Surgical excision of acoustic neuroma: patient outcome and provider caseload.

OBJECTIVES/HYPOTHESIS: For many complex surgical procedures, larger hospital or surgeon caseload is associated with better patient outcome. We examined the volume-outcome relationship for surgical excision of acoustic neuromas.

STUDY

DESIGN

Retrospective cohort study.

METHODS

The Nationwide Inpatient Sample (1996 to 2000) was used. Multivariate regression analyses were adjusted for age, sex, race, payer, geographic region, procedure timing, admission type and source, medical comorbidities, and neurofibromatosis status.

RESULTS

At 265 hospitals, 2643 operations were performed by 352 identified primary surgeons. Outcome was measured on a four-level scale at hospital discharge: death (0.5%) and discharge to long-term care (1.2%), to short-term rehabilitation (4.4%), and directly to home (94%). Outcomes were significantly better after surgery at higher-volume hospitals (OR 0.47 for fivefold-larger caseload, P <.001) or by higher-volume surgeons (OR 0.46, P <.001). Of patients who had surgery at lowest-volume-quartile hospitals, 12.3% were not discharged directly home, compared with 4.1% at highest-volume-quartile hospitals. There was a trend toward lower mortality for higher-volume hospitals (P =.1) and surgeons (P =.06). Of patients who had surgery at lowest-caseload-quartile hospitals, 1.1% died, compared with 0.6% at highest-volume-quartile hospitals. Postoperative complications (including neurological complications, mechanical ventilation, facial palsy, and transfusion) were less likely with high-volume hospitals and surgeons. Length of stay was significantly shorter with high-volume hospitals (P =.01) and surgeons (P =.009). Hospital charges were lower for high-volume hospitals (by 6% [P =.006]) and surgeons (by 6% [P =.09]).

CONCLUSION

For acoustic neuroma excision, higher-volume hospitals and surgeons provided superior short-term outcomes with shorter lengths of stay and lower charges.