High Subarachnoid Hemorrhage Patient Volume Associated With Lower Mortality and Better Outcomes

Abstract BACKGROUND: High-volume centers have better outcomes than low-volume centers when managing complex conditions including subarachnoid hemorrhage (SAH). OBJECTIVE: To quantify SAH volume-outcome association and determine the extent to which this association is influenced by aggressiveness of care. METHODS: A serial cross-sectional retrospective study using the Nationwide Inpatient Sample for 2002 to 2010 was performed. Included were all adult (older than 18 years of age) discharged patients with a primary diagnosis of SAH admitted from the emergency department or transferred to a discharging hospital; cases of trauma or arteriovenous malformation were excluded. Survey-weighted descriptive statistics estimated temporal trends. Multilevel logistic regression estimated volume-outcome associations for inpatient mortality and discharge home. Models were adjusted for demographic characteristics, year, transfer status, insurance status, all individual Charlson comorbidities, intubation, and all patient-refined, diagnosis-related group mortality. Analyses were repeated, excluding cases in which aggressive care was not pursued. RESULTS: A total of 32 336 discharges were included; 13 398 patients underwent clipping (59.1%) or coiling (40.9%). The inpatient mortality rate decreased from 32.2% in 2002 to 22.2% in 2010; discharge home increased from 28.5% to 40.8% during the same period. As SAH volume decreased from 100/year, the mortality rate increased from 18.7% to 19.8% at 80/year, 21.7% at 60/year, 24.5% at 40/year, and 28.4% at 20/year. As SAH patient volume decreased, the probability of discharge home decreased from 40.3% at 100/year to 38.7% at 60/year, and 35.3% at 20/year. Better outcomes persisted in patients receiving aggressive care and in those not receiving aggressive care. CONCLUSION: Short-term SAH outcomes have improved. High-volume hospitals have more favorable outcomes than low-volume hospitals. This effect is substantial, even for hospitals conventionally classified as high volume.

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Abstract W MP100: Hospital SAH Volume Associated With Better Outcomes

Stroke ◽

10.1161/str.45.suppl_1.wmp100 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Aditya S Pandey ◽

Neeraj Chaudhary ◽

Joseph J Gemmete ◽

Byron G Thompson ◽

James Burke

Keyword(s):

Systems Of Care ◽

Temporal Trends ◽

High Volume ◽

Primary Diagnosis ◽

Hospital Death ◽

Inpatient Mortality ◽

Cross Sectional ◽

Discharge Home ◽

Volume Outcome ◽

Aggressive Care

Objective: The net impact of hospital care on outcomes in subarachnoid hemorrhage (SAH) has not been well established. We hypothesized that increased experience and technical expertise at high volume hospitals would lead to better outcomes. Methods: We performed a serial cross-sectional retrospective study using the Nationwide Inpatient Sample from 2002-2010. All adult (>18 years) discharges with a primary diagnosis of SAH (ICD-9-CM 435) from 2002-2010 were included and records with trauma or AVM were excluded. Survey-weighted descriptive statistics were used to estimate temporal trends. Multi-level logistic regression was used to estimate volume-outcome associations for two outcomes: inpatient mortality and discharge home. Models were adjusted for demographics, year, transfer status, insurance status, all individual Charlson comorbidities, intubation, and APR-DRG mortality. Analyses were repeated by excluding records where aggressive care was not pursued _ no intubation, no procedures and in-hospital death within 48 hours. Results: A total of 66,818 discharges were included in the weighted sample, including 19, 356 who received clipping or coiling. Inpatient mortality declined from 32.2% (30.1%- 33.9%) to 22.2% (20.8%-23.6%) from 2002 to 2010 while discharges to home increased from 28.5% (27.0-30.03%) to 40.8% (39.1%-42.4%). Hospitals in the highest volume quintile (greater than 63 discharges per year) had an unadjusted inpatient mortality of 22.7% (95% CI 22.0%-23.2%) compared to 41.5% (39.0%-43.7%) in quintile 3 (11-21 discharges per year) compared to 51.9% (47.0 -55.7%) in quintile 1 (less than 6 discharges per year). Similar trends were observed when excluding cases where aggressive care was not pursued. The proportion of patients discharged home also increased with hospital volume: 39.3 %( 38.0-39.9%) in quintile 5 vs. 23.2% (21.0%-25.1%) in quintile 3 vs. 16.7% (13.0%-19.7%) in quintile 1. Conclusion: Inpatient SAH mortality has decreased over time while the likelihood of discharge home has increased. High volume hospitals have more favorable outcomes than low volume hospitals and the magnitude of this effect is substantial. SAH volume should be accounted for in developing SAH systems of care.

