Elsevier

Surgery

Volume 144, Issue 5, November 2008, Pages 736-743
Surgery

Original Communication
Surgical volume impacts bariatric surgery mortality: A case for centers of excellence

https://doi.org/10.1016/j.surg.2008.05.013Get rights and content

Background

Concerns regarding care quality prompted credentialing processes for bariatric “Centers of Excellence” (COE). It is hypothesized that high-volume surgeons and hospitals have better outcomes.

Objective

This population-based study examines the effect of bariatric surgery volume on mortality in Pennsylvania.

Methods

Between 1999 and 2003, 14,716 patients having gastric bypass surgery in Pennsylvania hospitals were identified from the Pennsylvania Health Care Cost Containment Council database. Individual surgeons and hospitals were stratified as high (> 100 cases/yr), medium (50–100 cases/yr), or low volume (< 50 cases/yr). The relationship between surgeon and hospital volume on length of stay (LOS), in-hospital, and 30-day mortality were examined, adjusting for age, gender, ethnicity, payor, and MedisGroups Admission Severity Group (ASG) score.

Results

There were 26–50 low (n = 2,158), 35–54 medium (n = 1,835), and 43–64 high (n = 10,723) volume hospitals in Pennsylvania. The mean volume/hospital increased between 1999 and 2003 (30–120 cases/yr) and in-hospital mortality decreased (0.8–0.2%). Thirty-day mortality (1.15%) was approximately 2 times the in-hospital mortality (0.37%). Male gender (odds ratio [OR] 3.6, P < .001), ASG (OR 2.5, P < .001), hospital and surgeon volume were associated with increased in-hospital and 30-day mortality. Controlling for other factors, patients treated by low- and medium-volume surgeons (OR 3.7, P = .002; OR 2.8, P = .015) and hospitals (OR 2.3, P = .01; OR 2.44, P = .017) had increased odds of 30-day mortality versus high-volume surgeons and hospitals. LOS was significantly shorter at high-volume hospitals as well.

Conclusions

In Pennsylvania, high volume is associated with decreased mortality and LOS. The results support the use of surgical volume in the COE credentialing process.

Section snippets

Data

Data on gastric bypass surgery performed in the Commonwealth of Pennsylvania between 1999 and 2003 were obtained from the Pennsylvania Health Care Cost Containment Council (PHC4). PHC4 is an independent state agency responsible for monitoring the quality and cost of health care, as well as improving access.19 The PHC4 data set contains hospital discharge data for all Pennsylvania hospitals. Variables included patient demographics (age, gender, race), admission and discharge diagnoses, surgical

Results

The total number of hospitals providing gastric bypass surgery grew from 119 in 1999 to 168 in 2001, and then declined to 114 in 2003 (Fig 1). Although the number of hospitals declined, the average volume of the remaining hospitals increased throughout the period. As seen in Fig 2, the average bariatric surgical volume of Pennsylvania hospitals grew from around 30 cases per year in 1999 to almost 120 per year in 2003. With the exception of the years 1999–2000, both the in-hospital and 30-day

Discussion

The Institute of Medicine (IOM), The Leapfrog Group, and others have identified medical errors as an important cause of preventable death in hospitals across the United States.12, 24 Physicians and other health care providers are under increasing pressure to develop systems of health care delivery that minimize potentially preventable complications. The epidemic of obesity and the rapid growth of bariatric surgery in the U.S. have focused attention on outcomes in bariatric surgery patients, and

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