title: Defining a Hospital Volume Threshold for Minimally Invasive Pancreaticoduodenectomy in the United States.
abstract: There is increasing interest in expanding use of minimally invasive pancreaticoduodenectomy (MIPD). This procedure is complex, with data suggesting a significant association between hospital volume and outcomes.
  
  
  
  To determine whether there is an MIPD hospital volume threshold for which patient outcomes could be optimized.
  
  
  
  Adult patients undergoing MIPD were identified from the Healthcare Cost and Utilization Project National Inpatient Sample from 2000 to 2012. Multivariable models with restricted cubic splines were used to identify a hospital volume threshold by plotting annual hospital volume against the adjusted odds of postoperative complications. The current analysis was conducted on August 16, 2016.
  
  
  
  Incidence of any complication.
  
  
  
  Of the 865 patients who underwent MIPD, 474 (55%) were male and the median patient age was 67 years (interquartile range, 59-74 years). Among the patients, 747 (86%) had cancer and 91 (11%) had benign conditions/pancreatitis. Overall, 410 patients (47%) had postoperative complications and 31 (4%) died in-hospital. After adjustment for demographic and clinical characteristics, increasing hospital volume was associated with reduced complications (overall association P < .001); the likelihood of experiencing a complication declined as hospital volume increased up to 22 cases per year (95% CI, 21-23). Median hospital volume was 6 cases per year (range, 1-60). Most patients (n = 717; 83%) underwent the procedure at low-volume (≤22 cases per year) hospitals. After adjustment for patient mix, undergoing MIPD at low- vs high-volume hospitals was significantly associated with increased odds for postoperative complications (odds ratio, 1.74; 95% CI, 1.03-2.94; P = .04).
  
  
  
  Hospital volume is significantly associated with improved outcomes from MIPD, with a threshold of 22 cases per year. Most patients undergo MIPD at low-volume hospitals. Protocols outlining minimum procedural volume thresholds should be considered to facilitate safer dissemination of MIPD.
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: Mohamed Abdelgadir
authors.initials: MA
authors.lastname: Adam
authors.affiliation: Department of Biostatistics, Duke University, Durham, North Carolina.
authors.forename: Samantha
authors.initials: S
authors.lastname: Thomas
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: Linda
authors.initials: L
authors.lastname: Youngwirth
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: Theodore
authors.initials: T
authors.lastname: Pappas
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: Sanziana A
authors.initials: SA
authors.lastname: Roman
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina3Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Sosa
mesh_terms: D000368:Aged; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010182:Pancreatic Diseases / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology