Surgical specialization and operative mortality in hepato-pancreatico-biliary (HPB) surgery

Introduction Surgeon specialization has been shown to result in improved outcomes but may not be the sole measure of surgical quality in hepato-pancreato-biliary (HPB) surgery. We attempted to determine which factors predominate in optimal patient outcomes between volume, surgeon, and hospital resources. Methods All non-transplant pancreatic (n=7195) and liver operations (n=4809) from the Nationwide Inpatient Sample (NIS) were examined from 1998-2005. Surgeons and hospitals were divided into two groups, transplant (TX) or non-transplant (non-TX), using the unique surgeon and hospital identifier of NIS. A logistic regression model examined the relationship between factors while accounting for patient and hospital factors. Results We identified 4,355 primary surgeons (165 TX, 4,190 non-TX) who performed HPB surgery in 675 hospitals across 12 different states. Non-TX surgeons performed the majority of pancreatic (97%) and liver procedures (81%). There was no difference in mortality after HPB surgery depending on surgeon specialty (p=0.59). Factors for inpatient death after HPB surgery included increasing age, male gender, and public insurance (p < 0.05). In addition, surgery performed at a TX center had a 21% lower odds of perioperative mortality. Discussion Non-TX surgeons performed the majority of pancreatic and liver surgery in the US. Hospital factors like support of transplantation but not surgical specialty, appeared to impact operative mortality. Future regulatory benchmarks should consider these types of center-based facilities and resources to assess patient outcomes.