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Volume-Based Trends in Thyroid Surgery

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Volume-Based Trends in Thyroid Surgery ORIGINAL ARTICLE Volume-Based Trends in Thyroid Surgery Christine G. Gourin, MD; Ralph P. Tufano, MD; Arlene A. Forastiere, MD; Wayne M. Koch, MD; Timothy M. Pawlik, MD, MPH; Robert E. Bristow, MD Objective: To characterize contemporary patterns of thy- pitalization (0.44; PϽ.001), and had a lower incidence roid surgical care and variables associated with access to of recurrent laryngeal nerve injury (0.46; P=.002), hy- high-volume care. pocalcemia (0.62; PϽ.001), and thyroid cancer surgery (0.89; P=.01). After controlling for other variables, thy- Design: Cross-sectional analysis. roid surgery in 2000-2009 was associated with high- volume surgeons (OR, 1.76; PϽ.001), high-volume hos- Setting: Maryland Health Service Cost Review Com- pitals (2.93; P Ͻ .001), total thyroidectomy (2.67; mission database. PϽ.001), and neck dissection (1.28; P=.02) but was less likely to be performed for cancer (0.83; PϽ.001). Patients: Adults who underwent surgery for thyroid dis- ease in Maryland between January 1, 1990, and July 1, Conclusions: The proportion of thyroid surgical pro- 2009. cedures performed by high-volume surgeons and in high- volume hospitals increased significantly from 1990- Results: Overall, 21 270 thyroid surgical procedures were 1999 to 2000-2009, with an increase in total performed by 1034 surgeons at 51 hospitals. Proce- thyroidectomy and neck dissection. Surgeon volume was dures performed by high-volume surgeons increased from significantly associated with complication rates. Thy- 15.7% in 1990-1999 to 30.9% in 2000-2009 (odds ratio roid cancer surgery was less likely to be performed by [OR], 3.69; PϽ.001), while procedures performed at high- high-volume surgeons and in 2000-2009 despite an in- volume hospitals increased from 11.9% to 22.7% (3.46; crease in surgical cases. Further investigation is needed PϽ.001). High-volume surgeons were more likely to per- to identify factors contributing to this trend. form total thyroidectomy (OR, 2.50; PϽ.001) and neck dissection (1.86; PϽ.001), had a shorter length of hos- Arch Otolaryngol Head Neck Surg. 2010;136(12):1191-1198 OSITIVE VOLUME-OUTCOME surer industry coalitions, such as the Leap- relationships exist for dis- frog Group, which requires nonrural hos- eases treated with techni- pitals to meet volume standards for cally complex surgery. Most selected surgical procedures to be eli- studies1-4 investigating vol- gible for beneficiary referral.6,7 Pume-outcome relationships have fo- There is a relative scarcity of literature cused on the relationship between hospi- regarding the relationship between vol- tal volume and operative mortality from ume and outcome in head and neck sur- cardiovascular, intrathoracic, and intra- gery. However, similar observations re- abdominal procedures and demonstrate garding the positive effect of hospital8-12 Author Affiliations: 5,13-16 Department of lower short- and long-term mortality rates and surgeon volume on outcome have Otolaryngology–Head and Neck for procedures performed at high- been reported for surgical treatment of pa- Surgery (Drs Gourin, Tufano, volume hospitals. Although less widely rotid, larynx, pharynx, and thyroid dis- and Koch), Department of studied, similar observations for volume ease and cervical metastases. The oldest Oncology, Sidney Kimmel and outcome have been reported for sur- documented relationship between vol- Comprehensive Cancer Center geon-based care, with lower surgical mor- ume and outcome is in the field of thy- (Dr Forastiere), and tality rates for patients treated by high- roid surgery. As cited by Becker,17 The- Department of Surgery volume surgeons, and surgeon volume odor Kocher reported operative mortality (Dr Pawlik), The Johns accounts for a large proportion of the effect of 13% for his first 100 thyroid proce- Hopkins Medical Institutions, of hospital outcome on surgical mortal- dures but by 1917 had performed 5000 and Kelly Gynecologic 5 Oncology Service, Department ity. These observations served as the ba- thyroidectomies with operative mortality of Gynecology and Obstetrics sis for the controversial adoption of hos- of only 0.5%, demonstrating a strong cor- (Dr Bristow), Baltimore, pital volume standards as a surrogate relation between surgical experience and Maryland. marker for quality by commercial in- clinical outcome. Despite this recogni- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 136 (NO. 12), DEC 2010 WWW.ARCHOTO.COM 1191 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 tion, limited data exist regarding volume-outcome rela- in the high-volume quartile performed more than 100 cases, and tionships in thyroid surgery, and most thyroid surgery all hospitals in the high-volume quartile performed more than in the United States is performed by low-volume (Յ3 cases 150 cases per year. per year) thyroid surgeons.15,18 In light of the increasing Secondary independent variables included were age, sex, race, emphasis on positive