Impact of Hospital and Surgeon Volumes in the Management of Complicated Portal Hypertension: Review of a Statewide Database in Florida

Abstract

Mortality after complex surgical procedures has been shown to be inversely related to hospital volume. The purpose of this study was to determine whether these findings are applicable to radiologic and surgical procedures for complicated portal hypertension. The Agency for Healthcare Administration for the State of Florida database was queried to determine outcomes after transjugular intrahepatic stent shunts (TIPS) or surgical shunts from 2000 to 2003. A total of 1486 patients underwent either TIPS (1321) or surgical shunts (165). Natural breakpoints occurred at two and six procedures per year were correlated with survival for surgical shunts but not TIPS. Overall mortality was not different between TIPS and surgical shunts (11.0 vs. 12.7%, P = 0.51); however, the cost of TIPS was significantly lower (62,000 ± 58.5 vs. 107,000 ± 97.8, P < 0.001) as well as the length of hospitalization (9 ± 9.0 days vs. 15 days ± 12.6 days, P < 0.001). Surgical procedures for complicated portal hypertension are rapidly being replaced by TIPS. Like with other complex procedures, outcomes are related to hospital volume.

Get full access to this article

View all access options for this article.

References

Birkmeyer

J.D.

, Finlayson

E.V.

, Birkmeyer

C.M.

Volume standards for high-risk surgical procedures: potential benefits of the Leapfrog initiative.

Surgery 2001; 130: 415–22.

Birkmeyer

J.D.

, Dimick

J.B.

, Birkmeyer

N.J.

Measuring the quality of surgical care: structure, process, or outcomes?

J Am Coll Surg 2004; 198: 626–32.

Birkmeyer

J.D.

, Stukel

T.A.

, Siewers

A.E.

Surgeon volume and operative mortality in the United States.

N Engl J Med 2003; 349: 2117–27.

Birkmeyer

J.D.

, Siewers

A.E.

, Finlayson

E.V.

Hospital volume and surgical mortality in the United States.

N Engl J Med 2002; 346: 1128–37.

Hall

, Tu

J.V.

High volume hospitals and physicians are associated with better outcomes for many conditions.

Evidence-based healthcare: a scientific approach to health policy 2003; 7: 40–1.

Comar

K.M.

, Sanyal

A.J.

Portal hypertensive bleeding.

Gastroenterol Clin North Am 2003; 32: 1079–105.

Bass

B.L.

, Turner

D.J.

Acute gastrointestinal hemorrhage. In: Townsend

C.M.

, ed. Townsend: Sabiston Textbook of Surgery, 17th ed. Philadelphia: W.B. Saunders; 2004: 1171–263.

Luketic

V.A.

Management of portal hypertension after variceal hemorrhage.

Clin Liver Dis 2001; 5: 677–707, ix.

Bass

N.M.

, Yao

F.Y.

The role of the interventional radiologist. Transjugular procedures.

Gastrointest Endosc Clin N Am 2001; 11: 131–61.

10.

Khuri

S.F.

, Daley

, Henderson

Relation of surgical volume to outcome in eight common operations: results from the VA National Surgical Quality Improvement Program.

Ann Surg 1999; 230: 414–29; discussion 429–32.

11.

Goodney

P.P.

, Siewers

A.E.

, Stukel

T.A.

Is surgery getting safer? National trends in operative mortality.

J Am Coll Surg 2002; 195: 219–27.

12.

Rosemurgy

A.S.

, Bloomston

, Serafini

F.M.

Frequency with which surgeons undertake pancreaticoduodenectomy determines length of stay, hospital charges, and in-hospital mortality.

J Gastrointest Surg 2001; 5: 21–6.

13.

Rosemurgy

A.S.

, Zervos

E.E.

, Bloomston

Post-shunt resource consumption favors small-diameter prosthetic H-graft portacaval shunt over TIPS for patients with poor hepatic reserve.

Ann Surg 2003; 237: 820–5; discussion 825–7.

14.

Rosemurgy

A.S.

, Goode

S.E.

, Zwiebel

B.R.

A prospective trial of transjugular intrahepatic portasystemic stent shunts versus small-diameter prosthetic H-graft portacaval shunts in the treatment of bleeding varices.

Ann Surg 1996; 224: 378–84; discussion 384–6.

15.

Rosemurgy

A.S.

, Bloomston

, Clark

W.C.

H-graft portacaval shunts versus TIPS: ten-year follow-up of a randomized trial with comparison to predicted survivals.

Ann Surg 2005; 241: 238–46.

16.

Rosemurgy

A.S.

, Serafini

F.M.

, Zweibel

B.R.

Trans-jugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: extended follow-up of an expanded randomized prospective trial.

J Gastrointest Surg 2000; 4: 589–97.