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PHOENIX – There is more evidence that it’s best to go with the pros: Adrenalectomies performed by higher-volume surgeons are associated with fewer complications, lower costs, and shorter lengths of stay than are those done by surgeons who dabble in the procedure.
The findings, presented at the annual Society of Surgical Oncology Cancer Symposium, come from a cross-sectional study of outcomes on all patients who underwent unilateral, partial, or bilateral adrenalectomies in the United States over a 7-year span.
"The frequency of adrenalectomy has steadily increased in the United States within the last few years, and with improvement of diagnostic and imaging modalities it’s likely that the rate of adrenal surgery will continue to rise," said Dr. Adam Hauch, a research resident in the department of surgery at Tulane University, New Orleans.
The prospects for the growth in the procedure prompted Dr. Hauch and colleagues to look at clinical and economic outcomes following adrenalectomy, and to see how surgeon volume, diagnosis, and type of surgery might affect outcomes.
They drew on discharge data from the Healthcare Cost and Utilization Project – National Inpatient Sample (HCUP-NIS), an administrative database sponsored by the U.S. Agency for Healthcare Research and Quality.
The information included International Classification of Diseases, Ninth Revision (ICD-9) codes identifying all adult patients who underwent adrenalectomies in U.S. hospitals from 2003 through 2009. Patients were divided into benign and malignant lesion groups.
The investigators found 7,829 procedures. Mean patient age was 50 years, most of the patients (74.4%) were white, and the majority were female (58.2%) and were privately insured (58.9%). Nearly all of the patients (98.3%) had one or no comorbidities at the time of admission. Only 42 patients (0.5%) died during their hospital stays.
More than three-fourths of the procedures (79.2%) were for benign disease; the remaining 20.8% of surgeries were for malignancies.
Low-volume surgeons, defined as those who performed one or fewer adrenalectomies on average per year, performed 41.7% of all procedures, compared with 34.7% for intermediate-volume surgeons (two to five per year) and 23.6% for high-volume surgeons (more than five per year).
The vast majority (97.1%) of procedures were unilateral/partial, and approximately 95% of surgeons in each experience category performed such procedures. Procedures for malignant disease accounted for 10.6% of cases for low-volume surgeons, 6.3% for intermediate-volume docs, and 4.3% of the most prolific surgeons.
It’s complicated
Risks for any complication were significantly higher among low-volume surgeons (18.8% of their cases), compared with 14.6% for those in the middle, and 11.6% for the high-volume operators (P less than .0001). High-volume performers had significantly lower risk for cardiovascular complications (P = .0008), pulmonary complications (P = .0481), bleeding (P = .0106), and technical difficulties during surgery (P = .0024).
In an analysis adjusted for patient demographic factors, payer, primary diagnosis, obesity, comorbidities, inpatient death, admission type, hospital teaching status and volume, surgeon, and type of procedure, low-volume surgeons were nearly twice as likely as were high-volume surgeons to have complications (adjusted odds ratio [aOR] 1.822, P less than .0001), and intermediate-volume surgeons had a nearly 1.5-fold higher risk (aOR 1.479, P = .0044).
Other risk factors for complications were bilateral vs. unilateral procedures (aOR 2.165, P = .0018), and malignant vs. benign disease (aOR 1.685, P less than .0001).
Not surprisingly, complications more than doubled mean total case charges, which ranged from $33,659 for uncomplicated unilateral cases to $73,021 for complicated cases (P = .0013), and from $47,284 for bilateral cases with no complications, to $141,461 for two-sided procedures with complications (P = .0221). Charges were higher for malignant cases than for benign cases without complications (P less than .0001), but complications brought the charges for both benign and malignant cases closer together .
Charges for noncomplicated procedures performed by high-volume surgeons were a comparative bargain at $27,324, compared with $33,499 for low- and intermediate-volume surgeons combined (P = .001). However, there were no significant differences by surgeon volume when complications arose.
Similarly, lengths of stay were prolonged when complications ensued for both unilateral cases (mean 3.7 days vs. 9.3 for complicated cases, P = .0042) and for bilateral cases (9.3 vs. 19.8, P = .025).
