title: Cost effectiveness after a pancreaticoduodenectomy: bolstering the volume argument.
abstract: BACKGROUND
  The cost implication of variability in pancreatic surgery is not well described. It was hypothesized that for a pancreaticoduodenectomy (PD), lower volume centres demonstrate worse peri-operative outcomes at higher costs.
  
  
  METHODS
  From 2009-2011, 9883 patients undergoing a PD were identified from the University HealthSystems Consortium (UHC) database and stratified into quintiles by annual hospital case volume. A decision analytic model was constructed to assess cost effectiveness. Total direct cost data were based on Medicare cost/charge ratios and included readmission costs when applicable.
  
  
  RESULTS
  The lowest volume centres demonstrated a higher peri-operative mortality rate (3.5% versus 1.3%, P < 0.001) compared with the highest volume centres. When both index and readmission costs were considered, the per-patient total direct cost at the lowest volume centres was $23,005, or 10.9% (i.e. $2263 per case) more than at the highest volume centres. One-way sensitivity analyses adjusting for peri-operative mortality (1.3% at all centres) did not materially change the cost effectiveness analysis. Differences in cost were largely recognized in the index admission; readmission costs were similar across quintiles.
  
  
  CONCLUSIONS
  For PD, low volume centres have higher peri-operative mortality rates and 10.9% higher cost per patient. Performance of PD at higher volume centres can lead to both better outcomes and substantial cost savings.
authors.affiliation: Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Sutton
authors.forename: Gregory C
authors.initials: GC
authors.lastname: Wilson
authors.forename: Ian M
authors.initials: IM
authors.lastname: Paquette
authors.forename: Koffi
authors.initials: K
authors.lastname: Wima
authors.forename: Dennis J
authors.initials: DJ
authors.lastname: Hanseman
authors.forename: R Cutler
authors.initials: RC
authors.lastname: Quillin
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Sussman
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Edwards
authors.forename: Syed A
authors.initials: SA
authors.lastname: Ahmad
authors.forename: Shimul A
authors.initials: SA
authors.lastname: Shah
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Abbott
mesh_terms: D017046:Cost Savings; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D003661:Decision Support Techniques; D017722:Hospital Charges; D017721:Hospital Costs; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume / Q000191:economics*; D006801:Humans; D007902:Length of Stay / Q000191:economics; D006278:Medicare / Q000191:economics; D018803:Models, Economic; D010190:Pancreatic Neoplasms / Q000191:economics* / Q000401:mortality / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D010359:Patient Readmission / Q000191:economics; D011183:Postoperative Complications / Q000191:economics; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States