title: National trends in esophageal surgery--are outcomes as good as we believe?
abstract: BACKGROUND
  Positive volume-outcome relationships in esophagectomy have prompted support for regionalization of care; however, outcomes have not recently been analyzed. This study examines national trends in provision of esophagectomy and reassesses the volume-outcome relationship in light of changing practice patterns and training paradigms.
  
  
  METHODS
  The Nationwide Inpatient Sample was queried from 1998 to 2006. Quantification of patients' comorbidities was made using the Charlson Index. Using logistic regression modeling, institutions' annual case volumes were correlated with risk-adjusted outcomes over time, as well as presence or absence of fellowship and residency training programs.
  
  
  RESULTS
  A nationwide total of 57,676 esophagectomies were recorded. In-hospital unadjusted mortality fell from 12% to 7%. Adjusting for comorbidities, greater esophagectomy volume was associated with improvements in the incidence of most measured complications, though mortality increased once greater than 100 cases were performed. Hospitals supporting fellowship training or a surgical residency program did not have higher rates of mortality or total complications.
  
  
  CONCLUSIONS
  The current national mortality rate of 7% following esophagectomy is higher than is reported in most contemporary case series. A greater annual esophagectomy volume improves outcomes, but only up to a point. Current training paradigms are safe.
authors.affiliation: Department of Surgery, University of North Carolina, Chapel Hill, NC 27599-7081, USA. geoffkohn@gmail.com
authors.forename: Geoffrey Paul
authors.initials: GP
authors.lastname: Kohn
authors.forename: Joseph Anton
authors.initials: JA
authors.lastname: Galanko
authors.forename: Michael Owen
authors.initials: MO
authors.lastname: Meyers
authors.forename: Richard Harry
authors.initials: RH
authors.lastname: Feins
authors.forename: Timothy Michael
authors.initials: TM
authors.lastname: Farrell
mesh_terms: D000230:Adenocarcinoma / Q000453:epidemiology / Q000401:mortality / Q000601:surgery*; D015897:Comorbidity; D004938:Esophageal Neoplasms / Q000453:epidemiology / Q000401:mortality / Q000601:surgery*; D016629:Esophagectomy / Q000401:mortality* / Q000639:trends; D005257:Fellowships and Scholarships; D005762:Gastroenterology / Q000193:education; D017052:Hospital Mortality; D006801:Humans; D007396:Internship and Residency; D016015:Logistic Models; D017063:Outcome Assessment, Health Care; D012042:Registries; D014481:United States / Q000453:epidemiology