Abstract
Objective:
To examine the relationship between surgeon volume and operative morbidity and mortality for laryngectomy.
Data Sources:
The Nationwide Inpatient Sample was used to identify 45,156 patients who underwent laryngectomy procedures for laryngeal or hypopharyngeal cancer between 2001–2011. Hospital and surgeon laryngectomy volume were modeled as categorical variables.
Methods:
Relationships between hospital and surgeon volume and mortality, surgical complications, and acute medical complications were examined using multivariable regression.
Results:
Higher-volume surgeons were more likely to operate at large, teaching, nonprofit hospitals and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, admitted electively, and to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Surgeons treating more than 5 cases per year were associated with lower odds of medical and surgical complications, with a greater reduction in the odds of complications with increasing surgical volume. Surgeons in the top volume quintile (>9 cases/year) were associated with a decreased odds of in-hospital mortality (OR=0.09 [0.01–0.74]), postoperative surgical complications (OR=0.58 [0.45–0.74]), and acute medical complications (OR=0.49 [0.37–0.64]). Surgeon volume accounted for 95% of the effect of hospital volume on mortality and 16–47% of the effect of hospital volume on postoperative morbidity.
Conclusion:
There is a strong volume-outcome relationship for laryngectomy, with reduced mortality and morbidity associated with higher surgeon and higher hospital volumes. Observed associations between hospital volume and operative morbidity and mortality are mediated by surgeon volume, suggesting that surgeon volume is an important component of the favorable outcomes of high-volume hospital care.
Keywords: volume, surgeon, laryngeal neoplasms, larynx cancer, laryngectomy, squamous cell cancer, surgery, Nationwide Inpatient Sample
Introduction
There is a favorable volume-outcome relationship between hospital volume and patient outcomes for complex surgical procedures1–4, including cancer surgery. For a number of high-risk, low-volume surgical procedures, high-volume hospital care is associated with improved morbidity and mortality. These observations have led to the adoption of minimum volume standards for select procedures with a strong volume-outcome association by purchasers such as the Leapfrog Group1,5 and institutions such as Johns Hopkins Medicine, Dartmouth-Hitchcock Medical Center, and the University of Michigan Health System.6 These initiatives link established volume-outcome relationships to stakeholder goals of ensuring that healthcare investments are tied to demonstrably improved outcomes.
For laryngeal cancer, high-volume hospital care is associated with improved short-and long-term morbidity and mortality.7–15 Laryngectomy surgery has increasingly become a low-volume, high-risk procedure because of a documented trend of increased use of primary chemoradiation, with an increase in cases performed for salvage rather than as primary treatment with resulting increased complexity and a corresponding decrease in procedures performed even at tertiary care institutions that limits trainee exposure.9,16 We have previously demonstrated that a minimum hospital volume threshold for laryngectomy is associated with reduced postoperative morbidity, with higher volumes associated with decreased mortality.17 While hospital volume can serve as a proxy measure for outcomes,18 it may not accurately reflect process measures of care including patient selection, preoperative evaluation, guideline adherence, and surgeon experience. For some technically complex procedures, surgeon volume explains a large proportion of the effect of hospital volume, with reduced morbidity and mortality with increasing experience.19 We undertook the present study to examine the relationship between surgeon volume and operative morbidity and mortality for laryngectomy and determine if the association between hospital volume and outcomes are modified by surgeon volume.
Methods
A cross-sectional analysis of patients with a diagnosis of laryngeal or hypopharyngeal cancer was performed using discharge data from the Nationwide Inpatient Sample (NIS), the largest all-payer inpatient care database in the United States, containing data from approximately 8 million hospital stays each year from a stratified sample of 20% of non-federal U.S. hospitals from participating states. The NIS database provides information regarding the index hospital admission and includes patient demographic data, primary and secondary diagnoses, primary and secondary procedures, hospital characteristics, and inpatient and discharge mortality rates. International Classification of Disease, 9th revision (ICD-9) codes were used to identify adult patients (≥18 years of age) who specifically underwent laryngectomy for a malignant laryngeal or hypopharyngeal neoplasm for the years 2001 to 2011, as previously described.17 Additional procedures such as neck dissection or pedicled or free flap reconstruction were recorded. Prior irradiation was obtained from the codes for previous exposure to therapeutic or other ionizing radiation (ICD-9).
