title: Provider Experience and the Comparative Safety of Laparoscopic and Open Colectomy.
abstract: OBJECTIVE
  To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy.
  
  
  METHODS
  National Medicare data (2008-2010) for beneficiaries undergoing laparoscopic or open colectomy.
  
  
  METHODS
  Using instrumental variable methods to address selection bias, we evaluated outcomes of laparoscopic and open colectomy. Our instrument was the regional use of laparoscopy in the year prior to a patient's operation. We then evaluated outcomes stratified by surgeons' annual volume of laparoscopic colectomy.
  
  
  RESULTS
  Laparoscopic colectomy was associated with lower mortality (OR: 0.75, 95 percent CI: 0.70-0.78) and fewer complications than open surgery (OR: 0.82, 95 percent CI: 0.79-0.85). Increasing surgeon volume was associated with better outcomes for both procedures, but the relationship was stronger for laparoscopy. The comparative safety depended on surgeon volume. High-volume surgeons had 40 percent lower mortality (OR: 0.60, 95 percent CI: 0.55-0.65) and 30 percent fewer complications (OR: 0.70, 95 percent CI: 0.67-0.74) with laparoscopy. Conversely, low-volume surgeons had 7 percent higher mortality (OR: 1.07, 95 percent CI: 1.02-1.13) and 18 percent more complications (OR: 1.18, 95 percent CI: 1.12-1.24) with laparoscopy.
  
  
  CONCLUSIONS
  This population-based study demonstrates that the comparative safety of laparoscopic and open colectomy is influenced by surgeon volume. Laparoscopic colectomy is only safer for patients whose surgeons have sufficient experience.
authors.affiliation: Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
authors.forename: Kyle H
authors.initials: KH
authors.lastname: Sheetz
authors.affiliation: Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.|Department of Health Management and Policy, Department of Economics, University of Michigan, Ann Arbor, MI.|National Bureau of Economic Research, Cambridge, MA.
authors.forename: Edward C
authors.initials: EC
authors.lastname: Norton
authors.affiliation: Department of Surgery, Dartmouth University, Hanover, NH.
authors.forename: John D
authors.initials: JD
authors.lastname: Birkmeyer
authors.affiliation: Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.|Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.
authors.forename: Justin B
authors.initials: JB
authors.lastname: Dimick
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003082:Colectomy / Q000009:adverse effects* / Q000401:mortality / Q000592:standards / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects* / Q000401:mortality / Q000592:standards / Q000706:statistics & numerical data; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D066231:Surgeons / Q000592:standards / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology
keywords: Comparative safety; colectomy; instrumental variables