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      In-hospital mortality and failure to rescue following hepatobiliary surgery in Germany - a nationwide analysis

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          Abstract

          Background

          Recent observational studies on volume-outcome associations in hepatobiliary surgery were not designed to account for the varying extent of hepatobiliary resections and the consequential risk of perioperative morbidity and mortality. Therefore, this study aimed to determine the risk-adjusted in-hospital mortality for minor and major hepatobiliary resections at the national level in Germany and to examine the effect of hospital volume on in-hospital mortality, and failure to rescue.

          Methods

          All inpatient cases of hepatobiliary surgery ( n = 31,114) in Germany from 2009 to 2015 were studied using national hospital discharge data. After ranking hospitals according to increasing hospital volumes, five volume categories were established based on all hepatobiliary resections. The association between hospital volume and in-hospital mortality following minor and major hepatobiliary resections was evaluated by multivariable regression methods.

          Results

          Minor hepatobiliary resections were associated with an overall mortality rate of 3.9% and showed no significant volume-outcome associations. In contrast, overall mortality rate of major hepatobiliary resections was 10.3%. In this cohort, risk-adjusted in-hospital mortality following major resections varied widely across hospital volume categories, from 11.4% (95% CI 10.4–12.5) in very low volume hospitals to 7.4% (95% CI 6.6–8.2) in very high volume hospitals (risk-adjusted OR 0.59, 95% CI 0.41–0.54). Moreover, rates of failure to rescue decreased from 29.38% (95% CI 26.7–32.2) in very low volume hospitals to 21.38% (95% CI 19.2–23.8) in very high volume hospitals.

          Conclusions

          In Germany, patients who are undergoing major hepatobiliary resections have improved outcomes, if they are admitted to higher volume hospitals. However, such associations are not evident following minor hepatobiliary resections. Following major hepatobiliary resections, 70–80% of the excess mortality in very low volume hospitals was estimated to be attributable to failure to rescue.

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          Most cited references 25

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          Hospital volume and failure to rescue with high-risk surgery.

          Although the relationship between surgical volume and mortality is well established, the mechanisms underlying these associations remain uncertain. We sought to determine whether increased mortality at low-volume centers was due to higher complication rates or less success in rescuing patients from complications. Using 2005 to 2007 Medicare data, we identified patients undergoing 3 high-risk cancer operations: gastrectomy, pancreatectomy, and esophagectomy. We first ranked hospitals according to their procedural volume for these operations and divided them into 5 equal groups (quintiles) based on procedure volume cutoffs that most closely resulted in an equal distribution of patients through the quintiles. We then compared the incidence of major complications and "failure to rescue" (ie, case fatality among patients with complications) across hospital quintiles. We performed this analysis for all operations combined and for each operation individually. With all 3 operations combined, failure to rescue had a much stronger relationship to hospital volume than postoperative complications. Very low-volume (lowest quintile) hospitals had only slightly higher complications rates (42.7% vs. 38.9%; odds ratio 1.17, 95% confidence interval, 1.02-1.33), but markedly higher failure-to-rescue rates (30.3% vs. 13.1%; odds ratio 2.89, 95% confidence interval, 2.40-3.48) compared with very high-volume hospitals (highest quintile). These relationships also held true for individual operations. For example, patients undergoing pancreatectomy at very low-volume hospitals were 1.7 times more likely to have a major complication than those at very high-volume hospitals (38.3% vs. 27.7%, P<0.05), but 3.2 times more likely to die once those complications had occurred (26.0% vs. 9.9%, P<0.05). Differences in mortality between high and low-volume hospitals are not associated with large differences in complication rates. Instead, these differences seem to be associated with the ability of a hospital to effectively rescue patients from complications. Strategies focusing on the timely recognition and management of complications once they occur may be essential to improving outcomes at low-volume hospitals.
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            Hospital volume and operative mortality in the modern era.

            To determine whether the relationship between hospital volume and mortality has changed over time.
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              Perioperative mortality for pancreatectomy: a national perspective.

              To analyze in-hospital mortality after pancreatectomy using a large national database. Pancreatic resections, including pancreaticoduodenectomy, distal pancreatectomy, and total pancreatectomy, remain the only potentially curative interventions for pancreatic cancer. The goal of this study was to define factors affecting outcomes after pancreatectomy for neoplasm. A retrospective analysis was performed using all patients undergoing pancreatic resections for neoplastic disease identified from the Nationwide Inpatient Sample from 1998 to 2003. Crude in-hospital mortality was analyzed by chi. A multivariable model was constructed to adjust for age, sex, hospital teaching status, hospital surgical volume, year of resection, payer status, and selected comorbid conditions. In all, 279,445 patient discharges were identified with a primary diagnosis of pancreatic neoplasm. A total of 39,463 (14%) patients underwent resection during that hospitalization. In-hospital mortality was 5.9% with a significant decrease from 7.8% to 4.6% from 1998 to 2003 by trend analysis (P 18/year)-volume centers (low-volume odds ratio = 3.3; 95% confidence interval, 2.3-4.; medium-volume, odds ratio = 2.1; 95% confidence interval, 1.5-3.0). The proportion of procedures performed at high volume centers increased from 30% to 39% over the 6-year time period (P < 0.0001) by trend test. This large observational study demonstrates an improvement in operative mortality for patients undergoing pancreatectomy for neoplastic disease from 1998 to 2003. In addition, a greater proportion of pancreatectomies were performed at high-volume centers in 2003. The regionalization of pancreatic surgery may have partially contributed to the observed decrease in mortality rates.
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                Author and article information

                Contributors
                christian.krautz@uk-erlangen.de
                Journal
                BMC Surg
                BMC Surg
                BMC Surgery
                BioMed Central (London )
                1471-2482
                29 July 2020
                29 July 2020
                2020
                : 20
                Affiliations
                [1 ]Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Klinik für Allgemein- und Viszeralchirurgie, Krankenhausstraße 12, 91054 Erlangen, Germany
                [2 ]GRID grid.5330.5, ISNI 0000 0001 2107 3311, Friedrich-Alexander-Universität Erlangen-Nürnberg, , Institut für Medizininformatik, Biometrie und Epidemiologie, ; Waldstraße 6, 91054 Erlangen, Germany
                [3 ]GRID grid.6734.6, ISNI 0000 0001 2292 8254, Technische Universität Berlin, , Department of Health Care Management, ; Straße des 17. Juni 135, 10623 Berlin, Germany
                [4 ]GRID grid.6734.6, ISNI 0000 0001 2292 8254, Technische Universität Berlin, , Department for Structural Advancement and Quality Management in Health Care, ; Straße des 17. Juni 135, 10623 Berlin, Germany
                Article
                817
                10.1186/s12893-020-00817-5
                7388497
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

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                © The Author(s) 2020

                Surgery

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