Patient and hospital characteristics on the variance of perioperative outcomes for pancreatic resection in the United States: A plea for outcome-based and not volume-based referral guidelines

Hypothesis: There is an effect of patient and hospital characteristics on perioperative outcomes for pancreatic resection in the United States. Design: Retrospective cohort study. Setting: Academic research. Patients: Patient data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project from January 1988 to January 2003. Main Outcome Measures: In-hospital mortality, perioperative complications, and mortality following a major complication. Results: A total of 103 222 patients underwent major pancreatic surgery. The annual number of pancreatic resections increased 15.0% during the 16-year study period. Resection for benign pancreatic disease increased 26.8%. Overall in-hospital mortality, perioperative complications, and mortality following a major complication were 6.5%, 35.6%, and 15.6%, respectively. Multivariate analysis demonstrated that significant independent predictors for these 3 perioperative outcomes were advancing age, male sex, medical comorbidity, and hospital volume for each type of pancreatic resection. The inhospital mortality for pancreatoduodenectomy increases with age and ranges from 1.7% to 13.8% (P <.001). After adjusting for other confounders, the odds of inhospital mortality for pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy in those 65 years or older were 4.78-fold, 3.84-fold, and 2.60-fold, respectively, lower in the high-volume hospitals compared with those in the lower-volume hospitals. Conclusions: Perioperative complications derived from this population-based study were higher than those reported in many case series. A significant disparity was noted in perioperative outcomes among surgical centers across the United States. An outcome-based referral guideline may have an immediate effect on improving the quality of care in patients who undergo pancreatic resection for benign and malignant disease.