The primary clinical endpoints (dependent variables) were inpatient mortality and postoperative complications. We used ICD-9 codes for specific comorbid illnesses to create categories for acute medical and surgical complications. Acute medical complications were defined using codes for acute cardiac events, acute pulmonary edema or failure, acute renal failure, acute hepatic failure, acute cerebrovascular events, sepsis, pneumonia, gastrointestinal bleeding, deep venous thrombosis/pulmonary embolism, and urinary tract infection assigned at the time of hospital discharge, as previously described.17 Surgical complications were defined using codes for complications directly resulting from surgical procedures assigned at the time of hospital discharge.17
Hospital volume was examined as an independent variable, as previously described.17 The average annual number of laryngectomy cases performed per year of surgical activity was calculated from the mean of the number of cases performed each year for each individual hospital, for the years in which that hospital performed at least one laryngectomy. Annual volumes were divided into quintiles, with high volume defined as those above the 80th percentile. Based on the quintile distribution of annual number of cases per hospital, hospitals were categorized as very low-volume (≤3 cases/year), low-volume (4–6 cases/year), medium-volume (7–15 cases/year), high-volume (16–28 cases/year), or very high-volume (>28 cases/year). Surgeon volume was similarly defined, resulting in a quintile distribution that categorized surgeon volume as very low-volume (1 case/year), low-volume (2 cases/year), medium-volume (3–5 cases/year), high-volume (6–9 cases/year) or very high-volume (>9 cases/year).
Secondary independent variables included were age, sex, race, payer source (commercial, health maintenance organization [HMO], Medicare, Medicaid, self-pay, or other), procedure, nature of admission (emergent/urgent, or elective), hospital ownership/control (not-for-profit or other), hospital bed size, hospital location (rural or urban), geographic region, hospital teaching status, prior radiation, and comorbidity. Comorbidity was graded using the Romano adaptation of the Charlson comorbidity index, excluding ICD-9 codes for the index cancer diagnosis from the solid tumor category, as previously described.9 As cancer staging information is not available in the NIS, ICD-9 codes for metastases were excluded as these are not a reliable surrogate for disease stage.
Data were analyzed using Stata 16 (StataCorp, College Station, TX). Associations between variables were analyzed using cross-tabulations and multivariable logistic regression. Data were weighted and modified hospital and discharge weights to correct for changes in sampling over time were applied. Variance estimation was performed using procedures for survey data analysis with replacement. Strata with one sampling unit were centered at the population mean. Variables with missing data for more than 10% of the population were coded with a dummy variable to represent the missing data in regression analysis. The primary clinical endpoints were evaluated using multivariable logistic regression analysis. To assess the relative contribution of surgeon and hospital volume to observed associations with hospital or surgeon volume, the attenuation of the odds ratio (OR) was computed as [ORH-ORHS]/[ORH-1], where ORH was the OR for the outcome of interest for a given hospital volume without adjusting for surgeon volume and ORHS was the OR for the outcome of interest for a given hospital volume after adjustment for surgeon volume; similar computations were made for high-volume surgeon care.19 This protocol was approved as exempt by the Johns Hopkins University School of Medicine Institutional Review Board.
Results
There were 45,156 cases in 2001–2011 performed at 5,516 hospitals, whose demographic information have previously been described17. Surgeon identifiers were available for 48% of cases (Table 1). Missing cases were evenly distributed across all hospital volume categories. High-volume surgeons comprised 2.7% of all surgeons and performed 19.2% of laryngectomy procedures, while 64.2% of surgeons were low-volume surgeons and performed 26.5% of all laryngectomy procedures (Figure 1). Higher-volume surgeons were more likely to operate at teaching hospitals, nonprofit hospitals, and hospitals with large bed size, and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, and admitted electively. The extent of surgery varied by volume, with higher volume surgeons more likely to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Low-volume surgeons were more likely to operate at low-volume hospitals, and high-volume surgeons were more likely to operate at high-volume hospitals: no surgeon in the top volume quintile operated at very low and low volume hospitals. Surgeons treating more than 5 cases/year were associated with lower odds of medical and surgical complications, with a greater reduction in rate of complications with increasing surgical volume (Figure 2). Rates of postoperative complications and mortality were lowest for hospitals in the top volume quintile.
Table 1.