Higher volume surgeons managed to get patients out faster, averaging 2.7 days for cases without complications, compared with 4.2 for low/intermediate-volume surgeons (P less than .0001). When complications arose, patients of higher-volume surgeons still had shorter lengths of stay (8.5 vs. 10.4 days), but this difference was not statistically significant.
Dr. Lawrence Kim, professor of surgery at the University of North Carolina, Chapel Hill, said after the presentation that the study showed the limitations of using administrative data.
He said that approximately "98% of the patients [in the study presented] had no comorbidities, which just does not mesh with the realities I have ever faced with adrenal patients."
The study was internally funded. Dr. Hauch reported having no financial disclosures.
While there are nuances to the surgical technique to remove the adrenal gland, what makes adrenal surgery unique is not necessarily the procedural aspect of it, but rather the clinical work-up and preoperative preparation of the patient. Adrenal tumors are often hormonally active. Depending on the type of hormonal activity, the needs of the patient before, during, and after surgery vary greatly. Is volume in this study really more of a marker for the patients who underwent appropriate work-up and treatment before surgery, and not a marker of the technical demands of the operation? And this study does not take into consideration the surgeon skill in advanced laparoscopy, as while some of these surgeons may be performing one or two adrenal cases a year, they also perform laparoscopic colon, kidney, pancreas, spleen, liver, or stomach surgery. These are cases with just as much, if not more, technical demands in the operating room.
And what about how the gland is removed? There are at least nine different surgical approaches to the adrenal gland. Is it open or is it minimally invasive? Are you approaching it from the front, the back, or laterally? Are you using the robot? And does it really matter if you are only doing two cases a year? While super-high-volume centers (they do way more than just five cases a year) are publishing their outcomes with using the robot and approaching the adrenal gland from the back, they also allude to the learning curve of the various procedures, as well as the progression in surgical approach acquisition. But what has yet to be determined is when should that additional approach be attempted? At what clinical volume does having eight different ways to take out the adrenal gland matter? Shouldn’t the first step be having one way to take out the adrenal gland that results in good outcomes? And how often do you need to perform each approach to ensure that you as the surgeon are at your best? And what about the fact that the anatomy for a right is completely different from the left? The combinations quickly become endless.
While we can continue to publish research showing high volume is better, we have to acknowledge that not all Americans have access to a high-volume surgeon. The barriers to accessing this care are complex, and are due to both system and patient factors. It is not just as simple as ensuring that everyone has health insurance.
Sarah Oltmann, M.D., is clinical instructor of endocrine surgery at the University of Wisconsin, Madison.
While there are nuances to the surgical technique to remove the adrenal gland, what makes adrenal surgery unique is not necessarily the procedural aspect of it, but rather the clinical work-up and preoperative preparation of the patient. Adrenal tumors are often hormonally active. Depending on the type of hormonal activity, the needs of the patient before, during, and after surgery vary greatly. Is volume in this study really more of a marker for the patients who underwent appropriate work-up and treatment before surgery, and not a marker of the technical demands of the operation? And this study does not take into consideration the surgeon skill in advanced laparoscopy, as while some of these surgeons may be performing one or two adrenal cases a year, they also perform laparoscopic colon, kidney, pancreas, spleen, liver, or stomach surgery. These are cases with just as much, if not more, technical demands in the operating room.
And what about how the gland is removed? There are at least nine different surgical approaches to the adrenal gland. Is it open or is it minimally invasive? Are you approaching it from the front, the back, or laterally? Are you using the robot? And does it really matter if you are only doing two cases a year? While super-high-volume centers (they do way more than just five cases a year) are publishing their outcomes with using the robot and approaching the adrenal gland from the back, they also allude to the learning curve of the various procedures, as well as the progression in surgical approach acquisition. But what has yet to be determined is when should that additional approach be attempted? At what clinical volume does having eight different ways to take out the adrenal gland matter? Shouldn’t the first step be having one way to take out the adrenal gland that results in good outcomes? And how often do you need to perform each approach to ensure that you as the surgeon are at your best? And what about the fact that the anatomy for a right is completely different from the left? The combinations quickly become endless.
