Do the 2018 Leapfrog Group Minimal Hospital and Surgeon Volume Thresholds for Esophagectomy Favor Specific Patient Demographics?. Issue 3 (September 2021)

• Record Type: Journal Article
• Authors: Clark, James M.; Cooke, David T.; Hashimi, Habiba; Chin, David; Utter, Garth H.; Brown, Lisa M.; Nuño, Miriam
• Is Part Of: Annals of surgery. Volume 274:Issue 3(2021)
• Publication Date: 2021-09
• Subjects: centralization -- esophagectomy -- regionalization -- surgical volume -- The Leapfrog Group -- volume thresholds; Surgery -- Periodicals; 617.005
• DOI: 10.1097/SLA.0000000000003553
• Languages: English
• ISSNs: 0003-4932

Abstract

Abstract : Objective: We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. Summary Background Data: Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. Methods: Patients undergoing esophagectomy for cancer were identified from the 2007–2013 New York and Florida Healthcare Cost and Utilization Project's State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18–57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age ≥71, ECI >4). Results: Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58–71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. Conclusions: Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities. Abstract : Supplemental Digital Content is available in the text