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In-hospital Mortality and Failure to Rescue Following Hepatobiliary Surgery in Germany - A Nationwide Analysis.

10.21203/rs.2.15901/v2 ◽

2020 ◽

Author(s):

Christian Krautz ◽

Christine Gall ◽

Olaf Gefeller ◽

Ulrike Nimptsch ◽

Thomas Mansky ◽

...

Keyword(s):

Mortality Rate ◽

Hospital Mortality ◽

Hospital Volume ◽

High Volume ◽

Hepatobiliary Surgery ◽

Failure To Rescue ◽

Volume Outcome ◽

Low Volume ◽

Very High ◽

Overall Mortality

Abstract Background: Recent observational studies on volume-outcome associations in hepatobiliary surgery were not designed to account for the varying extent of hepatobiliary resections and the consequential risk of perioperative morbidity and mortality. Therefore, this study aimed to determine the risk-adjusted in-hospital mortality for minor and major hepatobiliary resections at the national level in Germany and to examine the effect of hospital volume on in-hospital mortality, and failure to rescue. Methods: All inpatient cases of hepatobiliary surgery (n = 31,114) in Germany from 2009 to 2015 were studied using national hospital discharge data. After ranking hospitals according to increasing hospital volumes, five volume categories were established based on all hepatobiliary resections. The association between hospital volume and in-hospital mortality following minor and major hepatobiliary resections was evaluated by multivariable regression methods. Results: Minor hepatobiliary resections were associated with an overall mortality rate of 3.9% and showed no significant volume-outcome associations. In contrast, overall mortality rate of major hepatobiliary resections was 10.3%. In this cohort, risk-adjusted in-hospital mortality following major resections varied widely across hospital volume categories, from 11.4% (95% CI 10.4–12.5) in very low volume hospitals to 7.4% (95% CI 6.6–8.2) in very high volume hospitals (risk-adjusted OR 0.59, 95% CI 0.41–0.54). Moreover, rates of failure to rescue decreased from 29.38% (95% CI 26.7-32.2) in very low volume hospitals to 21.38% (95% CI 19.2-23.8) in very high volume hospitals. Conclusions: In Germany, patients who are undergoing major hepatobiliary resections have improved outcomes, if they are admitted to higher volume hospitals. However, such associations are not evident following minor hepatobiliary resections. Following major hepatobiliary resections, 70-80% of the excess mortality of the very low volume hospitals was estimated to be attributable to failure to rescue.

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Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states

Journal of Neurosurgery ◽

10.3171/jns.2003.99.5.0810 ◽

2003 ◽

Vol 99 (5) ◽

pp. 810-817 ◽

Cited By ~ 162

Author(s):

DeWitte T. Cross ◽

David L. Tirschwell ◽

Mary Ann Clark ◽

Dan Tuden ◽

Colin P. Derdeyn ◽

...

Keyword(s):

Emergency Department ◽

Subarachnoid Hemorrhage ◽

Mortality Rate ◽

Hospital Volume ◽

High Volume ◽

Mortality Rates ◽

Case Volume ◽

Content Type ◽

Hospital Case ◽

Fine Print

Object. The goal of this study was to determine whether a hospital's volume of subarachnoid hemorrhage (SAH) cases affects mortality rates in patients with SAH. For certain serious illnesses and surgical procedures, outcome has been associated with hospital case volume. Subarachnoid hemorrhage, usually resulting from a ruptured cerebral aneurysm, yields a high mortality rate. There has been no multistate study of a diverse set of hospitals to determine whether in-hospital mortality rates are influenced by hospital volume of SAH cases. Methods. The authors conducted an analysis of a retrospective, administrative database of 16,399 hospitalizations for SAH (9290 admitted through emergency departments). These hospitalizations were from acute-care hospitals in 18 states representing 58% of the US population. Both univariate and multivariate analyses were used to assess the case volume—mortality rate relationship. The authors used patient age, sex, Medicaid status, hospital region, data source year, hospital case volume quartile, and a comorbidity index in multivariate generalized estimating equations to model the relationship between hospital volume and mortality rates after SAH. Patients with SAH who were treated in hospitals in which low volumes of patients with SAH are admitted through the emergency department had 1.4 times the odds of dying in the hospital (95% confidence interval 1.2–1.6) as patients admitted to high-volume hospitals after controlling for patient age, sex, Medicaid status, hospital region, database year, and comorbid conditions. Conclusions. Patients with a diagnosis of SAH on their discharge records who initially presented through the emergency department of a hospital with a high volume of SAH cases had significantly lower mortality rates. Concentrating care for this disease in high-volume SAH treatment centers may improve overall survival.

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Caseload as a factor for outcome in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Journal of Neurosurgery ◽

10.3171/2013.9.jns13640 ◽

2014 ◽

Vol 120 (3) ◽

pp. 605-611 ◽

Cited By ~ 34

Author(s):

Hieronymus D. Boogaarts ◽

Martinus J. van Amerongen ◽

Joost de Vries ◽

Gert P. Westert ◽

André L. M. Verbeek ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Hospital Mortality ◽

Random Effects ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Meta Analysis ◽

Relative Weight ◽

High Volume ◽

Cochrane Library ◽

Endovascular Coiling ◽

Low Volume

Object Increasing evidence exists that treatment of complex medical conditions in high-volume centers is found to improve outcome. Patients with subarachnoid hemorrhage (SAH), a complex disease, probably also benefit from treatment at a high-volume center. The authors aimed to determine, based on published literature, whether a higher hospital caseload is associated with improved outcomes of patients undergoing treatment after aneurysmal subarachnoid hemorrhage. Methods The authors identified studies from MEDLINE, Embase, and the Cochrane Library up to September 28, 2012, that evaluated outcome in high-volume versus low-volume centers in patients with SAH who were treated by either clipping or endovascular coiling. No language restrictions were set. The compared outcome measure was in-hospital mortality. Mortality in studies was pooled in a random effects meta-analysis. Study quality was reported according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. Results Four articles were included in this analysis, representing 36,600 patients. The quality of studies was graded low in 3 and very low in 1. Meta-analysis using a random effects model showed a decrease in hospital mortality (OR 0.77 [95% CI 0.60–0.97]; p = 0.00; I2 = 91%) in high-volume hospitals treating SAH patients. Sensitivity analysis revealed the relative weight of the 1 low-quality study. Removal of the study with very low quality increased the effect size of the meta-analysis to an OR of 0.68 (95% CI 0.56–0.84; p = 0.00; I2 = 86%). The definition of hospital volume differed among studies. Cutoffs and dichotomizations were used as well as division in quartiles. In 1 study, low volume was defined as 9 or fewer patients yearly, whereas in another it was defined as fewer than 30 patients yearly. Similarly, 1 study defined high volume as more than 20 patients annually, and another defined it as more than 50 patients a year. For comparability between studies, recalculation was done with dichotomized data if available. Cross et al., 2003 (low volume ≤ 18, high volume ≥ 19) and Johnston, 2000 (low volume ≤ 31, high volume ≥ 32) provided core data for recalculation. The overall results of this analysis revealed an OR of 0.85 (95% CI 0.72–0.99; p = 0.00; I2 = 87%). Conclusions Despite the shortcomings of this study, the mortality rate was lower in hospitals with a larger caseload. Limitations of the meta-analysis are the not uniform cutoff values and uncertainty about case mix.