While we can continue to publish research showing high volume is better, we have to acknowledge that not all Americans have access to a high-volume surgeon. The barriers to accessing this care are complex, and are due to both system and patient factors. It is not just as simple as ensuring that everyone has health insurance.
Sarah Oltmann, M.D., is clinical instructor of endocrine surgery at the University of Wisconsin, Madison.
While there are nuances to the surgical technique to remove the adrenal gland, what makes adrenal surgery unique is not necessarily the procedural aspect of it, but rather the clinical work-up and preoperative preparation of the patient. Adrenal tumors are often hormonally active. Depending on the type of hormonal activity, the needs of the patient before, during, and after surgery vary greatly. Is volume in this study really more of a marker for the patients who underwent appropriate work-up and treatment before surgery, and not a marker of the technical demands of the operation? And this study does not take into consideration the surgeon skill in advanced laparoscopy, as while some of these surgeons may be performing one or two adrenal cases a year, they also perform laparoscopic colon, kidney, pancreas, spleen, liver, or stomach surgery. These are cases with just as much, if not more, technical demands in the operating room.
And what about how the gland is removed? There are at least nine different surgical approaches to the adrenal gland. Is it open or is it minimally invasive? Are you approaching it from the front, the back, or laterally? Are you using the robot? And does it really matter if you are only doing two cases a year? While super-high-volume centers (they do way more than just five cases a year) are publishing their outcomes with using the robot and approaching the adrenal gland from the back, they also allude to the learning curve of the various procedures, as well as the progression in surgical approach acquisition. But what has yet to be determined is when should that additional approach be attempted? At what clinical volume does having eight different ways to take out the adrenal gland matter? Shouldn’t the first step be having one way to take out the adrenal gland that results in good outcomes? And how often do you need to perform each approach to ensure that you as the surgeon are at your best? And what about the fact that the anatomy for a right is completely different from the left? The combinations quickly become endless.
While we can continue to publish research showing high volume is better, we have to acknowledge that not all Americans have access to a high-volume surgeon. The barriers to accessing this care are complex, and are due to both system and patient factors. It is not just as simple as ensuring that everyone has health insurance.
Sarah Oltmann, M.D., is clinical instructor of endocrine surgery at the University of Wisconsin, Madison.
PHOENIX – There is more evidence that it’s best to go with the pros: Adrenalectomies performed by higher-volume surgeons are associated with fewer complications, lower costs, and shorter lengths of stay than are those done by surgeons who dabble in the procedure.
The findings, presented at the annual Society of Surgical Oncology Cancer Symposium, come from a cross-sectional study of outcomes on all patients who underwent unilateral, partial, or bilateral adrenalectomies in the United States over a 7-year span.
"The frequency of adrenalectomy has steadily increased in the United States within the last few years, and with improvement of diagnostic and imaging modalities it’s likely that the rate of adrenal surgery will continue to rise," said Dr. Adam Hauch, a research resident in the department of surgery at Tulane University, New Orleans.
The prospects for the growth in the procedure prompted Dr. Hauch and colleagues to look at clinical and economic outcomes following adrenalectomy, and to see how surgeon volume, diagnosis, and type of surgery might affect outcomes.
They drew on discharge data from the Healthcare Cost and Utilization Project – National Inpatient Sample (HCUP-NIS), an administrative database sponsored by the U.S. Agency for Healthcare Research and Quality.
The information included International Classification of Diseases, Ninth Revision (ICD-9) codes identifying all adult patients who underwent adrenalectomies in U.S. hospitals from 2003 through 2009. Patients were divided into benign and malignant lesion groups.
The investigators found 7,829 procedures. Mean patient age was 50 years, most of the patients (74.4%) were white, and the majority were female (58.2%) and were privately insured (58.9%). Nearly all of the patients (98.3%) had one or no comorbidities at the time of admission. Only 42 patients (0.5%) died during their hospital stays.
More than three-fourths of the procedures (79.2%) were for benign disease; the remaining 20.8% of surgeries were for malignancies.