Population characteristics (%)
| Surgeon Volume Quintile | |||||
|---|---|---|---|---|---|
| Very Low 1 case/yr (N=5,813) |
Low 2 cases/yr (N=3,457) |
Medium 3–5 cases/yr (N=3,955) |
High 6–9 cases/yr (N=4,362) |
Very High >9 cases/yr (N=4,211) |
|
| Primary Site | |||||
| Larynx | 92.4 | 92.4 | 89.1 | 88.7 | 87.7 |
| Hypopharynx | 7.6 | 7.6 | 10.9 | 11.3 | 12.3 |
| Age Group | |||||
| ≤40 years | 1.6 | 1.6 | 1.9 | 1.9 | 2.3 |
| 40–64 years | 50.4 | 53.3 | 56.1 | 56.3 | 54.4 |
| 65–80 years | 41.6 | 40.3 | 37.5 | 38.4 | 37.6 |
| >80 years | 6.4 | 4.7 | 4.5 | 3.4 | 5.7 |
| Race | |||||
| White | 78.9 | 78.4 | 80.5 | 78.5 | 82.3 |
| Black | 14.0 | 13.7 | 12.5 | 12.4 | 9.2 |
| Hispanic | 4.7 | 5.1 | 3.2 | 6.2 | 6.0 |
| Asian/Pacific Islander | 0.5 | 0.1 | 0.9 | 1.3 | 1.0 |
| Other | 1.9 | 2.7 | 2.9 | 1.6 | 1.5 |
| Sex | |||||
| Male | 80.1 | 81.1 | 82.7 | 79.3 | 79.8 |
| Female | 19.9 | 18.9 | 17.3 | 20.7 | 20.2 |
| Nature of Admission | |||||
| Elective | 75.0 | 77.9 | 81.8 | 83.2 | 87.3 |
| Urgent/emergent | 25.0 | 22.1 | 18.2 | 16.8 | 12.7 |
| Comorbidity Score | |||||
| 0 | 44.5 | 47.5 | 53.6 | 56.5 | 60.8 |
| 1 | 36.0 | 34.9 | 33.0 | 29.9 | 26.1 |
| 2 | 15.5 | 11.2 | 10.1 | 10.5 | 9.1 |
| ≥3 | 4.0 | 6.4 | 3.3 | 3.1 | 4.0 |
| Payor | |||||
| Private/HMO | 29.7 | 31.4 | 30.2 | 34.2 | 37.9 |
| Medicare | 47.2 | 45.4 | 43.5 | 42.0 | 43.1 |
| Medicaid | 14.1 | 15.3 | 16.2 | 15.3 | 13.8 |
| Other | 9.0 | 7.9 | 10.1 | 8.5 | 5.2 |
| Teaching Status | |||||
| Non-teaching hospital | 43.2 | 39.7 | 21.6 | 4.1 | 0 |
| Teaching hospital | 56.8 | 60.3 | 78.4 | 95.9 | 100.0 |
| Hospital ownership | |||||
| Not-for profit | 88.4 | 89.2 | 96.1 | 97.7 | 100.0 |
| Other | 11.6 | 10.8 | 3.9 | 2.3 | 0 |
| Hospital location | |||||
| Rural | 6.1 | 8.5 | 5.0 | 4.3 | 4.5 |
| Urban | 93.8 | 91.5 | 95.0 | 95.7 | 95.5 |
| Hospital bed size | |||||
| Small | 8.5 | 8.3 | 9.3 | 10.8 | 13.3 |
| Medium | 23.3 | 23.3 | 24.1 | 18.2 | 11.0 |
| Large | 68.2 | 68.5 | 66.6 | 70.9 | 75.7 |
| Prior radiation | |||||
| No | 96.7 | 96.3 | 96.0 | 90.0 | 93.0 |
| Yes | 3.3 | 3.7 | 4.0 | 10.0 | 7.0 |
| Procedure | |||||
| Partial laryngectomy | 16.5 | 16.9 | 16.7 | 15.1 | 25.6 |
| Total laryngectomy | 83.5 | 83.1 | 83.3 | 84.9 | 74.4 |
| Flap | |||||
| No | 95.3 | 93.5 | 91.3 | 85.7 | 88.4 |
| Yes | 4.6 | 6.5 | 8.7 | 14.3 | 11.6 |
| Neck dissection | |||||
| No | 87.6 | 88.4 | 86.2 | 81.7 | 77.9 |
| Yes | 12.4 | 11.6 | 13.8 | 18.3 | 22.1 |
| Medical complication | |||||
| No | 69.9 | 74.9 | 78.5 | 82.1 | 83.7 |
| Yes | 30.1 | 25.1 | 21.5 | 17.9 | 16.3 |
| Surgical complication | |||||
| No | 63.0 | 66.2 | 68.0 | 72.7 | 75.6 |
| Yes | 37.0 | 33.8 | 32.0 | 27.3 | 24.4 |
| In-hospital death | |||||
| Died in hospital | 1.2 | 0.9 | 0.4 | 1.3 | 0.1 |
Figure 1.
