Effects of Physician Volume on Readmission and Mortality in Elderly Patients with Heart Failure: Nationwide Cohort Study

PURPOSE: Readmission and mortality rates of patients with heart failure are good indicators of care quality. To determine whether hospital resources are associated with care quality for cardiac patients, we analyzed the effect of number of physicians and the combined effects of number of physicians and beds on 30-day readmission and 1-year mortality. MATERIALS AND METHODS: We used national cohort sample data of the National Health Insurance Service (NHIS) claims in 2002–2013. Subjects comprised 2345 inpatients (age: >65 years) admitted to acute-care hospitals for heart failure. A multivariate Cox regression was used. RESULTS: Of the 2345 patients hospitalized with heart failure, 812 inpatients (34.6%) were readmitted within 30 days and 190 (8.1%) had died within a year. Heart-failure patients treated at hospitals with low physician volumes had higher readmission and mortality rates than high physician volumes [30-day readmission: hazard ratio (HR)=1.291, 95% confidence interval (CI)=1.020–1.633; 1-year mortality: HR=2.168, 95% CI=1.415–3.321]. Patients admitted to hospitals with low or middle bed and physician volume had higher 30-day readmission and 1-year mortality rates than those admitted to hospitals with high volume (30-day readmission: HR=2.812, 95% CI=1.561–5.066 for middle-volume beds & low-volume physicians, 1-year mortality: HR=8.638, 95% CI=2.072–36.02 for middle-volume beds & low-volume physicians). CONCLUSION: Physician volume is related to lower readmission and mortality for heart failure. Of interest, 30-day readmission and 1-year mortality were significantly associated with the combined effects of physician and institution bed volume.

The Association of Hospital Volume of Percutaneous Coronary Intervention with Cardiac Mortality / 보건행정학회지

BACKGROUND: This study investigates the potential volume and outcome association of coronary heart disease (CHD) patients who have undergone percutaneous coronary intervention (PCI) using a large and representative sample. METHODS: We used a National Health Insurance Service-Cohort Sample Database from 2002 to 2013 released by the Korean National Health Insurance Service. A total of 8,908 subjects were analyzed. The primary analysis was based on Cox proportional hazards models to examine our hypothesis. RESULTS: After adjusting for confounders, the hazard ratio of thirty-day and 1-year mortality in hospitals with a low volume of CHD patients with PCI was 2.8 and 2.2 times higher (p=0.00) compared to hospitals with a high volume of CHD patients with PCI, respectively. Thirty-day and 1-year mortality of CHD patients with PCI in low-volume hospitals admitted through the emergency room were 3.101 (p=0.00) and 2.8 times higher (p=0.01) than those in high-volume hospitals, respectively. Only 30-day mortality in low-volume hospitals of angina pectoris and myocardial infarction patients with PCI was 5.3 and 2.4 times those in high-volume hospitals with PCI, respectively. CONCLUSION: Mortality was significantly lower when PCI was performed in a high-volume hospital than in a low-volume hospital. Among patients admitted through the emergency room and diagnosed with angina pectoris, total PCI volume (low vs. high) was associated with significantly greater cardiac mortality risk of CHD patients. Thus, There is a need for better strategic approaches from both clinical and health policy standpoints for treatment of CHD patients.

Anesthetic Experiences of Liver Transplantation in a New Low Volume Hospital: Ewha Womans University Mokdong Hospital / 이화의대지

OBJECTIVES: Liver transplantation (LT) is the only treatment for end stage of liver failure. In Korea, annually it has been performed 1,300 cases. Most of LTs are performed in large volumes centers. More than half of centers performing LT in Korea are low volume hospital and started a LT program recently. We present our four-year experiences and outcomes of anesthesia for LT since 2013. METHODS: Anesthetic and surgical outcomes of 49 consecutive patients who received LT (living donor LT, 21 cases; deceased donor LT, 28 cases) between April 2013 and April 2017 were analyzed retrospectively. RESULTS: All patients were adult, with the mean age of 53.5±9.2 years. The most common cause of original liver diseases was hepatitis B virus-related liver cirrhosis (40.8%). The mean MELD (Model for End-stage Liver Disease) score was 18.8±10.7. Postreperfusion syndrome was observed in 34.7%, which were all controlled by calcium, norepinephrine, ephedrine and epinephrine. The mean postoperative intensive care unit stay of deceased donor LT recipients (13.6±9.0 days) was significantly longer than that of living donor LT recipients (8.0±3.3 days). There was no intraoperative mortality in patients receiving LT. Thirty-day post-transplant survival rate was 93.8% and 3-year survival rate was 88.6 %. The most common postoperative complication was pneumonia. CONCLUSION: We have started LT successfully with multidisciplinary team's steady effort. Adaptation and setting up LT protocol, adequate equipment, proper training at established transplant centers are essential to begin a successful LT program.

