title: Impact of surgeon demographics and technique on outcomes after esophageal resections: a nationwide study.
abstract: BACKGROUND
  Thoracic, cardiac, and general surgeons perform esophageal resections in the United States. This article examines the impact of surgeon subspecialty on outcomes after esophagectomy.
  
  
  METHODS
  Esophagectomies performed between 1998 and 2008 were identified in the Nationwide Inpatient Sample. Surgeons were classified as thoracic, cardiac, or general surgeons if greater than 65% of their operative case mix was representative of their specialty. Surgeons with less than 65% of a specialty-specific case mix served as controls. Regression equations calculated the independent effect of surgeon specialty, surgeon volume, and operative approach (transhiatal versus transthoracic) on outcomes.
  
  
  RESULTS
  Of the 40,589 patients who underwent esophagectomies, surgeon identifiers were available for 23,529 patients. Based on case mix, thoracic, cardiac, and general surgeons performed 3,027 (12.9%), 688 (2.9%), and 4,086 (17.4%) esophagectomies, respectively. Operative technique did not independently affect risk-adjusted outcomes-mortality, morbidity, and failure to rescue (defined as death after a complication). Surgeon volume independently lowered mortality and failure to rescue by 4% (p ≤ 0.002 for both), but not complications (p = 0.6). High-volume hospitals (>12 procedures/year) independently lowered mortality (adjusted odds ratio [AOR], 0.67, 95% confidence interval [CI], 0.46-0.96), and failure to rescue (AOR, 0.64; 95% CI, 0.44-0.94). Esophageal resections performed by general surgeons were associated with higher mortality (AOR, 1.87; 95% CI 1.02-3.45) and failure to rescue (AOR, 1.95; 95% CI, 1.06-3.61) but not complications (AOR, 0.97; 95% CI, 0.64-1.49).
  
  
  CONCLUSIONS
  General surgeons perform the major proportion of esophagectomies in the United States. Surgeon subspecialty is not associated with the risk of complications developing but instead is associated with mortality and failure to rescue from complications. Surgeon subspecialty case mix is an important determinant of outcomes for patients undergoing esophagectomy.
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, University of Missouri-Columbia School of Medicine, Columbia, MO 65212, USA. gopaldasr@health.missouri.edu
authors.forename: Raja R
authors.initials: RR
authors.lastname: Gopaldas
authors.forename: Castigliano M
authors.initials: CM
authors.lastname: Bhamidipati
authors.forename: Tam K
authors.initials: TK
authors.lastname: Dao
authors.forename: John G
authors.initials: JG
authors.lastname: Markley
mesh_terms: D002983:Clinical Competence; D016629:Esophagectomy / Q000401:mortality / Q000706:statistics & numerical data*; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D012042:Registries; D013043:Specialties, Surgical / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology