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Admission Volume As a Determinant of Outcome For Patients With Acute Pancreatitis

Anand Singla, MD, Jessica P Simons, MD, Sing Chau Ng, MS, James Hart, Jennifer F Tseng, MD MPH, Shimul A Shah, MD
UMass Medical School; Worcester, MA


PURPOSE OF STUDY
Optimal management of acute pancreatitis (AP) remains controversial. We sought to examine if treatment at a high volume (HV) hospital confers a mortality benefit.

METHODS USED:
Using the Nationwide Inpatient Sample 1998-2006, 416,489 adult discharges with a 1 diagnosis of AP were examined. Annual hospital volume was divided into equal tertiles based on admissions for AP (lowest tertile (LV) < 65/yr; 64/yr < medium (MV) < 118/yr; HV >117/yr). Adjusted mortality and length of stay (LOS) were primary outcomes.

SUMMARY OF RESULTS:
In-hospital mortality was 1.6%. Annual admissions increased over the study period (p < 0.0001). HV hospitals were large (82%), urban (99%), teaching centers (59%) (p < 0.0001) which cared for patients with more comorbidities (35.9% with > 2 comorbidities vs. 29.1% at LV hospitals) (p<0.0001). Cholecystectomy was the most common primary procedure (n=45,579) (26.2%). LV centers appeared more likely to perform pancreatic operations than HV hospitals (OR 1.50; 95%CI 1.32-1.70). Prolonged adjusted LOS was less likely at HV hospitals compared to LV (OR 0.75; 95%CI 0.71-0.79) or MV hospitals (OR 0.82; 95%CI 0.79-0.85). There was a significant independent in-hospital mortality benefit for HV centers (OR 0.68; 95%CI 0.62-0.76) even after adjusting for receipt of operation.

CONCLUSIONS:
Rates of admission for AP are increasing. High annual hospital volume of AP confers a shorter LOS and an in-hospital mortality benefit to patients admitted with AP. Further studies should tease out the mechanism for these benefits, including availability of specialists, quality of critical care, and timing of surgery.

TABLES AND CHARTS:
Multivariable Analysis of Factors Associated with Mortality
Variable Hazards Ratio 95% CI
Age 1.043 1.041 - 1.046
Female Gender 1.35 1.273 - 1.432
Black race 0.794 0.728 - 0.867
Private Insurance 0.831 0.760 - 0.907
Comorbidity ( > 3) 3.604 3.156 - 4.116
Teaching Hospital 1.455 1.361 - 1.557
Large Bedsize 1.623 1.461 - 1.802
High Volume Hospital 0.684 0.620 - 0.755

 

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