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Outcome of Aneurysmal Subarachnoid Hemorrhage in a Population‐Based Cohort: Retrospective Registry Study

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.121.000148 ◽

2021 ◽

Author(s):

Mathilde V. Iversen ◽

Tor Ingebrigtsen ◽

Jon A. Totland ◽

Roar Kloster ◽

Jørgen G. Isaksen

Keyword(s):

Subarachnoid Hemorrhage ◽

Mortality Rate ◽

Rural Population ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Population Based ◽

Modified Rankin Scale ◽

Timely Access ◽

The Mean ◽

Low Volume ◽

Aneurysm Repair

BACKGROUND Studies of aneurysmal subarachnoid hemorrhage report an association between higher patient volumes and better outcomes. In regions with dispersed settlement, this must be balanced against the advantages with shorter prehospital transport times and timely access. The aim of this study is to report outcome for unselected aneurysmal subarachnoid hemorrhage cases from a well‐defined rural population treated in a low‐volume neurosurgical center. METHODS This is a retrospective, population‐based, observational cohort study from northern Norway (population 486 450). The University Hospital of North Norway provides the only neurosurgical service. We retrieved data for all aneurysmal subarachnoid hemorrhage cases (n=332) admitted during 2007 through 2019 from an institution‐specific register. The outcome measures were mortality rates and functional status assessed with the modified Rankin scale. RESULTS The mean annual number of cases was 26 (range, 16–38) and the mean crude incidence rate 5.4 per 100 000 person‐years. Two hundred seventy‐nine of 332 (84%) cases underwent aneurysm repair, 158 (47.5%) with endovascular techniques and 121 (36.4%) with microsurgical clipping, while 53 (15.9%) did not. The overall mortality rate was 16.0% at discharge and 23.8% at 12 months. The proportion with a favorable outcome (modified Rankin scale scores 0–2) was 36.1% at discharge and 51.5% at 12 months. In subgroup analysis of cases who underwent aneurysm repair, the mortality rate was 4.7% at discharge and 11.8% at 12 months, and the proportion with a favorable outcome 42.3% at discharge and 59.9% at 12 months. CONCLUSIONS We report satisfactory outcomes after treatment of aneurysmal subarachnoid hemorrhage in a low‐volume neurosurgical department serving a rural population. This indicates a reasonable balance between timely access to treatment and hospital case volume

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Pediatric Hospital Volume and Induction Mortality in Pediatric Acute Lymphoblastic Leukemia (ALL)

Blood ◽

10.1182/blood.v124.21.2653.2653 ◽

2014 ◽

Vol 124 (21) ◽

pp. 2653-2653

Author(s):

Jennifer J. Wilkes ◽

Sean Hennessy ◽

Rui Xiao ◽

Susan R. Rheingold ◽

Alix E. Seif ◽

...

Keyword(s):

