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Surgeon Volume Trumps Specialty: Outcomes From 3,596 Pediatric Cholecystectomies
*Kesi Chen1, *Kevin Cheung2, Julie Ann Sosa1
1Department of Surgery, Yale University School of Medicine, New Haven, CT;2Department of Surgery, McMaster University, Hamilton, ON, Canada
Objective: To determine the effect of surgeon volume and specialty on clinical and economic outcomes after cholecystectomy in pediatric patients on a population level. Design: Retrospective cross-sectional study. Setting: Health Care Utilization Project Nationwide Inpatient Sample (HCUP-NIS). Patients: Children (≤17 years) who underwent laparoscopic cholecystectomy between 2003-07. Pediatric surgeons performed ≥90% of their total cases in children. High-volume surgeons were in the top tertile (N≥37/year) of total cholecystectomies performed. Main Outcome Measures: χ2, ANOVA, and multivariate linear and logistic regression analyses were used to assess in-hospital complications, median length of hospital stay (LOS), and total hospital costs (2007 dollars). Results: A total of 3,596 pediatric cholecystectomies were included. 76% of patients were aged 14-17 years; 79.7% were female, and 49.7% were white. There were 2,060 general surgeons performing 83.3% of cases, and 173 pediatric surgeons (16.7% of cases). 24% of general surgeons were high-volume; no pediatric surgeons were high-volume (p<0.001). Low-volume surgeons had more complications (15.5% vs 13%, p<0.05), longer LOS (2.6 vs 2.3 days, p<0.01), and higher costs ($9,462 vs $7,761, p<0.01) than high-volume surgeons. After stratifying for severity of biliary disease, high-volume surgeons had better outcomes than low-volume surgeons for all outcome measures. There were no differences in patient outcomes between general and pediatric surgeons. After adjustment in multivariate regression, surgeon volume, but not specialty, was an independent predictor of LOS (1.1 day difference, p<0.001) and cost ($1,077 difference, p<0.001). The only predictor of complications was greater severity of biliary disease (OR=1.95, p<0.001). Conclusions: High-volume surgeons have better outcomes after pediatric cholecystectomy than low-volume surgeons. To optimize outcomes in children after cholecystectomy, surgeon volume and laparoscopic experience should be considered above surgeon specialty.
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