Breast Cancer Specialist (EUSOMA), has made it possible to guarantee the best treatment for breast cancer patients. In breast units all cases must be discussed by a multidisciplinary team consisting of a radiologist, pathologist, surgeon, radiotherapist, medical oncologist, breast nurse, to give the patient a multidisciplinary and multi-professional treatment. The data published by Italian Agency for Health Services (AGENAS) showed in 2017 a percentage of over 70% of cases of breast cancer treated in centers with volumes greater than 135 cases. As shown in the literature, the reduction in mortality for patients treated for breast cancer, in addition to being related to an adequate diagnosis, treatment and follow-up, is guaranteed only in centers with a high volume of cases treated. The volume of cases treated is directly proportional as regards survival and inversely proportional as regards the need for second surgery. In fact, in the dedicated centers, a correct preoperative imaging and clinical diagnosis guarantees a correct therapeutic procedure. Finally, the volume of cases treated is also directly proportional to the patient’s quality of life, that is, to the esthetic result.

The positive relationship between volume and outcome in hepatobiliary surgery has long been demonstrated. As for other complex surgical procedures, improved both short- and long-term outcomes have been associated with a higher volume of procedures. However, whether the centralization of complex hepatobiliary procedures makes full sense because it should be associated with higher quality of care, as reported in the literature and precise criteria on what to centralize, where to centralize, and who should be entitled to perform complex procedures are still missing. Indeed, despite the generalized consensus on centralization in hepatobiliary surgery, this topic remains very complex because of the many determinants involved, some of which cannot be easily controlled. In the context of different health systems worldwide, such as national health systems and private insurances, there are different stakeholders that express different needs: politicians, patients, surgeons, institutions and medical associations do not have always the same needs. Starting from a review of the literature on centralization in hepatobiliary surgery, this chapter will propose some guidelines that, when not data-driven due to low levels of evidence in the literature, will be based on good clinical practice.

In pancreatic surgery the correlation between hospital volume and postoperative outcomes has been widely demonstrated. Hospital volume is a recognized independent determinant for in-hospital mortality, mainly due to a different effectiveness in the management of major postoperative complications. European countries and the United States have been pursuing centralization policies based on minimal annual hospital and surgeon volumes, in order to guarantee the lowest morbidity and mortality rates. In Italy, two models have been proposed as an alternative to centralization and both are founded on the decentralization of expertise to low-volume centers. The most recent evidence drawn from the Italian pancreatic surgery scene have confirmed the volume-outcome relationship and have shown the worrying features of surgery in low-volume hospitals: more non-resective surgery, higher mortality, and excessive costs. Also, a geographical gradient in mortality rates has been demonstrated in Italy: the highest mortality is observed in southern regions and the lowest in northern regions, but patient mobility reduces this difference. A centralization policy, based either on individual hospital outcomes or on a volume criterion, is certainly needed in our country and should pass through the regional accreditation of high-quality surgery hospitals and the homogeneous distribution of referral centers throughout the national territory.

Surgery is the cornerstone of the treatment for esophageal cancer, either alone or as a part of a multimodal approach including chemotherapy and radiotherapy. Despite the improvements in surgical techniques, esophagectomy remains a high-risk surgical procedure. In the last few decades, a large body of evidence has suggested the relationship between high surgical volume and better clinical outcomes, with lower mortality and morbidity rates. Experience of the surgeon and all care providers plays an important role during operation and perioperative period. For instance, an expert surgeon is more confident in promptly recognizing and treating postoperative complications, also involving several care processes. Additionally, a multidisciplinary board is more frequently present in a high-volume center and its evaluation is mandatory to define an appropriate oncological pathway. Despite this evidence, the centralization of esophageal surgery has actually taken place in only few healthcare systems and a clear threshold for high volume is not yet widely defined. In Italy the absence of a formal centralization policy has resulted in a heterogeneous situation and the only efforts towards centralization come from the initiative of the single regions, as in the case of the diagnostic, therapeutic and care pathways (PDTA) available in the Veneto Region.

There is a wealth of published evidence linking surgeon volume and disease outcome, with high-volume surgeons achieving lower mortality, shorter hospital stays, and fewer complications across a number of surgical specialties. Explanations for this effect include “practice makes perfect” and “selective referral” theories. This has influenced clinical practice, with more specialization and high-risk procedures being increasingly undertaken by high-volume surgeons. Improved outcomes in high-volume surgeons are also seen in endocrine surgery, with fewer complications, decreased length of stay and reduced hospital charges. This chapter aims to summarize the current data regarding the surgeon’s volume-outcome relationship for thyroidectomy, parathyroidectomy and adrenalectomy.

Background We analyzed center-level outcome correlations between valve surgery and coronary artery bypass graft (CABG) in New York (NY) State and how volume-outcome effect differ between case types. Methods We used the 2014-2016 NY cardiac surgery outcomes report. Center-level observed to-expected (observed-to-expected ratio [O/E]) ratio for operative mortality provided risk-adjusted operative outcomes for isolated CABG and valve operations. Correlation coefficient characterized the concordance in center-level outcomes in CABG and valve. Discordant outcomes were defined as having O/E ratio greater than 2 in one operation type with O/E ratio ≤1 in another. Linearized slope of volume-outcome effect in case types offered insights into centers with discordant performances between procedures. Results Among 37 NY centers, annual center volumes were 220 ± 120 cases for CABG and 190 ± 178 cases for valve operations. Modest center-level correlation between CABG and valve O/E ratio was shown (R2 = 0.31). Two centers had discordant performance between valve and CABG (O/E ≤ 1 for CABG while O/E > 2 for valve procedures). No centers had CABG O/E ratio greater than 2 while valve O/E ratio ≤1. Linearized slope describing volume-outcome effects showed stronger effect in valve operations compared to CABG: O/E ratio declined 0.1 units per 100 CABG volume increase, while O/E ratio declined 0.33 units per 100 valve volume increase. Conclusion In NY hospitals, favorable valve outcomes may indicate good CABG outcomes but good CABG outcomes may not ensure valve outcomes. Outcome variation in valve operation could be related to stronger volume-outcome effect in valve operations relative to CABG. Valve operations may benefit from regionalization.

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)