INTRODUCTION:Regionalization of care raises potential for differences in cost of care and outcome. This study was undertaken to determine if costs and outcome after pancreaticoduodenectomy vary by region in Florida, and whether costs and outcome are related. METHODS:Inpatient data for pancreaticoduodenectomy in Florida during 2010-2012 were obtained from the Florida Agency for Health Care Administration. Seven geographically different regions were designated based on "cost of living index" and "urban to rural population ratio". Hospital costs, LOS, in-hospital mortality, and the frequency with which surgeons performed pancreaticoduodenectomy were evaluated for these regions. RESULTS:Median hospital costs for pancreaticoduodenectomy by region ranged from $101,436-$214,971. Median hospital costs by region correlated positively with LOS (p < 0.0001) and in-hospital mortality (p < 0.0001), and negatively with the frequency of pancreaticoduodenectomies performed by high-volume surgeons (p < 0.0001). CONCLUSIONS:There are regional differences for hospital costs and outcome with pancreaticoduodenectomy in Florida. Regions with lower costs had more pancreaticoduodenectomies performed by high-volume surgeons, shorter LOS, and lower in-hospital mortality rates. Regional differences in cost and quality-of-care need to be studied and abrogated to provide uniform optimal care.

Since the Leapfrog Group established hospital volume criteria for pancreaticoduodenectomy (PD), the importance of surgeon volume versus hospital volume in obtaining superior outcomes has been debated. This study was undertaken to determine whether low-volume surgeons attain the same outcomes after PD as high-volume surgeons at high-volume hospitals. PDs undertaken from 2010 to 2012 were obtained from the Florida Agency for Health Care Administration. High-volume hospitals were identified. Surgeon volumes within were determined; postoperative length of stay (LOS), in-hospital mortality, discharge status, and hospital charges were examined relative to surgeon volume. Six high-volume hospitals were identified. Each hospital had at least one surgeon undertaking ≥ 12 PDs per year and at least one surgeon undertaking < 12 PDs per year. Within these six hospitals, there were 10 "high-volume" surgeons undertaking 714 PDs over the three-year period (average of 24 PDs per surgeon per year), and 33 "low-volume" surgeons undertaking 225 PDs over the three-year period (average of two PDs per surgeon per year). For all surgeons, the frequency with which surgeons undertook PD did not predict LOS, in-hospital mortality, discharge status, or hospital charges. At the six high-volume hospitals examined from 2010 to 2012, low-volume surgeons undertaking PD did not have different patient outcomes from their high-volume counterparts with respect to patient LOS, in-hospital mortality, patient discharge status, or hospital charges. Although the discussion of volume for complex operations has shifted toward surgeon volume, hospital volume must remain part of the discussion as there seems to be a hospital "field effect."

BACKGROUND:Concentration of care has been promoted as fostering superior outcomes. This study was undertaken to determine if the concentration of care is occurring in Florida for a pancreaticoduodenectomy, and if so, is it having a salutary effect.METHODS:The data for a pancreaticoduodenectomy were obtained from the Florida Agency for Health Care Administration for three 3-year periods:1992-1994, 2001-2003, 2010-2012; data were sorted by surgeon volume of pancreaticoduodenectomy during these periods and correlated with post-operative length of stay (LOS), in-hospital mortality and hospital charges (adjusted to 2012 dollars).RESULTS:Relative to 1992-1994, in 2010-2012 46% fewer surgeons performed 115% more pancreaticoduodenectomies with significant reductions in LOS and in-hospital mortality, and higher charges (P < 0.001 for each). From 1992-1994 to 2010-2012 there was an 18-fold increase in the number of pancreaticoduodenectomies by surgeons completing ≥ 12 per year (n = 45 to n = 806, respectively). During 2010-2012, the more frequently surgeons performed a pancreaticoduodenectomy, the shorter LOS, the lower in-hospital mortality, the greater the likelihood of discharge home and the lower the hospital charges (P < 0.03 for each).CONCLUSIONS:Over the last 20 years, the concentration of care has occurred in Florida with substantially fewer surgeons undertaking many more pancreaticoduodenectomies with dramatic improvements in LOS and in-hospital mortality, albeit with increased hospital charges.

Web of Knowledge, reference lists of retrieved articles and conference abstracts were searched for relevant studies (Search date Sept 2013).Case control studies with gastrectomy for benign diseases were included.Gastrectomy for malignant conditions was excluded.Standardized forms were used to extract data.Data was extracted by two reviewers independently.Odds ratio was calculated using comprehensive Meta-analysis software.Newcastle-Ottawa Scale (NOS) was used to assess the quality of study.Heterogeneity was also assessed.Random effects model was used for pooling the data.Results: Eleven case-control studies were included in this study (3951 cases/9609 control).Studies were reported from USA (6), Europe (4) and Taiwan (1).Seven studies included hospital based controls and 4 included population based controls.The sample sized ranged from 142 to 720 (cases) and 180 to 2098 (control).The age of the patients ranged from 20 -79 yrs.The risk of pancreatic cancer was not increased in patients with prior history of gastrectomy (OR 1.39; 95% CI, 0.95 -2.03, p= 0.09).Subgroup analysis based on the geographical location revealed the risk was not increased in the USA (OR 1.65; 95% CI, 0.96-2.82,p=0.068) or Europe (OR 1.13; 95% CI 0.61-2.08,p=0.07).Subgroup analysis for Asia was not performed as there was only one study.Subgroup analysis based on the design of the study (population based control or hospital based controls) showed no significant difference.As per Newcastle-Ottawa Scale, nine studies were of high quality (7 or more NOS points) and two were of low quality (6 NOS points).Subgroup analysis based on quality did not show any significant difference.Moderate heterogeneity was present (I square =56%) and thus random effects model was used for analysis.Conclusion: A prior history of gastrectomy for benign gastric disorders is not associated with an increased risk for pancreatic cancer.

211 open PD were performed.Operations were performed by three surgeons, who perform both open PD and RAPD.Conversion rate each year ranged from 15.4% to 38.9% (p = 0.81).Utilization of RAPD per year increased from 18% in 2009 to 26% for 2012-2013(p= 0.45).There was no statistical difference between tumor size (2 to 2.45cm, p=0.24), percentage of malignant lesions (30.8% to 62.5%, p=0.36), and post-operative pancreatic fistula rate (grade A-C)(30% to 50%, p= 0.28) between the study years.Compared to the open PD cohort, mean estimated blood loss was significantly less (500cc vs. 200cc) (p<0.001).Length of stay (LOS) also had a trend towards significance with average LOS of 11.5 days for the open PD versus 9 days in the RAPD cohort (p=0.06).However, there was a significant decrease in mean LOS for the RAPD cohort, from 10 days in 2009 to 7 days in 2013 (p= 0.03).The rate of BMI increase over time for RAPD was significantly higher compared to open PD cohort (p=0.04)(Figure 1).In comparison between groups in regard to overall surgical site infections, there was no difference between the open PD and RAPD groups (25% vs 28%, p=0.76).However, there was a trend towards a decrease rate of incisional infections in the RAPD group compared to open PD (8% vs 15%, p=0.32).Conclusion: Increasing experience with RAPD has led to higher overall utilization regardless of underlying patient disease.To achieve the maximal benefits of a minimally invasive approach to PD, we have significantly and purposely increased the selection of obese patients.While a larger cohort of RAPD patients is needed, our initial experience suggests that the greatest benefit of RAPD is best utilized in patients with a higher BMI.