Quality Comes with the (Anatomic) Territory: Evaluating the Impact of Surgeon Operative Mix on Patient Outcomes After Pancreaticoduodenectomy.
Recent support for centralization of complex operations, such as pancreaticoduodenectomy (PD), is based on surgeon-specific volume-outcome relationships. This study examined whether volume of anatomically related operations (operative mix), besides PD, is also independently associated with postoperative outcomes after PD. The study queried the Nationwide Inpatient Sample (2004-2009) for surgeons performing PD. Operative mix (OM) was defined as the year-specific number of other pancreatic, hepatic, biliary, and gastric operations performed by individual surgeons. Regression models included surgeon and hospital PD volume, adjusted for other hospital- and patient-specific factors. Among 1747 surgeons, 88.3% had low PD volume (≤ 5 cases/year), 8.9% had moderate PD volume (6-16 cases/year), and 2.8% had high PD volume (≥ 17 cases/year). Low-PD-volume surgeons with high OM (≥ 21 cases/year) (4.4%), moderate-PD-volume surgeons with high OM (3.4%), and high-PD-volume surgeons with high OM (2.7%) each had lower mortality than low-PD-volume surgeons with low OM (9.3%; all p ≤ 0.02). The frequency of prolonged hospitalization among low-PD/high-OM surgeons (45.3%) was lower than among low-PD/low-OM surgeons (61.6%; p < 0.001). Increasing OM volume was associated with decreased inpatient mortality, shorter hospital stay, and lower likelihood of any postoperative complication, using unadjusted regression (all p < 0.001). Adjusted regression results indicated that increasing OM volume is a significant predictor of decreased odds of a prolonged hospital stay (odds ratio [OR] 0.81; 95% confidence interval [CI] 0.73-0.90; p < 0.001). Surgeon PD volume is an important predictor of outcomes after PD. However, surgeon OM volume identifies a subset of lower-PD-volume surgeons with more favorable outcomes.