title: Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality.
abstract: OBJECTIVE
  To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitals
  
  
  BACKGROUND
  High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible. We examined low-volume hospitals and sought to identify characteristics of those with better outcomes.
  
  
  METHODS
  Using national data from Medicare and the American Hospital Association, we studied 4498 elderly patients who underwent an esophagectomy from 2004 to 2007. We divided hospitals into terciles based on esophagectomy volume and examined characteristics of patients and hospitals (size, nurse ratios, and presence of advanced medical, surgical, and radiological services). Our primary outcome was mortality. We identified 5 potentially beneficial systems characteristics in our data set and used multivariable logistic regression to determine whether these characteristics were associated with lower mortality rates at low-volume hospitals.
  
  
  RESULTS
  Of the 874 hospitals that performed esophagectomies, 83% (723) were low-volume hospitals whereas only 3% (25) were high-volume. Low-volume hospitals performed a median of 1 esophagectomy during the 4-year study period and cared for patients that were older, more likely to be minority, and more likely to have multiple comorbidities compared with high-volume centers. Low-volume hospitals that had at least 3 of 5 characteristics (high nurse ratios, lung transplantation services, complex medical oncology services, bariatric surgery services, and positron emission tomography scanners) had markedly lower mortality rates compared with low-volume hospitals with none of these characteristics (12.5% vs. 5.0%; P value = 0.042).
  
  
  CONCLUSIONS
  Low-volume hospitals with certain systems characteristics seem to achieve better esophagectomy outcomes. A more comprehensive study of the beneficial characteristics of low-volume hospitals is warranted because high-volume hospitals are difficult to access for many patients.
authors.affiliation: *Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA. lfunk@partners.org
authors.forename: Luke M
authors.initials: LM
authors.lastname: Funk
authors.forename: Atul A
authors.initials: AA
authors.lastname: Gawande
authors.forename: Marcus E
authors.initials: ME
authors.lastname: Semel
authors.forename: Stuart R
authors.initials: SR
authors.lastname: Lipsitz
authors.forename: William R
authors.initials: WR
authors.lastname: Berry
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Zinner
authors.forename: Ashish K
authors.initials: AK
authors.lastname: Jha
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016001:Confidence Intervals; D016208:Databases, Factual; D004938:Esophageal Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods / Q000401:mortality* / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends*; D006764:Hospitals, Community / Q000145:classification / Q000706:statistics & numerical data*; D006769:Hospitals, General / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare; D015999:Multivariate Analysis; D016017:Odds Ratio; D012189:Retrospective Studies; D018570:Risk Assessment; D013503:Surgery Department, Hospital / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014481:United States; D016526:Workload / Q000706:statistics & numerical data*