Mortality Rate ◽

Lymphoblastic Leukemia ◽

High Volume ◽

Mortality Rates ◽

P Value ◽

Hospital Inpatient ◽

Exact Test ◽

Patients Âgés ◽

Pediatric All ◽

Volume Outcome

Abstract Introduction: Survival in pediatric acute lymphoblastic leukemia (ALL) has increased dramatically over the past 40 years from less than 10% to 85%. Despite these gains, induction mortality rates have been shown to vary between institutions. This variation may relate to hospital factors such as patient volume. A volume-outcome association describes the relationship between how frequently a service is provided by a hospital to the quality of care received at the patient level. In adult care, higher procedural and patient volume has been associated with improved outcomes. Few studies have investigated a volume-outcome relationship in pediatric leukemia. We hypothesized that an inverse relationship exists between a hospital’s pediatric volume and their pediatric ALL induction mortality rates. Methods: A retrospective cohort of new onset ALL patients ages 0 to <19 years was assembled using three years of consecutive data from the Pediatric Health Information System (PHIS) and Perspective Data Warehouse (Premier). PHIS is comprised of free-standing children’s hospitals while Premier represents community institutions caring for both adult and pediatric patients. The primary outcome was inpatient mortality in the first 60 days after initiation of induction chemotherapy. Hospital pediatric volume was defined as the average annual number of inpatient discharges for patients ages of 1–19-years. Hospitals were then grouped into tertiles as low, medium or high volume. Descriptive analysis represented by counts and percentages with 95% confidence intervals. Fisher’s exact test and the non-parametric tests for trend were applied to assess association between a hospital’s ALL mortality rate and their pediatric volume tertile using STATA version 13. Results: 3456 patients with new onset ALL from 75 individual hospitals were included in our analysis. The induction mortality rate for the entire cohort was 0.87% (30/3456) with a range from 0.58% to 1.2% (Table 1). There was no significant inverse linear trend in mortality across the three pediatric volume categories (p= 0.218). Inpatient induction mortality was lowest in the low pediatric volume institutions, with resultant significant increased induction mortality rate when comparing medium volume institutions and high volume institutions to low volume institutions (Table 1). There was no difference in mortality rates between medium and high volume centers (p=0.468). Conclusions: Induction mortality in this pediatric ALL cohort is low and consistent with previously published literature. Contrary to our hypothesis, we observed a lower induction mortality rate in lowest volume institutions. While this finding may be real, it is likely that there are unmeasured confounders impacting the volume-outcome association in this ALL cohort. For instance, low pediatric volume centers may transfer sicker or more complex patients to medium or high volume centers due to lack of familiarity or comfort caring for a complicated patient with a rare diagnosis. The current dataset is limited and would require merger of alternate data sources to capture patient transfers from low to medium and high volume hospitals. Future analyses of these data will focus on adjusting for severity of illness at presentation among patients at the medium and high volume hospitals to see if an inverse association exists between volume and mortality. Table 1: Hospital Inpatient Volume and Disposition at Last Hospitalization in Induction Hospital Inpatient Pediatric Volume Total ALL patients Percent Mortality [95% CI of frequency] p value** Low (<6000) n= 27 512 0% [0-0.72%]* ref Medium (6000-9000) n=25 1371 1.2% [0.67-1.8%] 0.014 High (>9000) n=23 1573 0.89% [0.48-1.5%] 0.032 Total 75 Hospitals 3456 0.87% [0.58-1.2%] *97.5% one sided confidence interval **p value of Fisher’s exact test with reference as low pediatric volume tertile. Disclosures Rheingold: Novartis: Consultancy.

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Hospital-Volume Effects on Perioperative Outcomes in Peritoneal Dialysis Catheter Implantation: Analysis of 2,505 Cases

Peritoneal Dialysis International ◽

10.3747/pdi.2017.00095 ◽

2018 ◽

Vol 38 (6) ◽

pp. 419-423 ◽

Cited By ~ 1

Author(s):

Yoshitaka Kinoshita ◽

Toru Sugihara ◽

Hideo Yasunaga ◽

Hiroki Matsui ◽

Akira Ishikawa ◽

...

Keyword(s):

Regression Analysis ◽

Peritoneal Dialysis ◽

Adverse Events ◽

Hospital Volume ◽

High Volume ◽

Perioperative Outcomes ◽

Peritoneal Dialysis Catheter ◽

Volume Outcome ◽

Catheter Implantation ◽

Low Volume

Background Evidence regarding volume-outcome effects on peritoneal dialysis (PD) catheter implantation is limited. This study aimed to investigate associations between hospital volume (annual caseload of catheter implantation) and perioperative outcomes. Methods Clinical data for patients who underwent PD catheter implantation from 2007 to 2012 were extracted from the Japanese nationwide Diagnosis Procedure Combination database. Hospital volume was divided into tertiles: low-volume (1 – 6 cases/year), medium-volume (7 – 13 cases/year), and high-volume (≥ 14 cases/year). Multivariate logistic regression analysis for the occurrence of any adverse events and blood transfusion, and gamma-distributed log-linked linear regression analysis for postoperative length of stay were conducted with explanatory variables of hospital volume, age, sex, Charlson comorbidity index, history of hemodialysis, type of anesthesia, and type of hospital. Results Among 906, 855, and 744 cases in the low-volume, medium-volume, and high-volume groups, overall adverse events were 10.0%, 7.6%, and 6.0%, transfusion rates were 1.3%, 1.1%, and 0.9%, and median postoperative stays were 12, 10, and 9 days, respectively. In multivariate analyses, compared with the low-volume group, medium-volume and high-volume groups were associated with a lower incidence of overall adverse events (odds ratio [OR] = 0.71, p = 0.058, and OR = 0.59, p = 0.013, respectively) and shorter postoperative stay (% difference = -10.5%, p = 0.023, and % difference = -18.5%, p = 0.001, respectively), while no significant association was detected for transfusion. Conclusions Less frequent adverse events and shorter stays were observed in higher-volume centers. Inverse volume-outcome relationships in PD catheter implantation were confirmed.

