Surgeon Case Volume and Readmissions After Roux-en-Y Gastric Bypass: More Is Less

Adam Celio, MD, Matthew Burruss, MD, Kevin Kasten, MD, Walter Pofahl, MD, Walter Pories, MD, William Chapman, MD, Konstantinos Spaniolas, MD. Department of Surgery, Brody School of Medicine at East Carolina University

Introduction: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is a commonly performed bariatric procedure. Readmissions are being used as an indicator of quality care and there is a nationwide emphasis to reduce their incidence. Prior studies have explored surgeon case volume and patient outcomes in various surgical fields. In LRYGB surgery, surgeon volume studies have focused on technical outcomes, mainly using state registries to assess complication rates with limited data on readmissions. Our aim was to use nationwide data to explore the relationship between surgeon case volume and hospital readmissions following LRYGB.

Methods and Procedures: The Bariatric Outcomes Longitudinal Database (Surgical Review Corporation; Raleigh, NC) for 2011 was used for the purposes of this study. Analysis was restricted to patients who underwent non-revisional LRYGB. Surgeons performing more than 50 LRYGB during the study period were defined as high volume surgeons (HVS). A multivariable logistic regression model was used to examine the effect of surgeon volume on 30 day readmission while controlling for patient demographics and comorbidities. Data is presented as percentage or mean (standard deviation).

Results: We identified 32,521 patients that underwent LRYGB with an overall 30 day readmission rate of 5.5%, mean age 45.7 (12.0), and mean BMI 47.2 (8.0). There were no major differences in BMI [47.3 (8.1) vs 47.1 (7.9) p=0.282] or age [45.5 (12.0) vs 45.8 (12.0) p=0.030] between low volume surgeon (LVS) and HVS patients. HVS patients were more likely to have an American Society of Anesthesiology score >2 (74.7% vs 80.8%, p<0.001). LVS patients were more likely to be readmitted compared to those with a HVS (OR=0.85, 95% CI 0.77-0.94), with a readmission rate of 6.1% vs 5.2% (p=0.001). Additionally, LVS patients had higher rates of 30 day mortality (0.2% vs 0.1%, OR=0.50, 95% CI 0.27-0.91), complication (10.5% vs 8.6%, OR=0.81, 95% CI 0.75-0.87), reoperation (3.7% vs 3.0%, OR=0.82, 95% CI 0.72-0.93), and anastomotic leak (0.6% vs 0.4%, OR=0.64, 95% CI 0.46-0.87).

Conclusion: Readmission after LRYGB is significantly associated with surgeon operative volume; surgeons that perform less than 50 LRYGB per year are more likely to have 30 day readmissions and complications. Our findings support other more generalized studies that suggest surgeon case volume is inversely associated with increased risk of adverse outcomes and complications, and suggest that performance of LRYGB by high volume surgeons may decrease hospital readmission and healthcare utilization.

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