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10.1245/s10434-007-9381-0
Annals of Surgical Oncology 14:1846-1852 (2007)
© 2007 Society of Surgical Oncology
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Original Article

Factors Influencing the Volume-Outcome Relationship in Gastrectomies: A Population-Based Study

David L. Smith, MD1, Linda S. Elting, Dr.PH2, Peter A. Learn, MD1, Chandrajit P. Raut, MD3 and Paul F. Mansfield, MD4

1 Department of Surgery, Wilford Hall Medical Center, 2200 Bergquist Drive/Ste 1, Lackland AFB, Texas 78236, USA
2 Department of Biostatistics, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 447, Houston, Texas 77030, USA
3 Division of Surgical Oncology, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115, USA
4 Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 447, Houston, Texas 77030, USA

Correspondence: Address correspondence and reprint requests to: Paul F. Mansfield, MD; E-mail: pmansfie{at}mdanderson.org

Background: A relationship between hospital procedural volume and patient outcomes has been observed in gastrectomies for primary gastric cancer, but modifiable factors influencing this relationship are not well elaborated.

Methods: We performed a population-based study of 1864 patients undergoing gastrectomy for primary gastric cancers at 214 hospitals. Hospitals were stratified as high-, intermediate-, or low-volume centers. Multivariate models were constructed to evaluate the effect of institutional procedural volume and other hospital- and patient-specific factors on the risk of inhospital mortality, adverse events, and failure to rescue, defined as mortality after an adverse event.

Results: High-volume centers attained an in-hospital mortality rate of 1.0% and failure-to-rescue rate of .7%, both less than one-fifth of that seen at intermediate- and low-volume centers, although adverse event rates were similar across the three volume tiers. In multivariate modeling, treatment at a high-volume hospital decreased the odds of mortality (odds ratio [OR], .22; 95% confidence interval [95% CI], .05–.89), whereas treatment at an institution with a high ratio of licensed vocational nurses per bed increased the odds of mortality (OR, 1.96; 95% CI, 1.04–3.75). Being treated at a hospital with a greater than median number of critical care beds decreased odds of mortality (OR, .46; 95% CI, .25–.81) and failure to rescue (OR, .53; 95% CI, .29–.97).

Conclusions: Undergoing gastrectomy at a high-volume center is associated with lower inhospital mortality. However, improving the rates of mortality after adverse events and reevaluating nurse staffing ratios may provide avenues by which lower-volume centers can improve mortality rates.

Key Words: Gastrectomies • Volume-outcome • Population based • Nursing staffing




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