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Hospital Volume Does Not Influence in-Hospital Mortality of Autologous Hematopoietic Cell Transplant Among Multiple Myeloma Patients in the United States

Blood ◽

10.1182/blood.v128.22.392.392 ◽

2016 ◽

Vol 128 (22) ◽

pp. 392-392

Author(s):

Smith Giri ◽

Prajwal Dhakal ◽

Kathan Dilipbhai Mehta ◽

Vijaya R. Bhatt

Keyword(s):

Multiple Myeloma ◽

Mechanical Ventilation ◽

Hospital Volume ◽

Herpes Simplex Virus Infection ◽

High Volume ◽

Cell Transplant ◽

Inpatient Mortality ◽

Hematopoietic Cell Transplant ◽

Low Volume ◽

Simplex Virus

Abstract Introduction: Hospital volume and provider experience affects survival among patients with hematologic malignancies (Giri et al Blood 3359-60). Whether hospital volume affects outcomes of autologous hematopoietic cell transplant (autoSCT) among patients with multiple myeloma (MM) remains unclear. Methods: We utilized the Nationwide Inpatient Sample (NIS) database to identify all adults >18 years diagnosed with MM who underwent autoSCT in 2009-2011. NIS is the largest all-payer inpatient database in the US that captures about 20% of all US hospitalizations. Hospitals were divided into quartiles, based on the annual number of autoSCT performed, and classified into high volume (above 75th percentile) and low volume centers (below 25th percentile). In-hospital outcomes including inpatient mortality, infection, mechanical ventilation, and costs of hospitalization were compared between the two groups. All p-values were 2 sided, and the level of significance was chosen at 0.05. Statistical analysis was done using STATA 13.0 (StataCorp, College Station, TX). Results: A total of 2,750 autoSCTs were reported among patients with MM during the study period. The characteristics of study population included mean age of 58.7 ± 8.7 years, 56% males (n=1547) and 72% whites (n=1822). No significant difference existed in in-hospital mortality rate (0.86% vs. 1.59%; p=0.183) between high volume (≥178 autoSCTs per year) versus low volume centers (≤56 autoSCTs per year). The rate of fungal infection (5.32% vs. 4.94%; p=0.75), herpes simplex virus infection (1.58% vs. 1.59%; p=0.98), and the need for mechanical ventilation (1.87% vs. 1.27%) was similar between the high volume and low volume centers. Higher rates of stomatitis (57% vs. 46%; p<0.01), use of total parenteral nutrition (12.37% vs. 6.21%) and neutropenic fever (33.6% vs. 23.5%; p <0.01) were noted in high volume versus low volume centers. The cost of initial hospitalization was similar in the two groups (mean $ 161,085 vs. $ 154,161; p value 0.17). Conclusion: Our study demonstrates a low risk of inpatient mortality without center effect for autoSCT in MM in the recent years. The risks of fungal and herpes simplex virus infection were also similar between high volume and low volume centers. Higher rates of stomatitis, use of total parenteral nutrition and neutropenic fever were noted in high volume versus low volume centers. The reasons for these differences are not clear from our study but may relate to possible differences in patient characteristics or conditioning chemotherapy. Disclosures No relevant conflicts of interest to declare.

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Hospital case-volume is associated with case-fatality after aneurysmal subarachnoid hemorrhage

International Journal of Stroke ◽

10.1177/1747493018790073 ◽

2018 ◽

Vol 14 (3) ◽

pp. 282-289 ◽

Cited By ~ 2

Author(s):

Antti Lindgren ◽

Sarah Burt ◽

Ellie Bragan Turner ◽

Atte Meretoja ◽

Jin-Moo Lee ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Treatment Modality ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Tertiary Care ◽

