Elsevier

Pancreatology

Volume 19, Issue 6, September 2019, Pages 880-887
Pancreatology

Variation in use of open and laparoscopic distal pancreatectomy and associated outcome metrics in a universal health care system

https://doi.org/10.1016/j.pan.2019.07.047Get rights and content

Abstract

Background

Universal health care (UHC) should ensure equal access to and use of surgery, but few studies have explored variation in UHC systems. The objective was to describe practice of distal pancreatectomy in Norway covered exclusively by an UHC.

Methods

Data on all patients undergoing distal pancreatectomy from the Norwegian Patient Register over a 5-year period. Age- and gender-adjusted population-based resection rates (adj. per million/yr) for distal pancreatectomy were analysed across 4 regions and outcomes related to splenic salvage rate, hospital stay, reoperation, readmissions and 90-day mortality risk between regions. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.).

Results

Regional difference exist in terms of absolute numbers, with the majority of procedures done in one region (n = 331; 59.7%). Regional variation persisted for age- and gender-adjusted population-rates, with highest rate at 23.8/million/yr and lowest rate at 13.5/mill/yr (for a 176% relative difference; or an absolute difference of +10.3 resections/million/yr). Overall, a lapDP instead of an open DP was 3.5 times more likely in SouthEast compared to all other regions combined (lapDP rate: 83% vrs 24%, respectively; OR 15.4, 95% c.i. 10.1–23.5; P < 0.001). The splenic salvage rate was lower in SouthEast (19.9%) compared to all other regions (average 26.5%; highest in Central-region at 37.0%; P = 0.010 for trend). Controlled for other factors in multivariate regression, ‘region’ of surgery remained significantly associated with laparoscopic access.

Conclusion

Despite a universal health care system, considerable variation exists in resection rates, use of laparoscopy and splenic salvage rates across regions.

Introduction

The use of common surgical procedures can vary considerably across regions [1]. Even within countries having universal health care (UHC) coverage and similar access to care, the regional variation in provision of certain procedures, use of certain techniques (e.g. minimal invasive surgery) or surgical care can vary considerably [2,3]. In Scandinavia, variation in both the use of laparoscopic access and surgical care for gastrointestinal disease has been demonstrated [[2], [3], [4]].

A laparoscopic approach is increasingly advocated for resection of lesions in the distal pancreas with studies pointing to favourable short-term outcomes [5]. However, in studies reporting nationwide data, use of laparoscopic resections vary from 12% as reported in France [6] to 59% in Norway [7]. However, regional variation may exist within a country based on both catchment area, surgical volumes, hospital and surgeon practices but has not been investigated in detail.

In general, variation in surgical practice is largely described as or, believed to be, a result of differences in illness burden (e.g. variation in disease incidence, prevalence or stage), variation in diagnostic practices (e.g. threshold for use of imaging studies in the population) and variation in patients' attitudes towards intervention. However, data suggest that this can only explain a small degree of regional variation in surgery rates [1]. Evidence demonstrates that surgical variation results mainly from differences in physician beliefs about the indications for surgery and the extent to which patient preferences are incorporated into treatment decisions. These two components of clinical decision-making help to explain the so-called ‘surgical signatures’ of specific procedures, and why some consistently vary more than others.

We have previously shown that there was little variation in the population-based resections rates for pancreatoduodenectomy (Whipples procedure) across four health regions in Norway [8]. Notably, pancreatoduodenectomy is exclusively performed as open surgery in Norway and predominantly for malignant/premalignant conditions according to national guidelines. As a complex and high-risk procedure, the practice of pancreatoduodenectomy may be less prone to variation within a regulated system, compared to that of distal pancreatic resection. Variation in the practice of laparoscopic distal pancreatic resection is still evident with considerable differences in opinions, attitudes as well as experience in laparoscopy across the globe [9].

In Norway, the universal health care system allows for registration of all hospital-based procedures and hospital admissions that can be matched to a select number of valid and robust outcomes across all hospitals. In the ongoing process of adopting new techniques into routine practice in pancreatic surgery, an overall monitoring of procedural implementation and use across a health care system and their associated outcomes is highly warranted.

Thus, the aim of this study was to investigate the regional variation in use of distal pancreatectomy in a UHC system where fee-for-service and insurance coverage does not impact on surgical practice.

Section snippets

Study design

This was a longitudinal, observational national 5-year cohort study covering the universal health care system in Norway (from 1.1.2012 to 31.12.2016), as described in detail previously for nationwide data and time-trends [7,8,10] and consulting the guidelines for Strengthening the Reporting of Observational Studies in Epidemiology in Epidemiology (STROBE) [11].

Ethics

Centre of Clinical Documentation and Evaluation (SDKE, Northern Norway Regional Health Authority; Tromsø, Norway) holds a concession

Results

A total of 554 resections were included (Fig. 2), showing distribution of procedures between each RHA and the associated laparoscopy rate.

Discussion

The current study of practice of distal pancreatectomy in a UHC system found considerable variation across four health regions. Variation was evident for population-adjusted resection rates, to some extent for case-mix (including age-groups, gender and comorbidity in subgroups), for use of laparoscopic approach, for splenic salvage rate, and also for length of hospital stay. No differences between regions were found in other outcomes, including rates of reoperations, readmissions and 90-day

Disclaimer

Data from the Norwegian Patient Register has been used in this publication. The interpretation and reporting of these data are the sole responsibility of the authors, and no endorsement by the Norwegian Patient Register is intended nor should be inferred.

Author contributions

Conception or design of the work: KS.

Acquisition, analysis, or interpretation of data for the work: KS, LSN, DK, FO, KL.

Drafting the work: KS.

Revising it critically for important intellectual content: KS, LSN, DK, FO, KL.

Final approval of the version to be published: KS, LSN, DK, FO, KL.

Agreement to be accountable for all aspects of the work: KS, LSN, DK, FO, KL.

Funding

None.

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