Do the 2018 Leapfrog Group Minimal Hospital and Surgeon Volume Thresholds for Esophagectomy Favor Specific Patient Demographics?

James M. Clark, David T Cooke, Habiba Hashimi, David Chin, Garth H Utter, Lisa M Brown, Miriam A Nuno

Research output: Contribution to journalArticle

Abstract

Objective: We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. Summary Background Data: Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. Methods: Patients undergoing esophagectomy for cancer were identified from the 2007-2013 New York and Florida Healthcare Cost and Utilization Projects State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18-57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age -71, ECI >4). Results: Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58-71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. Conclusions: Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities.

Original languageEnglish (US)
JournalAnnals of Surgery
DOIs
StateAccepted/In press - Jan 1 2019

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Esophagectomy
Demography
Mortality
Comorbidity
Length of Stay
Low-Volume Hospitals
High-Volume Hospitals
Hospital Mortality
Surgeons
Health Care Costs
Inpatients
Logistic Models
Databases
Guidelines
Neoplasms

Keywords

  • centralization
  • esophagectomy
  • regionalization
  • surgical volume
  • The Leapfrog Group
  • volume thresholds

ASJC Scopus subject areas

  • Surgery

Cite this

@article{a3292b9714474246b8f29ded495af458,
title = "Do the 2018 Leapfrog Group Minimal Hospital and Surgeon Volume Thresholds for Esophagectomy Favor Specific Patient Demographics?",
abstract = "Objective: We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. Summary Background Data: Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. Methods: Patients undergoing esophagectomy for cancer were identified from the 2007-2013 New York and Florida Healthcare Cost and Utilization Projects State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18-57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age -71, ECI >4). Results: Of 4330 esophagectomy patients, 3515 (81{\%}) were male, median age was 64 (interquartile range 58-71), and mortality was 4.0{\%}. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0{\%}), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12{\%}). For mortality <1{\%}, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2{\%} when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53{\%} to 63{\%} when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19{\%} to 27{\%} when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. Conclusions: Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities.",
keywords = "centralization, esophagectomy, regionalization, surgical volume, The Leapfrog Group, volume thresholds",
author = "Clark, {James M.} and Cooke, {David T} and Habiba Hashimi and David Chin and Utter, {Garth H} and Brown, {Lisa M} and Nuno, {Miriam A}",
year = "2019",
month = "1",
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doi = "10.1097/SLA.0000000000003553",
language = "English (US)",
journal = "Annals of Surgery",
issn = "0003-4932",
publisher = "Lippincott Williams and Wilkins",

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TY - JOUR

T1 - Do the 2018 Leapfrog Group Minimal Hospital and Surgeon Volume Thresholds for Esophagectomy Favor Specific Patient Demographics?

AU - Clark, James M.

AU - Cooke, David T

AU - Hashimi, Habiba

AU - Chin, David

AU - Utter, Garth H

AU - Brown, Lisa M

AU - Nuno, Miriam A

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Objective: We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. Summary Background Data: Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. Methods: Patients undergoing esophagectomy for cancer were identified from the 2007-2013 New York and Florida Healthcare Cost and Utilization Projects State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18-57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age -71, ECI >4). Results: Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58-71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. Conclusions: Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities.

AB - Objective: We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. Summary Background Data: Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. Methods: Patients undergoing esophagectomy for cancer were identified from the 2007-2013 New York and Florida Healthcare Cost and Utilization Projects State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18-57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age -71, ECI >4). Results: Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58-71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. Conclusions: Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities.

KW - centralization

KW - esophagectomy

KW - regionalization

KW - surgical volume

KW - The Leapfrog Group

KW - volume thresholds

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