title: The Impact of Increasing Hospital Volume on 90-Day Postoperative Outcomes Following Pancreaticoduodenectomy.
abstract: Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system.
  
  
  
  A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients' 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases.
  
  
  
  Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers (>40 PD/year), 36.9% at medium-volume centers (20-39 PD/year), and 24.1% at lower-volume centers (10-19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) (p < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p < 0.0001) compared to lower-volume centers.
  
  
  
  Progressive increases in hospital volume correspond to improved 90-day outcomes following PD.
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Kagedan
authors.affiliation: Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
authors.forename: Nik
authors.initials: N
authors.lastname: Goyert
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
authors.forename: Qing
authors.initials: Q
authors.lastname: Li
authors.affiliation: Sunnybrook Health Sciences Centre, Toronto, ON, Canada.|Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.|Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Paszat
authors.affiliation: Sunnybrook Health Sciences Centre, Toronto, ON, Canada.|Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.|Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada.
authors.forename: Alexander
authors.initials: A
authors.lastname: Kiss
authors.affiliation: Sunnybrook Health Sciences Centre, Toronto, ON, Canada.|Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.|Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Craig C
authors.initials: CC
authors.lastname: Earle
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.|Sunnybrook Health Sciences Centre, Toronto, ON, Canada.|Faculty of Medicine, University of Toronto, Toronto, ON, Canada.|Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Karanicolas
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.|Faculty of Medicine, University of Toronto, Toronto, ON, Canada.|Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada.|Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
authors.forename: Alice C
authors.initials: AC
authors.lastname: Wei
authors.affiliation: Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
authors.forename: Nicole
authors.initials: N
authors.lastname: Mittmann
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. natalie.coburn@sunnybrook.ca.|Sunnybrook Health Sciences Centre, Toronto, ON, Canada. natalie.coburn@sunnybrook.ca.|Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. natalie.coburn@sunnybrook.ca.|Faculty of Medicine, University of Toronto, Toronto, ON, Canada. natalie.coburn@sunnybrook.ca.|Institute of Health Policy, Management, and Evaluation, Toronto, ON, Canada. natalie.coburn@sunnybrook.ca.|, 2075 Bayview Ave., Rm. T2-11, Toronto, ON, M4N 3M5, Canada. natalie.coburn@sunnybrook.ca.
authors.forename: Natalie G
authors.initials: NG
authors.lastname: Coburn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D017052:Hospital Mortality; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data*; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000401:mortality; D011183:Postoperative Complications / Q000209:etiology*; D011184:Postoperative Period; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013997:Time Factors
keywords: Hospital volume; Pancreatic cancer; Pancreaticoduodenectomy; Surgical complication