Low-volume surgeons, defined as those who performed one or fewer adrenalectomies on average per year, performed 41.7% of all procedures, compared with 34.7% for intermediate-volume surgeons (two to five per year) and 23.6% for high-volume surgeons (more than five per year).
The vast majority (97.1%) of procedures were unilateral/partial, and approximately 95% of surgeons in each experience category performed such procedures. Procedures for malignant disease accounted for 10.6% of cases for low-volume surgeons, 6.3% for intermediate-volume docs, and 4.3% of the most prolific surgeons.
It’s complicated
Risks for any complication were significantly higher among low-volume surgeons (18.8% of their cases), compared with 14.6% for those in the middle, and 11.6% for the high-volume operators (P less than .0001). High-volume performers had significantly lower risk for cardiovascular complications (P = .0008), pulmonary complications (P = .0481), bleeding (P = .0106), and technical difficulties during surgery (P = .0024).
In an analysis adjusted for patient demographic factors, payer, primary diagnosis, obesity, comorbidities, inpatient death, admission type, hospital teaching status and volume, surgeon, and type of procedure, low-volume surgeons were nearly twice as likely as were high-volume surgeons to have complications (adjusted odds ratio [aOR] 1.822, P less than .0001), and intermediate-volume surgeons had a nearly 1.5-fold higher risk (aOR 1.479, P = .0044).
Other risk factors for complications were bilateral vs. unilateral procedures (aOR 2.165, P = .0018), and malignant vs. benign disease (aOR 1.685, P less than .0001).
Not surprisingly, complications more than doubled mean total case charges, which ranged from $33,659 for uncomplicated unilateral cases to $73,021 for complicated cases (P = .0013), and from $47,284 for bilateral cases with no complications, to $141,461 for two-sided procedures with complications (P = .0221). Charges were higher for malignant cases than for benign cases without complications (P less than .0001), but complications brought the charges for both benign and malignant cases closer together .
Charges for noncomplicated procedures performed by high-volume surgeons were a comparative bargain at $27,324, compared with $33,499 for low- and intermediate-volume surgeons combined (P = .001). However, there were no significant differences by surgeon volume when complications arose.
Similarly, lengths of stay were prolonged when complications ensued for both unilateral cases (mean 3.7 days vs. 9.3 for complicated cases, P = .0042) and for bilateral cases (9.3 vs. 19.8, P = .025).
Higher volume surgeons managed to get patients out faster, averaging 2.7 days for cases without complications, compared with 4.2 for low/intermediate-volume surgeons (P less than .0001). When complications arose, patients of higher-volume surgeons still had shorter lengths of stay (8.5 vs. 10.4 days), but this difference was not statistically significant.
Dr. Lawrence Kim, professor of surgery at the University of North Carolina, Chapel Hill, said after the presentation that the study showed the limitations of using administrative data.
He said that approximately "98% of the patients [in the study presented] had no comorbidities, which just does not mesh with the realities I have ever faced with adrenal patients."
The study was internally funded. Dr. Hauch reported having no financial disclosures.
PHOENIX – There is more evidence that it’s best to go with the pros: Adrenalectomies performed by higher-volume surgeons are associated with fewer complications, lower costs, and shorter lengths of stay than are those done by surgeons who dabble in the procedure.
The findings, presented at the annual Society of Surgical Oncology Cancer Symposium, come from a cross-sectional study of outcomes on all patients who underwent unilateral, partial, or bilateral adrenalectomies in the United States over a 7-year span.
"The frequency of adrenalectomy has steadily increased in the United States within the last few years, and with improvement of diagnostic and imaging modalities it’s likely that the rate of adrenal surgery will continue to rise," said Dr. Adam Hauch, a research resident in the department of surgery at Tulane University, New Orleans.
The prospects for the growth in the procedure prompted Dr. Hauch and colleagues to look at clinical and economic outcomes following adrenalectomy, and to see how surgeon volume, diagnosis, and type of surgery might affect outcomes.
They drew on discharge data from the Healthcare Cost and Utilization Project – National Inpatient Sample (HCUP-NIS), an administrative database sponsored by the U.S. Agency for Healthcare Research and Quality.
