Variation in esophagectomy outcomes in hospitals meeting Leapfrog volume outcome standards

Abstract

Background: The Leapfrog Group established a minimum hospital case volume of 13 for esophageal resection in a response to known improved outcomes in larger volume centers. The aim of this study was to evaluate variation in short-term outcomes among hospitals that met the Leapfrog volume criteria.

Methods: Using the Washington State Comprehensive Hospital Abstract Reporting System, a retrospective cohort design evaluated all patients (≥18 years) undergoing esophageal resection for any diagnosis since the introduction of Leapfrog standards (2000 to 2007). The main outcome measures were hospital stay, readmissions within 30 days of discharge, discharge to an institutional care facility, operative reinterventions, and 90-day mortality.

Results: A total of 1,505 adult Washington state residents underwent esophageal resection without complex reconstruction (1,352 elective [89.8%]). Of 45 hospitals reporting at least one procedure, 5 (11%) met Leapfrog volume standards. Leapfrog hospitals accounted for 62% of the total elective volume. Overall, elective patients at Leapfrog hospitals had a lower adjusted risk of death compared with those at hospitals that did not meet criteria (odds ratio 0.50, p = 0.02). Across the different Leapfrog hospitals there was over fivefold variation in 90-day mortality (1.7% to 10.2%), 2.5-fold variation in reinterventions (8% to 20%), and fourfold variation in discharges to an institutional care facility (5.3% to 19.8%). Length of stay and readmission rate varied less.

Conclusions: Although referral to high-volume centers has been an important advance for complex surgical procedures, there is still a substantial degree of variability in outcomes among hospitals that met Leapfrog volume criteria for esophagectomy. Metrics such as process, individual surgeon volume, and risk-adjusted outcome measures may yield further opportunities for quality improvement that extend beyond hospital volume-based assessments.