Effect of Hospital Volume on In-hospital Morbidity and Mortality Following Pancreatic Surgery in Germany

Objective: We aimed to determine the effect of hospital volume on in-hospital mortality, and failure to rescue following major pancreatic resections using hospital discharge data of every inpatient case in Germany. Summary Background Data: Several studies have found strong volume-outcome relationships in pancreatic surgery, with high mortality in low-volume facilities. However, their datasets were only based on portions of national populations. In addition, these studies did not assess the effect of hospital volume according to other crucial variables such as medical indications, postoperative complications, and failure to rescue. Methods: We studied all inpatient cases of major pancreatic surgery (n = 60,858) in Germany from 2009 to 2014, using national hospital discharge data. We evaluated the association between hospital volume and in-hospital mortality following major pancreatic resections by using multivariate regression methods. In addition, we analyzed rates of major complications and failure to rescue across hospital volume quintiles. Results: Risk-adjusted in-hospital mortality varied widely across hospital volume quintiles, from 6.5% (95% CI 6.0-7.0) in very high volume hospitals to 11.5% (95% CI 10.9-12.1) in very low volume hospitals (OR 0.47, 95% CI 0.41-0.54). Rates of postoperative interventions necessary for complications and failure to rescue were lower in higher volume hospitals [eg, mortality following septic complications in very high volume hospitals: 24.2% (95% CI 22.4-26.1) vs. very low volume hospitals: 36.8% (34.9-38.7)]. Moreover, we estimated that centralization of surgical care to the minimum volume and mortality risk of the medium volume quintile could prevent at least 94 deaths per year. Conclusions: In Germany, patients who are undergoing major pancreatic resections have improved outcomes if they are admitted to higher volume hospitals. As current health policies failed to centralize pancreatic surgery procedures in Germany, new strategies to initiate a sufficient centralization process in the field of pancreatic surgery are needed.