The information included International Classification of Diseases, Ninth Revision (ICD-9) codes identifying all adult patients who underwent adrenalectomies in U.S. hospitals from 2003 through 2009. Patients were divided into benign and malignant lesion groups.
The investigators found 7,829 procedures. Mean patient age was 50 years, most of the patients (74.4%) were white, and the majority were female (58.2%) and were privately insured (58.9%). Nearly all of the patients (98.3%) had one or no comorbidities at the time of admission. Only 42 patients (0.5%) died during their hospital stays.
More than three-fourths of the procedures (79.2%) were for benign disease; the remaining 20.8% of surgeries were for malignancies.
Low-volume surgeons, defined as those who performed one or fewer adrenalectomies on average per year, performed 41.7% of all procedures, compared with 34.7% for intermediate-volume surgeons (two to five per year) and 23.6% for high-volume surgeons (more than five per year).
The vast majority (97.1%) of procedures were unilateral/partial, and approximately 95% of surgeons in each experience category performed such procedures. Procedures for malignant disease accounted for 10.6% of cases for low-volume surgeons, 6.3% for intermediate-volume docs, and 4.3% of the most prolific surgeons.
It’s complicated
Risks for any complication were significantly higher among low-volume surgeons (18.8% of their cases), compared with 14.6% for those in the middle, and 11.6% for the high-volume operators (P less than .0001). High-volume performers had significantly lower risk for cardiovascular complications (P = .0008), pulmonary complications (P = .0481), bleeding (P = .0106), and technical difficulties during surgery (P = .0024).
In an analysis adjusted for patient demographic factors, payer, primary diagnosis, obesity, comorbidities, inpatient death, admission type, hospital teaching status and volume, surgeon, and type of procedure, low-volume surgeons were nearly twice as likely as were high-volume surgeons to have complications (adjusted odds ratio [aOR] 1.822, P less than .0001), and intermediate-volume surgeons had a nearly 1.5-fold higher risk (aOR 1.479, P = .0044).
Other risk factors for complications were bilateral vs. unilateral procedures (aOR 2.165, P = .0018), and malignant vs. benign disease (aOR 1.685, P less than .0001).
Not surprisingly, complications more than doubled mean total case charges, which ranged from $33,659 for uncomplicated unilateral cases to $73,021 for complicated cases (P = .0013), and from $47,284 for bilateral cases with no complications, to $141,461 for two-sided procedures with complications (P = .0221). Charges were higher for malignant cases than for benign cases without complications (P less than .0001), but complications brought the charges for both benign and malignant cases closer together .
Charges for noncomplicated procedures performed by high-volume surgeons were a comparative bargain at $27,324, compared with $33,499 for low- and intermediate-volume surgeons combined (P = .001). However, there were no significant differences by surgeon volume when complications arose.
Similarly, lengths of stay were prolonged when complications ensued for both unilateral cases (mean 3.7 days vs. 9.3 for complicated cases, P = .0042) and for bilateral cases (9.3 vs. 19.8, P = .025).
Higher volume surgeons managed to get patients out faster, averaging 2.7 days for cases without complications, compared with 4.2 for low/intermediate-volume surgeons (P less than .0001). When complications arose, patients of higher-volume surgeons still had shorter lengths of stay (8.5 vs. 10.4 days), but this difference was not statistically significant.
Dr. Lawrence Kim, professor of surgery at the University of North Carolina, Chapel Hill, said after the presentation that the study showed the limitations of using administrative data.
He said that approximately "98% of the patients [in the study presented] had no comorbidities, which just does not mesh with the realities I have ever faced with adrenal patients."
The study was internally funded. Dr. Hauch reported having no financial disclosures.
AT SSO 2014
Major finding: Patients of low-volume surgeons were nearly twice as likely as were those of high-volume surgeons to have complications following adrenalectomy (adjusted odds ratio 1.822, P less than .0001).
Data source: Cross-sectional analysis of data on 7,829 patients.
Disclosures: The study was internally funded. Dr. Hauch reported having no financial disclosures.
