James T. McPhee

Perioperative Mortality for Pancreatectomy: A National Perspective

Objective:To analyze in-hospital mortality after pancreatectomy using a large national database. Summary and Background Data: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. Methods: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 χ2. 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. Results: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 < 0.0001). Resections done at low (<5 procedures/year)- and medium (5–18/year)-volume centers had higher mortality compared with those at high (>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. Conclusions: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.

Pancreatic neuroendocrine tumors: the impact of surgical resection on survival

Although surgical resection is generally recommended for patients with localized pancreatic neuroendocrine tumors (PNETs), the impact of resection on overall survival is unknown. The authors investigated the survival advantage of pancreatic resection using a national database.

Endovascular treatment of ruptured abdominal aortic aneurysms in the United States (2001-2006): A significant survival benefit over open repair is independently associated with increased institutional volume

OBJECTIVE Endovascular aortic repair (EVAR) has gained wide acceptance for the elective treatment of abdominal aortic aneurysms (AAA), leading to interest in similar treatment of ruptured abdominal aortic aneurysms (RAAA). The purpose of this study was to evaluate national outcomes after EVAR for RAAA and to assess the effect of institutional volume metrics. METHODS The Nationwide Inpatient Sample was used to identify patients treated with open or EVAR for RAAA, 2001-2006. Procedure volume was determined for each institution categorizing hospitals as low-, medium-, and high-volume. The primary outcome was in-hospital mortality. Secondary outcomes related to resource utilization. Multivariable logistic regression models were used to determine independent predictors of EVAR usage and mortality. RESULTS From 2001 to 2006, an estimated 27,750 hospital discharges for RAAA occurred; 11.5% were treated with EVAR. EVAR utilization increased over time (5.9% in 2001 to 18.9% in 2006, P < .0001) while overall RAAA rates remained constant. EVAR had a lower overall in-hospital mortality than open repair (31.7% vs 40.7%, P < .0001), an effect which amplified when stratified by institutional volume. On multivariable regression, open repair independently predicted mortality (odds ratio [OR] 1.56; 95% confidence interval [CI] 1.29-1.89). EVAR usage for RAAA increased with age (>80 years) (OR 1.58; 95% CI 1.30-1.93), high elective EVAR volume (>40/y) vs medium (19-40/y) (OR 2.65; 95% CI 1.86-3.78) and low (<19/y) (OR 5.37; 95% CI 3.60-8.0). EVAR had a shorter length of stay (11.1 vs 13.8 days, P < .0001), higher discharges to home (65.1% vs 53.9%, P < .0001), and lower charges (

Surgeon volume impacts hospital mortality for pancreatic resection.

108,672 vs

Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005

114,784, P < .0001). CONCLUSIONS In the United States, for RAAA, EVAR had a lower postoperative mortality than open repair. Higher elective open repair as well as RAAA volume increased this mortality advantage for EVAR. These results support regionalization of RAAA repair to high volume centers whenever possible and a wider adoption of endovascular repair of RAAA nationwide.

National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007

Objective:Improved outcomes after pancreatic resection (PR) by high volume (HV) surgeons have been reported in single center studies, which may be confounded with potential selection and referral bias. We attempted to determine if improved outcomes by HV surgeons are reproducible when patient demographic factors are controlled at the population level. Methods:Using the Nationwide Inpatient Sample, discharge records with surgeon identifiers for all nontrauma PR (n = 3581) were examined from 1998 to 2005. Surgeons were divided into 2 groups: (HV; ≥5 operations/year) or low volume (LV; <5 operations/year). We created a logistic regression model to examine the relationship between surgeon type and operative mortality while accounting for patient and hospital factors. To further eliminate differences in cohorts and determine the true effect of surgeon volume on mortality, case-control groups based on patient demographics were created using propensity scores. Results:One hundred thirty-four HV and 1450 LV surgeons performed 3581 PR in 742 hospitals across 12 states that reported surgeon identifier information over the 8-year period. Patients who underwent PR by HV surgeons were more likely to be male, white raced, and a resident of a high-income zip code (P < 0.05). Significant independent factors for in-hospital mortality after PR included increasing age, male gender, Medicaid insurance, and surgery by HV surgeon. HV surgeons had a lower adjusted mortality compared with LV surgeons (2.4% vs. 6.4%; P < 0.0001). Conclusions:After controlling for patient demographics and factors, pancreatic resection by a HV surgeon in this case-controlled cohort was independently associated with a 51% reduction in in-hospital mortality.

