Elsevier

World Neurosurgery

Volume 114, June 2018, Pages e254-e266
World Neurosurgery

Original Article
Surgeon Annual and Cumulative Volumes Predict Early Postoperative Outcomes After Brain Tumor Resection

https://doi.org/10.1016/j.wneu.2018.02.172Get rights and content

Highlights

  • Surgeon volume affects postoperative outcomes from an annual and cumulative experience standpoint.

  • Subspecialization in neuro-oncology should be considered.

  • Postoperative neurologic morbidity should be routinely included in outcome studies.

Objective

Surgeon volume has been previously shown to affect patient outcomes. However, data related to neuro-oncologic surgery are limited and do not include neurologic morbidities as an outcomes measure. In this study, we aimed to determine if 5-year surgeon cumulative and annual volumes predict early postoperative outcomes in patients after brain tumor surgery.

Methods

A population-based cohort of patients (n = 10,258) undergoing brain tumor resection between 2005 and 2014 were included for study using the New York Statewide Planning and Research Cooperation System. Surgeons were categorized by their cumulative and annual surgical volume.

Results

Patients treated by high cumulative/high annual (HC/HA) volume surgeons had shorter length of stay (median, 5 days vs. 8 days vs. 8 days vs. 6 days, respectively; P < 0.01), lower charges (median, 70,025 vs. $77,043 vs. $93,715 vs. $77,018 respectively; P < 0.01) and less nonroutine discharge (41% vs. 48% vs. 50.9% vs. 43.9% respectively; P < 0.01) compared with patients treated by surgeons from the low cumulative/low annual (LC/LA), LC/HA, HC/LA groups. Similarly, HC/HA volume surgeons also had lower rate of hydrocephalus (9.9% vs. 10.4% vs. 13.7% respectively; P = 0.02), medical complications (6.9% vs. 11.2% vs. 11.5% respectively; P < 0.01), neurologic complications (44.1% vs. 46.8% vs. 48.1% respectively; P = 0.03), 30-day reoperation (5.1% vs. 6.9% vs. 7.1% respectively; P < 0.01) and 30-day death (3.3% vs. 5.4% vs. 5.2%; P < 0.01) compared with LC/LA and LC/HA volume surgeons.

Conclusions

There is some evidence for improved postoperative outcomes when surgery is performed by HC and HA volume surgeons. This finding suggests that subspecialization in surgical neuro-oncology should be considered.

Introduction

Patients with brain tumors may present with either primary or metastatic disease, often requiring complex multidisciplinary care. Surgical management is often the initial management for these tumors because resection affords both diagnosis and therapeutic benefits. Although many factors affect patient outcome and overall survival after surgery, patient performance status is a crucial factor and one that is strongly influenced by surgical complications.1 With the increased focus on surgical quality and outcomes, surgeon experience and its effect on outcomes is appreciated as a priority area for health research. The modern assessment of surgical experience and its effect on outcomes can be traced back to the early 1990s, when the New York State Department of Health initiated a cardiac surgery registry to monitor short-term outcomes related to individual surgeons.2, 3 In the early 2000s, seminal studies by Birkmeyer et al.4, 5 highlighted the importance of the volume–outcome relationship in many surgical areas.

In surgical neuro-oncology, there are an increasing number of studies assessing volume–outcome relationships.6, 7, 8, 9 However, these studies have been cross-sectional and have not investigated the impact of accumulated experience on outcomes. Our recent studies have shown the importance of cumulative 5-year volume in rectal surgery and lack of accumulated surgery effect in cholecystectomy.10 Therefore, accumulated experience might be important in some surgical areas and not critical in others. The aim of this study was to determine if 5-year surgeon cumulative and annual volumes have an impact on early postoperative outcomes in patients with primary and metastatic brain tumors.

Section snippets

Data Source

Our study used the New York Statewide Planning and Research Cooperation System (SPARCS). Established in 1979, SPARCS is an all-payer database that collects patient-level data from every hospital discharge, ambulatory surgery, outpatient service, and emergency department admission in New York State. The data contain patient demographics, diagnoses, procedures, length of stay, outcomes, and charges. Patients are assigned with unique encrypted identifiers to allow for longitudinal studies.

