title: Outcomes Improvement Is Not Continuous Along the Learning Curve for Pancreaticoduodenectomy at the Hospital Level.
abstract: BACKGROUND
  Most studies on learning curves for pancreaticoduodenectomy have been based on single-surgeon series at tertiary academic centers or are inferred indirectly from volume-outcome relationships. Our aim is to describe mortality rates associated with cumulative surgical experience among non-teaching hospitals.
  
  
  METHODS
  Observational study of a statewide inpatient database. Analysis included hospitals that began performing pancreaticoduodenectomy between 1996 and 2010, as captured by the California Office of Statewide Health Planning and Development database. Cases were numbered sequentially within each hospital. The same sequential series (e.g., first 10 cases, 11th through 20th cases) were identified across hospitals. The outcome measure was in-hospital mortality.
  
  
  RESULTS
  A total of 1210 cases from 143 non-teaching hospitals were analyzed. The average age was 63 years old, and the majority of patients were non-Hispanic white. The median overall mortality rate was 9.75 %. The mortality rate for the first 10 aggregated cases was 11.3 %. This improved for subsequent cases, reaching 7.1 % for the 21st-30th cases. However, the mortality rate then increased, reaching 16.7 % by the 41st-50th cases before falling to 0.0 % by the 61st-70th cases.
  
  
  CONCLUSIONS
  Initial improvement in surgical outcomes relative to cumulative surgical experience is not sustained. It is likely that factors other than surgical experience affect outcomes, such as less rigorous assessment of comorbidities or changes in support services. Vigilance regarding outcomes should be maintained even after initial improvements.
authors.affiliation: School of Medicine, University of California, San Diego, La Jolla, CA, USA.
authors.forename: Taylor M
authors.initials: TM
authors.lastname: Coe
authors.affiliation: Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Zhi Ven
authors.initials: ZV
authors.lastname: Fong
authors.affiliation: Department of Surgery, Irvine Medical Center, University of California, Irvine, Orange, CA, USA.
authors.forename: Samuel E
authors.initials: SE
authors.lastname: Wilson
authors.affiliation: Department of Surgery, SUNY Stony Brook, Stony Brook, NY, USA.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Talamini
authors.affiliation: Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Keith D
authors.initials: KD
authors.lastname: Lillemoe
authors.affiliation: Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA. dchang8@mgh.harvard.edu.
authors.forename: David C
authors.initials: DC
authors.lastname: Chang
mesh_terms: D000328:Adult; D000368:Aged; D002140:California; D002983:Clinical Competence; D016208:Databases, Factual; D005260:Female; D017052:Hospital Mortality; D006761:Hospitals; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D016577:Pancreaticoduodenectomy / Q000193:education / Q000401:mortality* / Q000706:statistics & numerical data
keywords: Learning curve; Mortality; Outcomes improvement; Pancreaticoduodenectomy