title: The relative effect of hospital and surgeon volume on failure to rescue among patients undergoing liver resection for cancer.
abstract: BACKGROUND
  Although previous reports have focused on factors at the hospital level to explain variations in postoperative outcomes, less is known regarding the effect of provider-specific factors on postoperative outcomes such as failure-to-rescue (FTR) and postoperative mortality. The current study aimed to quantify the relative contributions of surgeon and hospital volume on the volume-outcomes relationship among a cohort of patients undergoing liver resection.
  
  
  METHODS
  Patients undergoing liver surgery for cancer were identified using the Nationwide Inpatient Sample from 2001 and 2009. Multivariable logistic regression analysis was performed to identify factors associated with mortality and FTR. Point estimates were used to calculate the relative effects of hospital and surgeon volume on mortality and FTR.
  
  
  RESULTS
  A total of 5,075 patients underwent liver surgery and met inclusion criteria. Median patient age was 62 years (interquartile range, 52-70) and 55.2% of patients were male. Mortality was lowest among patients treated at high-volume hospitals and among patients treated by high-volume surgeons (both P < .001). Similar patterns in FTR were noted relative to hospital and surgeon volume (hospital volume: low vs intermediate vs high; 10.3 vs 9.0 vs 5.2%; surgeon volume: low vs intermediate vs high, 11.1 vs 9.1 vs 4.1%; both P < .05). On multivariable analysis, compared with high-volume surgeons, lower volume surgeons demonstrated greater odds for mortality (intermediate: odds ratio [OR], 2.27 [95% CI, 1.27-4.06; P = .006]; low, OR, 2.83 [95% CI, 1.52-5.27; P = .001]), and FTR (intermediate: OR, 2.86 [95% CI, 1.53-5.34, P = .001]; low, OR, 3.40 [95% CI, 1.75-6.63; P < .001]). While hospital volume accounted for 0.5% of the surgeon volume effect on increased FTR for low-volume surgeons, surgeon volume accounted for nearly all of the hospital volume effect on increased FTR in low-volume hospitals.
  
  
  CONCLUSIONS
  The risk of complications, mortality, and FTR were less among both high-volume hospitals and high-volume surgeons, but the beneficial effect of volume on outcomes was attributable largely to surgeon volume.
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Stefan
authors.initials: S
authors.lastname: Buettner
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Faiz
authors.initials: F
authors.lastname: Gani
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Neda
authors.initials: N
authors.lastname: Amini
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Gaya
authors.initials: G
authors.lastname: Spolverato
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Yuhree
authors.initials: Y
authors.lastname: Kim
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Arman
authors.initials: A
authors.lastname: Kilic
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Doris
authors.initials: D
authors.lastname: Wagner
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD. Electronic address: tpawlik1@jhmi.edu.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D005260:Female; D006498:Hepatectomy / Q000401:mortality*; D017052:Hospital Mortality; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data*; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data*; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality* / Q000628:therapy; D012307:Risk Factors; D066231:Surgeons / Q000706:statistics & numerical data*; D014481:United States