Surgical volume and quality of care for esophageal resection: do high-volume hospitals have fewer complications?
BACKGROUND
Previous studies have shown that high-volume hospitals (HVHs) have lower mortality rates than low-volume hospitals (LVHs). However, little is known regarding the relationship of morbidity to hospital volume. The objective of the current study was to investigate the relative incidence of postoperative complications after esophageal resection at HVHs and LVHs.


METHODS
All patients discharged from a nonfederal, acute-care hospital in Maryland after esophageal resection from 1994 to 1998 were included (n = 366). Rates of 10 postoperative complications were compared at HVHs and LVHs. Risk-adjusted analyses were performed using multiple logistic regression.


RESULTS
High-volume hospitals had a mortality rate of 2.5% compared with 15.4% at LVHs (p < 0.001), with a case-mixed adjusted odds ratio (OR) of death equal to 5.7 (95% confidence interval [CI], 2.0 to 16; p < 0.001). Low-volume hospitals had a profound increase in the risk of several complications after adjusting for case-mix: renal failure (OR, 19; 95% CI, 1.9 to 178; p = 0.01), pulmonary failure (OR, 4.8; 95% CI, 1.6 to 14; p = 0.002), septicemia (OR, 4.0; 95% CI, 1.1 to 15; p = 0.04), reintubation (OR, 2.9; 95% CI, 1.4 to 6.1; p = 0.004), surgical complications (OR, 3.3; 95% CI, 1.6 to 6.9; p = 0.001), and aspiration (OR, 1.8; 95% CI, 1.0 to 3.3; p = 0.04).


CONCLUSIONS
Patients undergoing esophageal resection at LVHs were at a markedly increased risk of postoperative complications and death. Pulmonary complications are particularly prevalent at LVHs and contribute to the death of patients having surgery at those centers.
Dimick
Justin B
JB
Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA.
Pronovost
Peter J
PJ
Cowan
John A
JA
Lipsett
Pamela A
PA
D000328:Adult; D000368:Aged; D015897:Comorbidity; D004935:Esophageal Diseases / Q000453:epidemiology / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects* / Q000706:statistics & numerical data; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data; D018570:Risk Assessment; D013274:Stomach Neoplasms / Q000601:surgery