Surgeon case volume, not institution case volume, is the primary determinant of in-hospital mortality after elective open abdominal aortic aneurysm repair

OBJECTIVE Carotid endarterectomy (CEA) remains the procedure of choice for treatment of patients with severe carotid artery stenosis. The role of carotid artery stenting (CAS) in this patient group is still being defined. Prior single and multicenter studies have demonstrated economic savings associated with CEA compared with CAS. The purpose of this study was to compare surgical outcomes and resource utilization associated with these two procedures at the national level in 2005, the first year in which a specific ICD-9 procedure code for CAS was available. METHODS All patient discharges for carotid revascularization for the year 2005 were identified in the Nationwide Inpatient Sample based on ICD9-CM procedure codes for CEA (38.12) and CAS (00.63). The primary outcome measures of interest were in-hospital mortality and postoperative stroke; secondary outcome measures included total hospital charges and length of stay (LOS). All statistical analyses were performed using SAS version 9.1 (Cary, NC), and data are weighted according to the Nationwide Inpatient Sample (NIS) design to draw national estimates. Univariate analyses of categorical variables were performed using Rao-Scott chi(2), and continuous variables were analyzed by survey weighted analysis of variance (ANOVA). Multivariate logistic regression was performed to evaluate independent predictors of postoperative stroke and mortality. RESULTS During 2005, an estimated 135,701 patients underwent either CEA or CAS nationally. Overall, 91% of patients underwent CEA. The mean age overall was 71 years. Postoperative stroke rates were increased for CAS compared with CEA (1.8% vs 1.1%, P < .05), odds ratio (OR) 1.7; (95% confidence interval [CI] 1.2-2.3). Overall, mortality rates were higher for CAS compared with CEA (1.1% vs 0.57%, P < .05) this difference was substantially increased in regard to patients with symptomatic disease (4.6% vs 1.4%, P < .05). By logistic regression, CAS trended toward increased mortality, OR 1.5; (95% CI .96-2.5). Overall, the median total hospital charges for patients that underwent CAS were significantly greater than those that underwent CEA (

Predictive factors of 30-day unplanned readmission after lower extremity bypass

30,396 vs

Regionalization of abdominal aortic aneurysm repair: Evidence of a shift to high-volume centers in the endovascular era

17,658 P < .05). CONCLUSIONS Based on a large representative sample during the year 2005, CEA was performed with significantly lower in-hospital mortality, postoperative stroke rates, and lower median total hospital charges than CAS in US hospitals. As the role for CAS becomes defined for the management of patients with carotid artery stenosis, clinical as well as economic outcomes must be continually evaluated.

Outcomes of lower extremity bypass performed for acute limb ischemia

OBJECTIVE This study compared, at a national level, trends in utilization, mortality, and stroke after carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA) from 2005 to 2007. METHODS The Nationwide Inpatient Sample (NIS) was queried for patient discharges with International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes for CAS and CEA. The primary outcomes were in-hospital mortality, stroke, hospital charges, and discharge disposition. Subgroup analyses were performed to evaluate these outcomes by neurologic presentation using χ(2) and multivariable logistic regression. RESULTS Of the 404,256 discharges for carotid revascularization, CAS utilization was 66% higher in 2006 than in 2005 (9.3% vs 14%, P = .0004). Crude mortality, stroke, and median charges remained higher for CAS than for CEA; discharge to home was more common after CEA. Results improved from 2005 to 2007. By logistic regression of the total cohort from 2005 to 2006, CAS was independently predictive of mortality (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.08-2.00; P < .0001). Independent predictors of stroke included CAS (OR, 1.43; 95% CI, 1.18-1.73; P < .0001) and symptomatic disease (OR, 2.4; 95% CI, 2.06-2.93;P < .0001). Among subgroups based on neurological presentation, regression showed that CAS significantly increased the odds of stroke in asymptomatic patients (OR, 1.6; 95% CI, 1.2-2.0; P = .0003). Among symptomatic patients, CAS increased the odds of in-hospital death (OR, 3.0; 95% CI, 1.7-5.1, P < .0001) and trended toward significance for stroke (OR, 1.7; 95% CI, 1.0-2.8; P = .0569). CONCLUSION Utilization of CAS has increased from the years 2005 to 2007 with some improvements in the outcome. Despite improvements in outcome, resource utilization remains significantly higher for CAS than CEA.