Feasibility of Gastric Cancer Surgery at Low Volume Hospitals

PURPOSE: Most gastric cancer patients undergo operations at large tertiary hospitals in Korea. However, some patients are treated at low volume hospitals. We investigated patient outcomes after gastric surgery at a secondary hospital and compared with outcomes of large volume centers. MATERIALS AND METHODS: We included 184 patients who underwent gastric surgery for gastric cancer at our hospital from January 2003 to December 2008. We conducted a retrospective study and evaluated the clinicopathological characteristics, clinical outcomes and survival rate of patients. RESULTS: Mean age was 61.7 years old. Male to female ratio was 2.2 : 1. Proportion of early gastric cancer was 38.6% and that of advanced gastric cancer was 61.4%. The 5 year overall survival rate of 184 patients was 66.3%. The overall survival rate was significantly lower for people over 62 years old. The morbidity rate and mortality at our hospital were 10.3% and 0.5%, respectively. CONCLUSIONS: The overall survival rate, morbidity and mortality were similar to those of the previous reports from Korea. Treatment of gastric cancer at a secondary hospital is feasible and safe. Standardization of operations and management of gastric cancer patients of the Korean Gastric Cancer Association is the most important factor to achieve these outcomes.

Feasibility of Gastric Cancer Surgery at Low Volume Hospitals

PURPOSE: Most gastric cancer patients undergo operations at large tertiary hospitals in Korea. However, some patients are treated at low volume hospitals. We investigated patient outcomes after gastric surgery at a secondary hospital and compared with outcomes of large volume centers. MATERIALS AND METHODS: We included 184 patients who underwent gastric surgery for gastric cancer at our hospital from January 2003 to December 2008. We conducted a retrospective study and evaluated the clinicopathological characteristics, clinical outcomes and survival rate of patients. RESULTS: Mean age was 61.7 years old. Male to female ratio was 2.2 : 1. Proportion of early gastric cancer was 38.6% and that of advanced gastric cancer was 61.4%. The 5 year overall survival rate of 184 patients was 66.3%. The overall survival rate was significantly lower for people over 62 years old. The morbidity rate and mortality at our hospital were 10.3% and 0.5%, respectively. CONCLUSIONS: The overall survival rate, morbidity and mortality were similar to those of the previous reports from Korea. Treatment of gastric cancer at a secondary hospital is feasible and safe. Standardization of operations and management of gastric cancer patients of the Korean Gastric Cancer Association is the most important factor to achieve these outcomes.

A Study of Sixty Consecutive Whipple Procedure by Single Surgeon

PURPOSE: To review the current standards of pancreaticoduodectomies and show that excellent results can be achieved by a single surgeon. METHODS: A case series of consecutive patients, operated on during the period March 1999 to February 2003, were retrospectively evaluated. The patients' medical records were abstracted for demographic data, clinical presentation, operative indication, operative time, amount of transfusion, perioperative morbidity, mortality and other operative records. RESULTS: The average age was 57.5 years, ranging from 35 to 78. Jaundice was the main presenting symptom (68.3%) and preoperative PTBD was performed at 34 cases (56.7%). The most common indication for this procedure was cancer of the ampulla of Vater (28 cases, 47.3%) and the second was pancreatic head cancer (14 cases, 23.6%). A total of 60 patients underwent a pancreaticoduodectomy during the 4 year period. Fifty-three patients underwent a pylorus- preserving pancreaticoduodectomy (PPPD) and 5 a classical Whipple procedure. The operation lasted an average of 367 minutes, ranging from 250 to 555. The mean operative blood loss was 750 ml, ranging from 180 to 2400. About seventy- two percent of patients had no major complications, 28% had one or two more major complications and there was only one operative mortality (1.7%). The major morbidity was leakage of the pancreaticojejunostomy (5 cases, 8.3%). Delayed gastric emptying occurred in 6 patients. CONCLUSION: The above study demonstrates that a complicated procedure, such as the Whipple pancreaticoduodectomy, can be performed with excellent results by a single surgeon with sufficient experience. The most important prerequisite is that the surgeon be adequately trained in the procedure. In low-volume hospitals, the case load should be restricted to a minimal number of trained surgeons in order to concentrate the experience.

Relationship between Percutaneous Transluminal Coronary Angioplasty Volume and Associated Immediate Outcome / 예방의학회지

OBJECTIVES: To explore the relationship between Percutaneous Transluminal Coronary Angioplasty (PTCA) volume and the associated immediate outcome. METHODS: A total of 1,379 PTCAs were performed in 25 hospitals in Korea between October 1 and December 31 in 1997. Data from 1,317 PTCAs (95.5%) were collected through medical record abstraction. Inter-observer reliability of the data was examined using the Kappa statistic on a subsample of 110 PTCA procedures from five hospitals. Intra-observer reliability of the data was also examined. PTCA success and immediate adverse outcomes were selected as the outcome variables. A successful PTCA was defined as a case that shows less than 50% diameter stenosis and more than 20% reduction of diameter stenosis. Immediate adverse outcomes included deaths during the same hospitalization, emergency coronary artery bypass graft (CABG) within 24 hours after PTCA, and acute myocardial infarction within 24 hours after PTCA. The numbers of PTCAs performed in 1997 per hospital were used as the volume variables. RESULTS: Without adjusting for patient risk factors that may affect outcomes, procedures at high volume hospitals (200 cases per year) had a greater success rate (P=0.001) than low volume hospitals. There was a marginally significant difference (P=0.070) in major adverse outcome rates between high and low volume hospitals. After adjusting for risk factors, there were significant differences in procedural failure and major adverse outcome rates between high and low volume hospitals. CONCLUSIONS: After adjusting for patient clinical risk factors, the hospital volume of PTCA was associated with immediate outcomes. It is recommended that a PTCA volume per year be established in order to improve the immediate outcome of this procedure in Korea.