Original article
General thoracic
Continued Relevance of Minimum Volume Standards for Elective Esophagectomy: A National Perspective

Presented at the Fifty-seventh Annual Meeting of The Society of Thoracic Surgeons, Virtual Meeting, Jan 29-31, 2021.
https://doi.org/10.1016/j.athoracsur.2021.07.061Get rights and content

Abstract

Background

Despite minimum volume recommendations, the majority of esophagectomies are performed at centers with fewer than 20 annual cases. The present study examined the impact of institutional esophagectomy volume on in-hospital mortality, complications, and resource use after esophageal resection.

Methods

The 2010-2018 Nationwide Readmissions Database was queried to identify all adult patients undergoing esophagectomy for malignancy. Hospitals were categorized as a high-volume hospital (HVH) if performing at least 20 esophagectomies annually and as a low-volume hospital (LVH) if performing fewer than 20 esophagectomies annually. Multivariable models were developed to study the impact of volume on outcomes of interest, which included in-hospital mortality, complications, duration of hospitalization, inflation adjusted costs, readmissions, and nonhome discharge.

Results

Of an estimated 23,176 hospitalizations, 45.6% occurred at HVHs. Incidence of esophagectomy increased significantly along with median institutional caseload over the study period, while the proportion on hospitals considered HVHs remained steady at approximately 7.4%. After adjusting for relevant patient and hospital characteristics, HVH status was associated with decreased mortality (AOR, 0.65), length of stay (β = -1.83), pneumonia (AOR, 0.69), prolonged ventilation (AOR, 0.50), sepsis (AOR, 0.80), and tracheostomy (AOR, 0.66) but increased odds of nonhome discharge (AOR, 1.56; all P < .01), with LVH status as reference.

Conclusions

Many clinical outcomes of esophagectomy are improved with no increment in costs when performed at centers with an annual caseload of at least 20, as recommended by patient advocacy organizations. These findings suggest that centralization of esophageal resections to high-volume centers may be congruent with value-based care models.

Section snippets

Patients and Methods

The 2010 to 2018 Nationwide Readmissions Database (NRD) was used to identify all elective adult (≥18 years) hospitalizations for esophagectomy. Maintained as a part of the Healthcare Cost and Utilization Project, the NRD provides accurate estimates for up to 57.8% of all U.S. hospitalizations using robust sampling methodologies and survey weights.5 The study cohort was derived from nearly 17 million annual hospitalizations using International Classification of Diseases (ICD)–Ninth and Tenth

Results

During the study period, an estimated 23,176 patients underwent elective esophagectomy for malignancy, with an increase in annual volume from 2137 cases in 2010 to 3016 in 2018. The number of unique hospitals performing an elective esophagectomy increased from 296 in 2010 to 481 in 2018, while the median institutional caseload increased from 2 (IQR, 1-5) to 3 (IQR, 1-7) over the same period (all NPtrend < 0.001). The proportion of hospitals considered HVH according to Leapfrog criteria remained

Comment

Administration of minimum volume thresholds to ensure quality of complex operations has faced numerous challenges in the United States.13 While a large body of literature over the past 2 decades has demonstrated a significant volume-outcome relationship, critics have suggested real-world irrelevance of minimum volume requirements with general improvements in perioperative safety.4 In the present study, we characterized the association of volume thresholds on outcomes of elective esophagectomy

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