title: Specialization and utilization after hepatectomy in academic medical centers.
abstract: BACKGROUND
  Specialized procedures such as hepatectomy are performed by a variety of specialties in surgery. We aimed to determine whether variation exists among utilization of resources, cost, and patient outcomes by specialty, surgeon case volume, and center case volume for hepatectomy.
  
  
  METHODS
  We queried centers (n = 50) in the University Health Consortium database from 2007-2010 for patients who underwent elective hepatectomy in which specialty was designated general surgeon (n = 2685; 30%) or specialist surgeon (n = 6277; 70%), surgeon volume was designated high volume (>38 cases annually) and center volume was designated high volume (>100 cases annually). We then stratified our cohort by primary diagnosis, defined as primary tumor (n = 2241; 25%), secondary tumor (n = 5466; 61%), and benign (n = 1255; 14%).
  
  
  RESULTS
  Specialist surgeons performed more cases for primary malignancy (primary 26% versus 15%) while general surgeons operated more for secondary malignancies (67% versus 61%) and benign disease (18% versus 13%). Specialists were associated with a shorter total length of stay (LOS) (5 d versus 6 d; P < 0.01) and lower in-hospital morbidity (7% versus 11%; P < 0.01). Patients treated by high volume surgeons or at high volume centers were less likely to die than those treated by low volume surgeons or at low volume centers, (OR 0.55; 95% CI 0.33-0.89) and (OR 0.44; 95% CI 0.13-0.56).
  
  
  CONCLUSIONS
  Surgical specialization, surgeon volume and center volume may be important metrics for quality and utilization in complex procedures like hepatectomy. Further studies are necessary to link direct factors related to hospital performance in the changing healthcare environment.
authors.affiliation: Department of Surgery, Surgical Outcomes Analysis & Research (SOAR), University of Massachusetts Medical School, Worcester, Massachusetts. Electronic address: joshua.shaw3@umassmemorial.org.
authors.forename: Joshua J
authors.initials: JJ
authors.lastname: Shaw
authors.forename: Heena P
authors.initials: HP
authors.lastname: Santry
authors.forename: Shimul A
authors.initials: SA
authors.lastname: Shah
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000368:Aged; D016208:Databases, Factual; D005260:Female; D013502:General Surgery / Q000706:statistics & numerical data*; D006498:Hepatectomy / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008113:Liver Neoplasms / Q000401:mortality* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D013043:Specialties, Surgical / Q000706:statistics & numerical data*
keywords: Cost; Hepatectomy; Outcomes; Specialty; Utilization