Does the success of a procedure depend on how often it is performed at a hospital or by a particular surgeon? Is a patient's access to procedures such as liver transplantation influenced by patient characteristics such as socioeconomic factors, geographic location, insurance or referral source? These questions and other important quality of care and disparities issues will be discussed via three new research presentations at Digestive Disease Week® 2008 (DDW®) in SanDiego, California.
"Past research has indicated that success rates for procedures are influenced by the volume of that procedure performed at a center. As researchers and medical professionals, we are constantly striving to understand the factors that determine whether a patient has a successful outcome," said Marcia R. Cruz-Correa, MD, PhD, FASGE, associate professor of medicine and biochemistry, University of Puerto Rico, Comprehensive Cancer Center. "The research presented today sheds new light on our understanding of the influences of high-volume vs. low-volume hospitals or surgeons, as well as the influence of demographics such as a patient's race, location or insurance coverage."
High Volume Surgery and Outcome After Liver Resection: Surgeon or Center?
Despite several recent studies that have shown that high-volume centers have improved outcomes after liver resection, researchers found that center volume appears to have a positive effect on in-hospital mortality only when performed by high-volume surgeons at high-volume centers. When controlling for differences in high-volume centers or in patients themselves, investigators found that liver resection patients treated by high-volume surgeons or centers alone did not achieve a survival benefit.
"Previous studies have told us that certain characteristics have a beneficial effect on a patient's success rate primarily due to access of care including race, income, insurance coverage and whether the surgery is elective," said Shimul A. Shah, MD, assistant professor of surgery at the University of Massachusetts Medical School. "We wanted to control for these factors to study the relationship between the volume of the center and the surgeon to see if either or both has an effect on the success rate."
Using the Nationwide Inpatient Sample (NIS), researchers identified all liver resections with available hospital and surgeon identifiers performed between 1998 and 2005. Incorporating patient and hospital factors, they adjusted for background characteristics and created matched control groups of low-volume and high-volume hospitals.
Researchers found that the factors that significantly decreased risk of in-hospital mortality after liver resection were private insurance and elective admission type. Further, they found that only liver resections performed by high-volume surgeons at high-volume centers were associated with improved in-hospital mortality.
While the NIS database allowed the researchers to study more than 3,000 liver resections performed in the U.S., limitations in the study include that the research is based on retrospective data and that the database uses diagnostic and procedural coding. Furthermore, the database collected in-hospital mortality rates, whereas the researchers involved in the study would ideally like to study mortality rates for periods beyond hospital discharge.
Does it Matter Where You Are Hospitalized for Inflammatory Bowel Disease?
Hospitals with a high annual volume of patients with inflammatory bowel disease (IBD) have lower mortality rates among hospitalized IBD patients who undergo surgery and shorter post-operative stays for Crohn's disease (CD). Additionally, there was no increase in length of stay or hospitalization costs despite caring for patients with more severe disease.
Inflammatory bowel diseases are chronic gastrointestinal disorders often requiring hospitalization or surgical intervention, which result in higher health-care costs. Investigators sought to find out whether past patient-care experience related to higher volume resulted in increased physician familiarity with the management of complex patients and affected outcomes in hospitalized IBD patients. They did this by analyzing the relationship between hospital volume and outcomes of IBD-related hospitalizations.
Investigators used data from more than 140,000 discharges from the Nationwide Inpatient Sample (NIS). IBD-related hospitalizations were identified as having either Crohn's disease or ulcerative colitis (UC). Hospitals were divided into low-, medium- and high-volume centers. Centers at which one to 50 patients had IBD listed as the primary discharge code were considered low-volume, centers at which 51 to 150 patients had IBD listed as their discharge code were considered medium-volume, and centers with more than 151 patients who had IBD listed as their discharge code were considered high-volume. Outcomes included in-hospital mortality, length of stay, frequency of surgery and length of post-operative stay and post-operative complications.
Patients hospitalized at high-volume centers that required surgery had only one-third the mortality rate of similar patients hospitalized at low-volume hospitals, the study concluded. The results also showed that patients at high-volume centers were more likely to undergo surgery, and had a trend towards shorter post-operative stays for Crohn's disease. Ashwin N. Ananthakrishnan, MD, MPH, a clinical gastroenterology fellow with the division of gastroenterology and hepatology at the Medical College of Wisconsin, added that these differences were more pronounced in patients with CD than in those with UC. Also, as investigators expected, patients at high-volume centers had more associated complications, which may be because complicated cases are more likely to end up in these specialty centers and larger hospitals.
"Patients with IBD who need surgery have much lower mortality rates at high-volume hospitals compared with low-volume hospitals," said Ananthakrishnan. "People are more likely to have surgery at a high-volume hospital, which may be due to more referrals, but could also mean that these hospitals may be more sensitive to the need for early surgery than low-volume hospitals."
He added that the results suggest a possible role for designated centers for the care of complex, hospitalized IBD patients. However, the first step is to further study what hospitals with good outcomes are doing differently and see how they can be applied to all hospitals.
Access to Liver Transplantation: Indirect Measures of Delayed Referral
Investigators found ethnic disparities among people seeking treatment for liver transplantation, and they attributed these disparities to factors including socioeconomic status, insurance, geographic location, referral source and delayed referral. The findings indicate that some ethnic groups will wait longer to get help, even if they have access to it, putting them at risk for advanced disease.
Researchers conducted a respective cohort study of all patients evaluated for liver transplantation at the University of Cincinnati Medical Center between 2003 and 2006. Data collected included demographics, insurance payer, diagnosis, referral source and Model for End-Stage Liver Disease (MELD) score.
In the study, 243 patients were evaluated, of which 162 were male (66.7 percent), with a median age of 55. There were 222 (91 percent) Caucasian patients and 18 (7.4 percent) African American patients. (Due to the smaller numbers of Asian American and Hispanic American patients in the cohort, further analysis was restricted to African Americans and Caucasians.) Insurance payers were private (53 percent) or government (50 percent). The underlying causes of cirrhosis included hepatitis C (25 percent), alcohol (23 percent), and nonalcoholic steatohepatitis (12 percent). Median MELD score was 13.
There was no difference in age, gender or etiology of liver disease between African American and Caucasian patients, but African Americans were more likely to have a high MELD score (56 percent vs. 15 percent) and less likely to have private insurance (6 percent vs. 59 percent).
Investigators concluded that a high MELD score among African American patients suggests a delayed appearance at the transplant center. Therefore, despite access to treatment centers, they do not appear to be using them. Financial resources were not an issue since the transplant center was public and provided treatment free of charge.
When asked why they did not take advantage of services earlier, study participants responded in a variety of ways: some had not previously been aware of available services, they did not realize that certain physical symptoms such as black stool or jaundice suggested illness, or they did not know enough about their family medical history to adequately assess their own risk. Investigators also said some people were distrustful of health-care settings for cultural reasons.
"Strategies that focus on delayed treatment -- despite its availability -- need to be addressed in order to eliminate ethnic disparities in liver transplant access," said Guy Neff, MD, MBA, associate professor of medicine and medical director of the transplant center at the University of Cincinnati. "The findings of this study will have lasting effects on long-term health-care outcomes in this country."
Neff added that now that ethnic disparities are evident, the next steps are to find out why the problems exist and how to address them.
Materials provided by American Gastroenterological Association. Note: Content may be edited for style and length.
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