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Exploring The Volume-Outcomes Relationship For Adrenal Surgery
Jay Simhan1, Marc C Smaldone1, Daniel Canter1, Fang Zhu1, Russell Starkey1, Karyn B Stitzenberg2, Robert G Uzzo1, Alexander Kutikov1
1Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA;2University of North Carolina Hospitals, Chapel Hill, NC

Introduction: Although centralization of surgical procedures to high volume centers has been described previously, patterns of care for adrenal surgery are unknown. We investigated trends in regionalization of care for patients undergoing adrenalectomy using hospital discharge data from 3 Northeastern states.
 
Materials and Methods: Using 1996-2009 hospital discharge data from NY, NJ and PA, all patients >=18 years undergoing adrenalectomy were identified. Hospital volume status was assigned by quintiles based on number of procedures performed on a per-hospital basis in 1996 and divided as very low volume hospital (VLVH), low (LVH), moderate (MVH), high (HVH) and very high (VHVH).  Outcome variables were examined by volume status over time using logistic regression models.
 
Results: From 1996 to 2009, 8,338 patients underwent adrenalectomy with a shift towards regionalization to VHVHs (17 to 42%, p<0.001).  For each successive year, odds of having surgery performed at a VHVH increased by 9% (OR 1.09 [CI 1.08-1.10]). There were significant differences in patient age, race, geographic location, and payer group (p<0.0001) comparing VLVHs to VHVHs. Patients at VHVHs were less likely to be >=55 years (OR 0.76 [CI 0.72-0.80]), insured through Medicaid (OR 0.59 [CI 0.40-0.85]), or be uninsured (OR 0.30 [CI 0.21-0.43]). Controlling for year treated, patients were less likely to die in the hospital if treated at a VHVH (OR 0.38 [CI 0.19-0.75]).
 
Conclusions:
 These data demonstrates centralization of adrenalectomy to VHVHs since 1996 with improved clinical outcomes. Inequities in access to care to higher volume centers appear to exist and require further investigation.


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