title: Low-Volume vs High-Volume Centers and Management of Fournier's Gangrene in Washington State.
abstract: BACKGROUND
  Fournier's gangrene (FG) is a life-threatening infection affecting the perineum and genitals. Complex patient management often necessitates transfer to tertiary centers. We aimed to characterize hospital transfer patterns and assess morbidity among patients with FG in Washington State.
  
  
  METHODS
  The Washington State Comprehensive Hospital Abstract Reporting System includes claims from all hospital discharges in Washington. We identified patients with FG between 2007 and 2013, based on diagnosis and treatment codes. Analyses were stratified by center volume (low-volume centers [LVCs] or high-volume centers [HVCs]), and transfer status. Variables of interest included number of debridements, septic shock, acute renal failure, acute respiratory failure, length of hospitalization, and death.
  
  
  RESULTS
  We identified 165 FG patients. Only 1 HVC treated more than 2 FG patients per year. Overall mortality was 6.7%. Most patients (57%) were treated entirely at LVCs; 87% of patients treated at the HVC were transferred from an LVC. High-volume center-treated patients had similar baseline comorbidities (p = 0.77) and similar mortality (p = 0.87), despite higher rates of septic shock (p < 0.01) and respiratory failure (p = 0.01) compared with LVC patients. Among HVC-transferred patients, immediate compared with delayed transfer was associated with fewer debridements (p < 0.01), lower rates of septic shock (p = 0.05), and acute renal failure (p = 0.04).
  
  
  CONCLUSIONS
  Patients treated at the HVC were more acutely ill, yet mortality was similar compared with patients treated solely at LVCs, suggesting a benefit to transfer of high acuity patients. Immediate vs delayed transfer may benefit FG health outcomes; however, this may also reflect greater disease acuity of patients with delayed transfer status.
authors.affiliation: Department of Urology, University of Washington School of Medicine, Seattle, WA.
authors.forename: Nathan
authors.initials: N
authors.lastname: Osbun
authors.affiliation: Department of Urology, University of Washington School of Medicine, Seattle, WA.
authors.forename: Lindsay A
authors.initials: LA
authors.lastname: Hampson
authors.affiliation: Department of Urology, University of Washington School of Medicine, Seattle, WA.
authors.forename: Sarah K
authors.initials: SK
authors.lastname: Holt
authors.affiliation: Department of Urology, University of Washington School of Medicine, Seattle, WA.
authors.forename: John L
authors.initials: JL
authors.lastname: Gore
authors.affiliation: Department of Urology, University of Washington School of Medicine, Seattle, WA.
authors.forename: Hunter
authors.initials: H
authors.lastname: Wessells
authors.affiliation: Department of Urology, University of Washington School of Medicine, Seattle, WA. Electronic address: voelzke@uw.edu.
authors.forename: Bryan B
authors.initials: BB
authors.lastname: Voelzke
mesh_terms: D000328:Adult; D000368:Aged; D003646:Debridement; D005260:Female; D018934:Fournier Gangrene / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D017052:Hospital Mortality; D006760:Hospitalization; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume; D006801:Humans; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer; D012189:Retrospective Studies; D014861:Washington