Influence of Surgical Subspecialty Training on In-Hospital Mortality for Gastrectomy and Colectomy Patients

Mark A. Callahan, MD, Paul J. Christos, MS, MPH, Heather T. Gold, PhD, Alvin I. Mushlin, MD, ScM, John M. Daly, MD

Disclosures

Annals of Surgery. 2003;238(4) 

In This Article

Abstract and Introduction

Objective: This study examined the relationship of surgeon subspecialty training and interests to in-hospital mortality while controlling for both hospital and surgeon volume.
Summary Background Data: The relationship between volume of surgical procedures and in-hospital mortality has been studied and shows an inverse relationship.
Methods: A large Statewide Planning and Research Cooperative System was used to identify all 55,016 inpatients who underwent gastrectomy (n = 6434) or colectomy (n = 48,582) between January 1, 1998 and December 31, 2001. Surgical subspecialty training and interest was defined as surgeons who were members of the Society of Surgical Oncology (training/interest; n = 68) or the Society of Colorectal Surgery (training; n = 61) during the study period. The association of in-hospital mortality and subspecialty training/interest was examined using a logistic regression model, adjusting for demographics, comorbidities, insurance status, and hospital and surgeon volume.
Results: Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (adjusted odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (adjusted OR = 0.70; 95% CI = 0.46, 1.08; P = 0.10).
Conclusions: For gastrectomies and colectomies, risk-adjusted mortality is substantially lower when performed by subspecialty interested and trained surgeons, even after accounting for hospital and surgeon volume and patient characteristics. These findings may have implications for surgical training programs and for regionalization of complex surgical procedures.

The relationship between hospital and surgeon volume and outcomes of care has been documented in numerous studies.[1,2,3,4,5,6,7,8,9,10,11] Outcomes, including mortality, complications, and resource use, have been shown to be lower for high-volume hospitals and surgeons.[3,4,5,6] This observed association has led to calls for surgical care programs providing complex operative procedures to be regionalized at high-volume centers as a way to improve the quality of care.[3] For example, the Leapfrog Group has recommended that insurance carriers contract with hospitals meeting certain volume standards for coronary artery bypass, coronary angioplasty, and several other complex procedures as a way to improve outcomes.[12,13]

Despite the large number of studies documenting improved outcomes associated with higher surgical volumes, the causal links in this relationship are not well understood.[2,3] Many studies have accounted for patient characteristics (including comorbidities, age, and insurance status) that may underlie the observed differences, and recent work has shown that surgeon volume in addition to hospital volume is associated with hospital mortality rates.[3,6] To further understand the relationship between volume and surgical outcomes, we sought to evaluate whether having surgical subspecialty training or a special surgical interest had an impact on treatment-related mortality beyond the volume relationship.

To address this question, we developed a multivariate model to evaluate the independent effect of having subspecialty surgical training or major surgical interest on the outcome of hospital mortality for patients undergoing gastrectomy or colectomy. We identified surgeons in New York State with subspecialty training or major surgical interest (defined through membership in surgical subspecialty societies) and compared patient outcomes after treatment by these physicians for colectomy and gastrectomy procedures to surgeons without subspecialty training or major surgical interest.

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