Analysis of Bariatric Surgeon, Hospital Volumes for Increased Patient Outcomes for Bariatric (Weight-Loss) Surgery

Recent research into patient outcomes based on hospital volumes shows an increased success rate at hospitals with greater hospital volumes. Subsequently, costs at these hospitals have decreased due to the increase in efficiency.

Study: The Relationship Between Hospital Volume and Outcome in Bariatric Surgery at Academic Medical Centers

A study performed by a group of medical experts in 2004 examined 24,166 patients, all of which underwent Roux-en-Y gastric bypass surgery between 1999 and 2002. Outcomes of bariatric surgery, including length of hospital stay, morbidity, observed and expected mortality, and costs were compared between hospitals of varying volumes. The data used was controlled in the moderation of patients studied based on risk.

Here is a graph of the total hospitals and patients examined:

Hospital Type Surgeries Per Year Number of Hospitals Number of Patients
Low-Volume <50 44 2,722
Medium-Volume 50-100 27 7,634
High-Volume >100 22 13,810
Total 93 24,166

The study revealed that those who went to any of the high-volume hospitals examined generally had a shorter length of stay, lower morbidity and mortality, and decreased costs. In relation, those who went to one of the medium- or low-volume hospitals often met the opposite.

The sheer amount of instances used in this study validate the accuracy of the result. Though this research was gathered over a decade ago, these effects continue to apply today, since surgeons have yet to become machines. Until then, studies on the chance of human error should remain correct.

As shown in the study, the time spent in the hospital, overall complications, mortality rate, and costs are directly related to the number of surgeries performed at the hospital. While the complication rates are somewhat similar between low- and high- volume hospitals, the mortality rates lean vastly in favor of high-volume hospitals.

Here are some graphs of the relationship of results between low- and high-volume hospitals:

Study: Volume-Outcome Association in Bariatric Surgery

A newer study (2012) on the same topic examined 24 other studies involving a total of 458,032 patients. The same results were concluded.

“A positive association between annual surgeon volume and patient outcomes was reported in 11 of 13 studies. A positive association between annual hospital volume and patient outcomes was reported in 14 of 17 studies.” - Zevin B - Volume-outcome association in bariatric surgery: a systematic review.

Although the evidence is overwhelming, the article recommends further research into the study in the future. It states that the characteristics of high-volume surgeons also requires further investigation.

Based on this evidence, it is fair to formulate the importance of a high hospital volume, especially in bariatric surgery. The critical amount of research in this area over the timespan of a decade confirms that high-volume hospitals often generate better patient outcomes than medium- or low-volume hospitals, and that other factors, such as hospital stay and costs, are directly related to this factor.

Study: Work Hours, Sleep Deprivation on Safety and Performance

Now that’s not to say that surgeons should be pushed to their limit to ensure a maximum hospital volume. A study from 2007 covered the growing interest in the “impact of resident-physician and nurse work hours on patient safety,” says the article.

The evidence demonstrates that medical officials with shifts longer than 12.5 hours experience fatigue and have an increased risk of injury and medical error. Furthermore, medical officials with 24-hour on-call shifts were also examined. They reported increased risk of a sharps injury or a motor vehicle crash on the drive home.

“As compared to when working 16-hours shifts, on-call residents have twice as many attentional failures when working overnight and commit 36% more serious medical errors. They also report making 300% more fatigue-related medical errors that lead to a patient's death.” - Lockley SW - Effects of health care provider work hours and sleep deprivation on safety and performance

The study concludes that long work hours cause fatigue and are a decrement in performance and safety of medical officials. It also deems the current work hours of such employes in the United States as unsafe. It ends with a call to action, stating that the United States must “establish and enforce safe work-hour limits” if they are to reduce the high rate of medical injuries and errors among medical employees.

This information counteracts unnecessarily high surgeon volumes in compensation for a low surgeon count. A low-volume hospital probably already has a limited number of surgeons, so raising the volume on those surgeons might only worsen the situation.

Conclusion

These studies, showing reproducibility, strongly suggest that bariatric hospitals which perform at high volumes contribute to higher patient outcomes. Looking at a surgeon’s performance alone only tells part of the story; patients with significant weight should also consider the hospital’s surgical volume. To ensure the best results, surgeons should avoid working long hours at many high-volume hospitals.

To ensure the best results, surgeons should avoid working long hours at many high-volume hospitals. Surgeons are able to accomplish this by setting limits on their daily surgical volume. This would help reduce complications and risks, and in turn increase patient safety and outcomes.

References

The Relationship Between Hospital Volume and Outcome in Bariatric Surgery at Academic Medical Centers

Bariatric surgery performed at hospitals with more than 100 cases annually is associated with a shorter length of stay, lower morbidity and mortality, and decreased costs. This volume–outcome relationship is even more pronounced for a subset of patients older than 55 years, for whom in-hospital mortality was 3-fold higher at low-volume compared with high-volume hospitals. High-volume hospitals also have a lower rate of overall postoperative and medical care complications, which may be related in part to formalization of the structures and processes of care.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356460/
Nguyen, Ninh, Mahbod Paya, C. Stevens, Shahrzad Mavandadi, Kambiz Zainabadi, and Samuel Wilson. "The Relationship Between Hospital Volume and Outcome in Bariatric Surgery at Academic Medical Centers." Annals of Surgery. U.S. National Library of Medicine. Web. 15 July 2015.

Work Hours, Sleep Deprivation on Safety and Performance

Long work hours and sleep deprivation have been shown to make 300% more fatigue-related medical errors that lead to a patient’s death. The weight of evidence strongly suggests that extended-duration work shifts significantly increase fatigue and impair performance and safety.
http://www.ncbi.nlm.nih.gov/pubmed/18173162
Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler CA, Landrigan CP; Harvard Work Hours, and Health and Safety Group. "Work Hours, Sleep Deprivation on Safety and Performance."National Center for Biotechnology Information. U.S. National Library of Medicine, 1 Nov. 2007. Web. 15 July 2015.

Volume-Outcome Association in Bariatric Surgery

The overall methodological quality of the reviewed studies was fair. A positive association between annual surgeon volume and patient outcomes was reported in 11 of 13 studies. A positive association between annual hospital volume and patient outcomes was reported in 14 of 17 studies.
http://www.ncbi.nlm.nih.gov/pubmed/22584692
B. Zevin, R. Aggarwal, TP Grantcharov. "Volume-outcome Association in Bariatric Surgery: A Systematic Review." National Center for Biotechnology Information. U.S. National Library of Medicine, n.d. Web. 30 July 2015.



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