Impact of Hospital Volume on Postoperative Morbidity and Mortality Following a Colectomy for Ulcerative Colitis

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doi:10.1053/j.gastro.2008.01.004 Copyright © 2008 AGA Institute Published by Elsevier Inc.

Clinical–Alimentary Tract

Impact of Hospital Volume on Postoperative Morbidity and Mortality Following a Colectomy for Ulcerative Colitis

Gilaad G. Kaplan, Ellen P. McCarthy‡, Z. Ayanian§, Korzenik, Hodin¶ and Bruce E. Sands ‡Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MassachusettsInflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta; CanadaMGH Crohn’s and Colitis Center and Gastrointestinal Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts§Division of General Medicine, Brigham and Women’s Hospital and Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts¶Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts Received 17 August 2007; accepted 13 December 2007. Available online 10 January 2008.

Background & Aims: Postoperative morbidity and mortality following a colectomy for ulcerative colitis (UC) has been primarily reported from tertiary care referral centers that perform a high volume of operations; however, the postoperative outcomes among nonselected hospitals are not known. We set out to evaluate postoperative morbidity and mortality using a nationally representative database and to determine the factors that influenced outcomes.

Methods: We analyzed the 1995–2005 Nationwide Inpatient Sample to identify 7108 discharges for UC patients who underwent a total abdominal colectomy. The effects of hospital volume on postoperative morbidity and mortality were evaluated in logistic regression models adjusting for demographic and clinical factors.

Results: Postoperative mortality and morbidity rates were 2.3% and 30.8%, respectively. Most operations were performed in low-volume hospitals that had an increased risk of death (adjusted odds ratio [aOR], 2.42; 95% confidence interval [CI]: 1.26–4.63). In-hospital mortality was increased in patients who were admitted emergently (aOR, 5.40; 95% CI: 3.48–8.40), aged 60–80 years (aOR, 8.70; 95% CI: 3.30–22.92), and those with Medicaid (aOR, 4.29; 95% CI: 2.13–8.66). Emergently admitted UC patients whose surgery was performed 6 days after their admission had significantly increased likelihood of in-hospital death (aOR, 2.12; 95% CI: 1.13–3.97).

Conclusions: Postoperative mortality was lowest in hospitals that performed the highest volume of operations. Increasing the proportion of total colectomies performed in high-volume hospitals may improve clinical outcomes for patients with UC.

Abbreviations: ICD-9-CM, International Classification of Diseases, 9th Version, Clinical Modification; IPAA, ileal pouch anal anastomosis; IQR, interquartile range; NIS, nationwide inpatient sample; OR, odds ratio; aOR, adjusted odds ratio; UC, ulcerative colitis

G.K. is Canadian Institutes of Health Research and Alberta Heritage Foundation for Medical Research Clinical Fellow. Conflicts of interest and financial disclosures: Ellen McCarthy, Hodin, and Ayanian have none to declare. Gilaad Kaplan: served on an advisory board for Abbot Laboratories and UCB Pharma. Bruce Sands: Abbot Laboratories research grants, honoraria for speaking, scientific advisory board; Centocor research grants, honoraria for speaking, scientific advisory board; UCB Pharma honoraria for speaking, scientific advisory board; Procter & Gamble consulting and lecturing fees; Shire consulting fees. Korzenik: consulting and lecture fees from Procter & Gamble, Shire Pharmaceuticals, Isis Pharmaceuticals, Cytokine Pharmasciences, Berlex, and Centocor and research support from Danisco. A US patent entitled “Stimulating Neutrophil Function to Treat Inflammatory Bowel Disease (6500418)” was issued December 31, 2002. Dr Korzenik is one of the inventors. The patent is owned by Washington University and licensed by Berlex Laboratories.Address requests for reprints to: Gilaad Kaplan, MD, MPH, Inflammatory Bowel Disease Clinic, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada. fax: .

Gastroenterology Volume 134, Issue 3, March 2008, Pages 680-687.e1