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Is Annual Surgical Volume Enough? The Role of Experience and Specialization on Inpatient Mortality Following Hepatectomy
Daniel A Hashimoto, Yanik J Bababekov, Sahael M Stapleton, Keith D Lillemoe, David C Chang, Parsia A Vagefi
Massachusetts General Hospital, Boston, MA

OBJECTIVE(S):
The impact of annual surgical volume on post-operative outcomes has been extensively examined. However, the impact of cumulative surgeon experience and specialty training on this relationship warrants investigation.
METHODS:
The New York Statewide Planning and Research Cooperative System inpatient database was queried for patients ≥18 years who underwent wedge hepatectomy or lobectomy from 2000-2014. Patient data included demographics and comorbidities. Surgeon-specific data included annual hepatectomy volume, experience [early-career vs. late-career (<20 vs. ≥20 years since medical school graduation, respectively)], and specialty training (general, transplant, or oncologic). Adjusting for both patient and surgeon factors, multiple logistic regression was performed to identify predictors of the primary endpoint - inpatient mortality.
RESULTS:
13,467 cases were analyzed. Overall inpatient mortality was 2.35% and was significantly lower among surgeons with >30 cases per year (1.5% vs. 3.1%, p<0.001). In unadjusted analysis, this difference appeared to persist in early-career (1.2 vs. 2.8%, p<0.001) and late-career surgeons (1.8% vs. 3.2%, p<0.001). However, once risk-adjusted, annual volume was associated with reduced mortality only among early-career surgeons (OR 0.826, p=0.01) and general surgeons (OR 0.685, p=0.01). No volume effect was seen among late-career or specialty-trained surgeons.
CONCLUSIONS:
Cumulative experience and specialty training offset the effect of annual volume on inpatient mortality following hepatectomy, demonstrating that annual surgical volume alone is a poor surrogate for overall experience. Furthermore, this study highlights the need for longitudinal coaching of early-career surgeons by experienced faculty and the importance of fellowship training in hepatic surgery.


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