volume-outcome relationships as APR-DRG (All Patient Refined Diagnosis Related Groups) case complexity score (1-4), APR-DRG mortality risk score (1-4), a proxy for quality of care, and the potential impact of length of stay, intensive care unit days, other specialty unit care this relationship on referral and practice patterns, we un- days, payer source (commercial, health maintenance organi- dertook the present study to characterize contemporary zation [HMO], Medicare or Medicaid, or self-pay), nature of patterns of thyroid surgical care through an analysis of admission (emergent/urgent or other), readmission, inpatient statewide data according to hospital and surgeon vol- death, hospital type (university, community teaching, or com- ume, and to investigate temporal changes as well as vari- munity), procedure, and a diagnosis of thyroid cancer. A com- ables associated with access to high-volume care. munity teaching hospital was defined as a nonuniversity hos- pital with a residency program in general surgery or otolaryngology–head and neck surgery. Thyroid surgery– METHODS specific complications of recurrent laryngeal nerve injury and hypocalcemia were included as secondary independent vari- A cross-sectional analysis of patients with a diagnosis of thy- ables but were also analyzed separately as primary indepen- roid disease was performed using hospital discharge data from dent variables to determine factors associated with an in- nonfederal acute care hospitals in Maryland collected by the creased risk of these complications. For statistical analysis of Maryland Health Service Cost Review Commission (HSCRC). temporal trends, the study period was divided into 2 time in- The HSCRC database provides information regarding the in- tervals: 1990-1999 and 2000-2009. American Joint Commis- dex hospital admission (surgery) and is limited to 30 days of sion on Cancer tumor stage, tumor grade, histologic subtype, follow-up. Adult patients (Ն18 years) who underwent an ab- and outcome beyond 30 days were not available from the HSCRC lative procedure for benign or malignant thyroid disease in Mary- database. land between January 1, 1990, and July 1, 2009, comprised the Data were analyzed using a statistical software program study population. International Classification of Disease, Ninth (STATA 10; StataCorp LP, College Station, Texas). Standard Revision (ICD-9) codes for benign diseases (ICD-9 codes 241.0, statistical analysis, including unpaired t tests and analysis of 241.1, 241.9, 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, variance for continuous data and ␹2 tests for categorical data, 242.30, 242.31, 226, 237.4, 239.7, 240.9, 242.4, 246, 246.1, were used to evaluate factors associated with volume cat- 246.2, 246.9, 648.1, and 874.2) and malignant diseases (ICD-9 egory. Bivariate logistic regression analysis was used to deter- code 193) of the thyroid were used for sorting. All cell types mine variables that were significantly associated with the out- were included. Surgical procedures included in this analysis were come of interest. Multiple logistic regression analysis was used limited to ablative procedures: excision of lesion (ICD-9 code to identify factors associated with high-volume surgical care, 06.31), isthmusectomy or partial thyroidectomy (ICD-9 code with surgeon or hospital volume as the outcome variable of in- 06.39), unilateral lobectomy (ICD-9 code 06.2), complete thy- terest; factors associated with complications, with recurrent la- roidectomy (ICD-9 code 06.4), other (unspecified) operations ryngeal nerve injury or hypocalcemia as the outcome variable on thyroid glands (ICD-9 code 06.98), substernal thyroidec- of interest; and factors associated with temporal trends, with tomy (ICD-9 code 06.5) (including partial [ICD-9 code 06.51] time interval as the outcome variable of interest. Collinearity or complete [ICD-9 code 06.52] substernal thyroidectomy), and was checked by performing a multiple regression analysis and neck dissection (ICD-9 codes 40.40, 40.41, 40.42, and 40.3). by calculating the variance inflation factors and removing vari- Postoperative surgical complications were derived from codes ables with a variance inflation factor greater than 10.0, which assigned at the time of hospital discharge for recurrent laryn- suggests collinearity. Variables that were hypothesized to have geal nerve injury (ICD-9 codes 478.3, 478.30, 478.31, 478.32, predictive value and those that were significant in bivariate analy- 478.33, 478.34, and 951.8), hypoparathyroidism (ICD-9 code sis were entered into the regression models. Models were se- 252.1), and hypocalcemia (ICD-9 codes 275.4, 275.40, 275.49, quentially built to identify variables that were significantly as- 264.40, 275.41, and 275.49). sociated with high-volume surgeons or hospitals. A second Individual surgeon and individual hospital annual thyroid sur- approach used stepwise backward variable selection to deter- gery case volumes were the primary independent variables in this mine which subset of variables was predictive of the outcome study.
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