Distribution of cases by hospital and surgeon volume quintile. Surgeons in the top volume quintile comprised 2.7% of all surgeons and performed 19.2% of laryngectomy procedures, while 64.2% of surgeons were in the bottom volume quintile and performed 26.5% of all laryngectomy procedures. Hospitals in the top volume quintile represented 1.7% of all hospitals and performed 19.4% of laryngectomy procedures, while 68.2% of hospitals were in the bottom volume quintile and performed 30.0% of all laryngectomy procedures. Low volume surgeons were more likely to operate at low volume hospitals, and high-volume surgeons were more likely to operate at high volume hospitals: no surgeon in the top volume quintile operated at very low and low volume hospitals.
Figure 2.
In-hospital mortality, surgical complication, and acute medical complication rates by hospital and surgeon volume quintile.
Multiple logistic regression analysis of variables associated with in-hospital mortality, postoperative surgical complications, and acute medical complications demonstrated that compared to surgeons in the bottom quintile, those in the top volume quintile (>9 cases/year) were significantly associated with a lower odds for in-hospital death (OR=0.09 [0.01–0.74]), and the lowest odds of postoperative surgical complications (OR=0.58 [0.50–0.79]), and acute medical complications (OR=0.63 [0.48–0.81]), after controlling for all other variables (Table 2). Surgeons treating more than 5 cases/year also had lower odds of postoperative complications but were not associated with differences in in-hospital mortality. Adjusting for hospital volume attenuated the strength of the associations between surgeon volume and complications, but the association with surgeon volume remained significant. Adjusting for hospital volume had no effect on the association between high surgeon volume and mortality.
Table 2.
Adjusted odds ratio for surgical morbidity and mortality, by surgeon and hospital volume.
| Surgeon Volume, Unadjusted for Hospital Volume | Surgeon Volume, Adjusted for Hospital Volume | Proportion of Effect of Surgeon Volume Attributable to Hospital Volume | Hospital Volume, Unadjusted for Surgeon Volume | Hospital Volume, Adjusted for Surgeon Volume | Proportion of Effect of Hospital Volume Attributable to Surgeon Volume | |
|---|---|---|---|---|---|---|
| Odds Ratio (95% CI) | % | Odds Ratio (95% CI) | % | |||
| In-hospital death | ||||||
| Medium volume | 0.35 (0.11–1.10) | 0.32 (0.11–0.90) | ¥ | 0.63 (0.29–1.34) | 1.20 (0.21–6.74) | ¥ |
| High-volume | 1.01 (0.33–3.05) | 0.87 (0.21–3.53) | ¥ | 0.54 (0.25–1.12) | 1.79 (0.51–6.22) | ¥ |
| Very high-volume | 0.09 (0.01–0.74) | 0.07 (0.01–0.65) | 0 | 0.45 (0.23–0.88) | 0.97 (0.28–3.29) | 95 |
| Postoperative surgical complications | ||||||
| Medium volume | 0.89 (0.71–1.10) | 0.91 (0.74–1.13) | ¥ | 0.81 (0.66–0.98) | 0.90 (0.67–1.21) | 47 |
| High-volume | 0.67 (0.51–0.87) | 0.73 (0.55–0.96) | 18 | 0.72 (0.58–0.88) | 0.78 (0.59–1.08) | 21 |
| Very high-volume | 0.58 (0.45–0.74) | 0.66 (0.50–0.88) | 19 | 0.63 (0.50–0.79) | 0.70 (0.54–0.92) | 19 |
| Acute medical complications | ||||||
| Medium volume | 0.72 (0.56–0.93) | 0.80 (0.62–1.02) | 29 | 0.74 (0.59–0.92) | 0.69 (0.48–0.99) | 0 |
| High-volume | 0.55 (0.41–0.72) | 0.67 (0.49–0.92) | 27 | 0.65 (0.51–0.83) | 0.58 (0.42–0.81) | 0 |
| Very high-volume | 0.49 (0.37–0.64) | 0.63 (0.45–0.87) | 27 | 0.63 (0.48–0.81) | 0.69 (0.49–0.98) | 16 |
there was no statistically significant effect of volume.
