Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy

Background. Reports of better results at national referral centers than at low-volume community hospitals have prompted calls for regionalizing pancre aticoduodenectomy (the Whipple procedure). We examined the relationship bet ween hospital volume and mortality with this procedure across all US hospit als. Methods. Using information form the Medicare claims database, we performed a national cohort study of 7229 Medicare patients more than 65 years old un dergoing pancreaticoduodenectomy between 1992 and 1995. We divided the stud y population into approximate quartiles according to the hospital's average annual volume of pancreaticoduodenectomies in Medicare patients: very low (<1/y), low (1-2/y), medium (2-5/y), and high (5+/y). Using multivariate lo gistic regression to account for potentially confounding patient characteri stics, we examined the association between institutional volume and in-hosp ital mortality, our primary outcome measure. Results. More than 50% of Medicare patients undergoing pancreaticoduodenect omy received care at hospitals performing fewer than 2 such procedures per year. In-hospital mortality rates at these low- and very-low-volume hospita ls were 3- to 4-fold higher than at high-volume hospitals (12% and 16%, res pectively, vs 4%, P<.001). Within the high-volume quartile, the 10 hospital s with the nation's highest volumes had lower mortality rates than the rema ining high-volume centers (2.1% vs 6.2%, P<.01). The strong association bet ween institutional volume and mortality could not be attributed to patient case-mix differences or referral bias. Conclusions. Although volume-outcome relationships have been reported for m any complex surgical procedures, hospital experience is particularly import ant with pancreaticoduodenectomy. Patients considering this procedure shoul d be given the option of care at a high-volume referral center.