Study Population

Patients

Results

Our study included 10,258 patients and 479 surgeons from New York State between 2005 and 2014 (Supplementary Figure 1). Patients were allocated into 4 distinct groups according to their surgeon's cumulative and annual volume, which were LC/LA, LC/HA, HC/LA, and HC/HA.

The number of annual brain tumor resections remained constant from 1034 in 2005 to 982 in 2014 (P = 0.39, Figure 1). There was a moderate increase in surgeries performed by HC/HA volume surgeons, from 46.5% to 50.3% (P = 0.02, see

Discussion

This is the first study to clarify the relationship of both cumulative and annual volume on postoperative patient outcomes after craniotomies for brain tumor resection. We used a comprehensive New York State cohort that included all patients undergoing surgery from 2005 to 2014. This data set was unique in that it provided for longitudinal analysis rather than the more standard cross-sectional assessment. This analysis allowed for the assessment of the effects of annual versus accumulated

References (14)

  • E.L. Hannan et al.

    New York State's Cardiac Surgery Reporting System: four years later

    Ann Thorac Surg

    (1994)
  • J.S. Abelson et al.

    Evaluating cumulative and annual surgeon volume in laparoscopic cholecystectomy

    Surgery

    (2017)
  • K.R. Lamborn et al.

    Prognostic factors for survival of patients with glioblastoma: recursive partitioning analysis

    Neuro Oncol

    (2004)
  • Cardiovascular Disease Data and Statistics

  • J.D. Birkmeyer et al.

    Surgeon volume and operative mortality in the United States

    N Engl J Med

    (2003)
  • J.D. Birkmeyer et al.

    Hospital volume and surgical mortality in the United States

    N Engl J Med

    (2002)
  • V.T. Trinh et al.

    Surgery for primary supratentorial brain tumors in the United States, 2000-2009: effect of provider and hospital caseload on complication rates

    J Neurosurg

    (2015)
There are more references available in the full text version of this article.

Cited by (16)

  • High-Value Care Outcomes of Meningiomas

    2023, Neurosurgery Clinics of North America
  • Interhospital transfer of patients with malignant brain tumors undergoing resection is associated with routine discharge

    2022, Clinical Neurology and Neurosurgery
    Citation Excerpt :

    Another limitation of the NRD is the lack of data on referring hospitals to inform reasons for transfer. The NRD also does not provide data on specific surgeons, which could be a factor to consider as provider volume can also impact outcomes [26–28]. In our analysis of NRD patients undergoing resection of malignant brain tumors, IHT was independently associated with routine discharge and prolonged LOS and was not associated with in-hospital mortality.

  • Hospital Case-Volume and Patient Outcomes Following Pediatric Brain Tumor Surgery in the Pediatric Health Information System

    2022, Pediatric Neurology
    Citation Excerpt :

    One of the most well-known examples of this is coronary artery bypass graft surgery in the field of cardiac surgery.3 This volume-outcome effect has also been shown for children undergoing vascular neurosurgical procedures4,5 and for surgical neuro-oncologic outcomes overall.6,7 A child burdened with the diagnosis of a brain tumor will not only require surgery but also potentially other complex interventions and adjuvant therapies.

  • Intraoperative Use and Benefits of Tractography in Awake Surgery Patients

    2020, World Neurosurgery
    Citation Excerpt :

    The main limitation of the present study was the highly heterogeneous histologic features of the tumors studied. Some studies have reported fewer neurological and medical complications in patients treated at a high-volume center.30-32 Regarding the present study, the greater technical skills obtained over time by the surgical team could have influenced the data, nevertheless the main surgeon is a senior oncological neurosurgeon in our department and had been well trained in the procedure before the present study had begun.

View all citing articles on Scopus

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. This work was funded by the Empire Clinical Research Investigators Program.

View full text