Similarly, hospitals in the top volume quintile (>28 cases/year) were significantly associated with a lower odds for in-hospital death (OR=0.45 [0.23–0.88]), and the lowest odds of postoperative surgical complications (OR=0.63 [0.50–0.79]), and acute medical complications (OR=0.63 [0.48–0.81]), after controlling for all other variables (Table 2). Hospitals treating more than 6 cases/year also had lower odds of surgical and acute medical complications but were not associated with differences in in-hospital mortality. Adjusting for surgeon volume markedly attenuated the strength of the association between volume and in-hospital mortality, and the association between hospital volume and mortality became insignificant. Adjusting for surgeon volume attenuated the strength of the association between hospital volume and surgical complications, with only hospitals in the top-volume quintile remaining significantly associated with surgical complications. Adjusting for surgeon volume had the smallest effect on the association between hospital volume and acute medical complications, only attenuating the association between hospitals in the top-volume quintile and acute medical complications, with hospital volume remaining significant.
Discussion
These data demonstrate that there is a significant association between volume and outcomes for laryngectomy surgery, with minimum hospital and surgeon volume thresholds associated with reduced mortality and morbidity. While both high-volume hospitals and high-volume surgeons were associated with reduced morbidity and mortality, surgeon volume accounted for 95% of the apparent effect of high-volume hospital care on in-hospital mortality and modified the association between hospital volume and postoperative surgical complications. Hospital volume attenuated the association between surgeon volume and postoperative medical and to a lesser extent, surgical complications, but had no impact on the association between surgeon volume and mortality. These data suggest that for laryngectomy, high-volume surgeon volume care is a significant predictor of postoperative outcomes, with surgeon volume having the greatest impact on postoperative mortality.
This is the first analysis to our knowledge of surgeon volume thresholds for a specific procedure of interest in head and neck cancer surgery, excluding thyroidectomy.20–23 A relationship between surgeon volume and outcomes is well established for high-risk, complex abdominal, thoracic, and vascular procedures,24,25 and minimum hospital and surgeon volume standards for select procedures have been endorsed by the Leapfrog Group and their member health care institutions.5,26 The Leapfrog Group is a consortium of major companies and other private and public healthcare purchasers whose members leverage health care purchasing by incentivizing adherence to published measures of health care quality, including minimum hospital and surgeon volume standards known to be associated with outcomes.5 Data is more limited for head and neck cancer surgery, but there is a recognized association between hospital volume and short- and long-term survival.13,27 The lower short-term mortality associated with head and neck cancer surgery performed at high-volume hospitals appears to be associated with differences in the response to and management of complications, suggesting that volume is a proxy for process measures that impact outcomes of care.28
The majority of evidence supporting a volume-outcome relationship for head and neck cancer surgery is not diagnosis- or procedure-specific, and primarily focuses on hospital volumes. For larynx cancer surgery, high-volume hospital care has been shown to be associated with greater patient complexity, greater extent of surgery, lower short- and long-term mortality, and an increased likelihood of high-quality treatment using evidenced-based guidelines for laryngeal cancer care. However, even after controlling for quality of care, there remains a survival advantage for high-volume hospital care, and a minimum volume threshold appears necessary for quality measurement.29,30 That threshold ranges from 6 to 12 cases per year and combines a variety of procedures, which may not all be sensitive to volume or even process measures.9,15,30 The ideal target for hospital volume as a proxy measure for outcomes are high-risk, low-volume procedures with wide variation in outcomes across hospitals.28
We have previously reported that there is a significant volume-outcome relationship for laryngectomy, with improved outcomes seen with increasing hospital volume. Laryngectomy is increasingly a low-volume, high-risk procedure because of several interrelated factors. The increasing use of chemoradiation as primary treatment has made laryngectomy a far less common operation than it was two decades ago, and when laryngectomy is performed, it is increasingly performed for salvage.9,31–33 Salvage laryngectomy usually requires a free or pedicled flap to reconstruct radiated tissue to reduce wound healing complications and preserve some degree of swallowing function.9,34 Because of this increased case complexity, laryngectomy surgery has become increasingly centralized at higher-volume hospitals, yet case numbers have decreased such that laryngectomy is no longer used as a key indicator case for otolaryngology residency training.16 Given these factors, hospital volume may not accurately reflect process measures of care for laryngectomy including patient selection, preoperative evaluation, guideline adherence, and surgeon experience.