Case Fatality ◽

High Volume ◽

Day Case ◽

Case Volume ◽

Hospital Case ◽

Low Volume

Background Inverse association between hospital case-volume and case-fatality has been observed for various nonsurgical interventions and surgical procedures. Aims To study the impact of hospital case-volume on outcome after aneurysmal subarachnoid hemorrhage (aSAH). Methods We included aSAH patients who underwent aneurysm coiling or clipping from tertiary care medical centers across three continents using the Dr Foster Stroke GOAL database 2007–2014. Hospitals were categorized by annual case-volume (low volume: <41/year; intermediate: 41–70/year; high: >70/year). Primary outcome was 14-day in-hospital case-fatality. We calculated proportions, and used multiple logistic regression to adjust for age, sex, differences in comorbidity or disease severity, aneurysm treatment modality, and hospital. Results We included 8525 patients (2363 treated in low volume hospitals, 3563 treated in intermediate volume hospitals, and 2599 in high-volume hospitals). Crude 14-day case-fatality for hospitals with low case-volume was 10.4% (95% confidence interval (CI) 9.2–11.7%), for intermediate volume 7.0% (95% CI 6.2–7.9%; adjusted odds ratio (OR) 0.63 (95%CI 0.47–0.85)) and for high volume 5.4% (95% CI 4.6–6.3%; adjusted OR 0.50 (95% CI 0.33–0.74)). In patients with clipped aneurysms, adjusted OR for 14-day case-fatality was 0.46 (95% CI 0.30–0.71) for hospitals with intermediate case-volume and 0.42 (95% CI 0.25–0.72) with high case-volume. In patients with coiled aneurysms, adjusted OR was 0.77 (95% CI 0.55–1.07) for hospitals with intermediate case-volume and 0.56 (95% CI 0.36–0.87) with high case-volume. Conclusions Even within a subset of large, tertiary care centers, intermediate and high hospital case-volume is associated with lower case-fatality after aSAH regardless of treatment modality, supporting centralization to higher volume centers.

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In-hospital Mortality and Failure to Rescue Following Hepatobiliary Surgery in Germany - A Nationwide Analysis.

10.21203/rs.2.15901/v1 ◽

2019 ◽

Author(s):

Christian Krautz ◽

Christine Gall ◽

Olaf Gefeller ◽

Ulrike Nimptsch ◽

Thomas Mansky ◽

...

Keyword(s):

Mortality Rate ◽

Hospital Mortality ◽

Hospital Volume ◽

High Volume ◽

Hepatobiliary Surgery ◽

Failure To Rescue ◽

Discharge Data ◽

Low Volume ◽

Very High ◽

Overall Mortality

Abstract Objective To determine the risk-adjusted in-hospital mortality for hepatobiliary resections at the national level in Germany and to examine the effect of hospital volume on in-hospital mortality, and failure to rescue. Summary Background Data There is a paucity of population-based outcome data on hepatobiliary surgery in European countries, including Germany. Methods We studied all inpatient cases of hepatobiliary surgery (n = 31,114) in Germany from 2009 to 2015, using national hospital discharge data. After ranking hospitals according to increasing hospital volumes, five volume categories were established based on all hepatobiliary resections. We evaluated the association between hospital volume and in-hospital mortality following minor and major hepatobiliary resections by using multivariable regression methods. Results Minor hepatobiliary resections were associated with an overall mortality rate of 3.9% and showed no significant volume-outcome associations. In contrast, overall mortality rate of major hepatobiliary resections was 10.3%. In this cohort, risk-adjusted in-hospital mortality following major resections varied widely across hospital volume categories, from 11.4% (95% CI 10.4–12.5) in very low volume hospitals to 7.4% (95% CI 6.6–8.2) in very high volume hospitals (risk-adjusted OR 0.59, 95% CI 0.41–0.54). Moreover, rates of failure to rescue decreased from 29.38% (95% CI 26.7-32.2) in very low volume hospitals to 21.38% (95% CI 19.2-23.8) in very high volume hospitals. Conclusions In Germany, patients who are undergoing major hepatobiliary resections have improved outcomes if they are admitted to higher volume hospitals. Given the high rates of nationwide in-hospital mortality, health political strategies to initiate a sufficient centralization process of major hepatobiliary surgery in Germany are needed.

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