In the present study, we found that surgeon volume explained a large proportion of the effect of hospital volume on laryngectomy outcomes, with reduced morbidity associated with a minimum volume threshold of 5 cases/year, and a minimum surgeon volume threshold of 9 cases/year explained 95% of the effect of hospital volume on mortality. These data suggest that there is an effect of surgeon experience on outcomes that is independent of hospital volume and likely influences patient selection, preoperative evaluation and preparation, technical skill, and postoperative care. Higher surgeon volumes have been reported to be associated with greater adherence to guideline-recommended processes of care for head and neck cancer including preoperative multidisciplinary consultation, which in turn may impact the decision to perform surgery and the extent of surgery.35 Technical ability can influence the success of surgery: higher lymph node yield from neck dissection is associated with survival36–38 and has been shown to be more likely with experienced surgeons.11 Our data suggest that both high-volume surgeons and hospitals are associated with more favorable postoperative outcomes for laryngectomy, but that the effect on mortality is largely explained by surgeon volume. Further study is warranted to better define the specific process measures associated with high-volume surgeon care that may contribute to this observation.
These data suggest that the use of minimum surgeon volume standards for laryngectomy surgery may improve outcomes, but the implementation of such a policy raises issues of practicality and access. The regionalization of head and neck cancer treatment to improve outcomes has been implemented in Canada, but requires significant resources to support travel burden, infrastructure requirements, and the impact on practice volume loss on low-volume surgeons.12,27,39 In the US, recent data suggests that regionalization in this country may result in fragmented care and negatively impact survival.40 The sickest and most socioeconomically disadvantaged head and neck cancer patients have been shown to be the least able to travel to high-volume academic medical centers for treatment.41 Because a significant proportion of laryngectomy surgeries are still performed at low-volume centers by low-volume surgeons, identifying and translating the practices of high-volume surgeons through national-level education efforts and guideline development offers the most balanced approach to improve national laryngectomy outcomes in an era when volumes are dropping and case complexity is rising.
There are several well-known limitations to the use of administrative hospital discharge data which may impact our findings. Case mix adjustment including identification of comorbid conditions is limited to discharge diagnosis codes. The NIS database is limited to a 30-day postoperative window and does not contain information about stage, prior treatment, or readmission, which could impact surgical care and both short and long-term outcomes. Process measures related to perioperative care and decision-making cannot be determined from administrative data. Secondary procedures, prior treatment with radiation, and postoperative complications not identified at the time of discharge may be underreported. Furthermore, the 2001–2011 data were chosen to match and allow for comparison with our group’s prior work demonstrating hospital volume’s relationship to outcomes using this cohort of patients. While the clinical landscape of laryngeal cancer has changed in the last 10–20 years, with higher volumes of more technically challenging salvage surgery and lower overall trainee exposure, we believe these do not change the fundamental factors at play, and if anything, would lead to a underestimate of the importance of surgeon volume. Finally, unique surgeon identifiers were not available for all patients, and for those who it was, generally only includes the ablative surgeon by convention. This did limit analysis of surgeon volume to a subset of patients that may not accurately represent all surgeons performing laryngectomy and could bias results towards ablative surgical volumes. Despite these limitations, the NIS is the largest US inpatient surgical database that includes hospital- and surgeon-level data and represents the spectrum of the US medical system, from community to academic, reflecting real world practices.
Conclusion
These data demonstrate a strong volume-outcome relationship for laryngectomy, with reduced morbidity and mortality associated with higher surgeon and higher hospital volumes. The observed associations between hospital volume and postoperative morbidity and in particular, mortality, were mediated by surgeon volume. This study suggests that a critical component of the benefit of high-volume hospital care in laryngectomy may be the case volume of the individual surgeon.
Acknowledgments
AS is supported by the National Institute for Deafness and Communication Disorders training grant 2T32DC000027.
Footnotes
Financial disclosures: nothing to disclose
Conflict of interest: none
Level of Evidence: 4
References
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