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Esophagectomy Outcomes at Low-Volume Hospitals: The Association Between Systems Characteristics and Mortality

Funk, Luke M. MD, MPH*,†; Gawande, Atul A. MD, MPH*,†; Semel, Marcus E. MD, MPH*,†; Lipsitz, Stuart R. ScD; Berry, William R. MD, MPH*,†; Zinner, Michael J. MD; Jha, Ashish K. MD, MPH*,‡,§

doi: 10.1097/SLA.0b013e318213862f
Original Article

Objective: To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitals

Background: High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible. We examined low-volume hospitals and sought to identify characteristics of those with better outcomes.

Methods: Using national data from Medicare and the American Hospital Association, we studied 4498 elderly patients who underwent an esophagectomy from 2004 to 2007. We divided hospitals into terciles based on esophagectomy volume and examined characteristics of patients and hospitals (size, nurse ratios, and presence of advanced medical, surgical, and radiological services). Our primary outcome was mortality. We identified 5 potentially beneficial systems characteristics in our data set and used multivariable logistic regression to determine whether these characteristics were associated with lower mortality rates at low-volume hospitals.

Results: Of the 874 hospitals that performed esophagectomies, 83% (723) were low-volume hospitals whereas only 3% (25) were high-volume. Low-volume hospitals performed a median of 1 esophagectomy during the 4-year study period and cared for patients that were older, more likely to be minority, and more likely to have multiple comorbidities compared with high-volume centers. Low-volume hospitals that had at least 3 of 5 characteristics (high nurse ratios, lung transplantation services, complex medical oncology services, bariatric surgery services, and positron emission tomography scanners) had markedly lower mortality rates compared with low-volume hospitals with none of these characteristics (12.5% vs. 5.0%; P value = 0.042).

Conclusions: Low-volume hospitals with certain systems characteristics seem to achieve better esophagectomy outcomes. A more comprehensive study of the beneficial characteristics of low-volume hospitals is warranted because high-volume hospitals are difficult to access for many patients.

Supplemental digital content is available in the text.Many Americans undergo esophagectomies at low-volume institutions, despite their higher overall mortality rates. We used national Medicare data to examine whether a subset of low-volume hospitals achieved better outcomes. We found that low-volume hospitals with a set of key systems characteristics, such as high nurse ratios and lung transplantation services, had esophagectomy mortality rates that were comparable to medium- and high-volume centers.

*Department of Health Policy and Management, Harvard School of Public Health, Boston, MA

Center for Surgery and Public Health

Division of General Medicine, Brigham and Women's Hospital, Boston, MA

§VA Boston Healthcare System, Boston, MA

Reprints: Luke M. Funk, MD MPH, Harvard School of Public Health, Department of Health Policy and Management, 677 Huntington Avenue; Kresge Building, Office 440; Boston, MA 02115. E-mail:

Dr. Funk is supported by the Department of Surgery, Brigham and Women's Hospital. Dr. Semel is supported by an NIH research training grant in digestive diseases and surgery (T32DK007754-11). Dr. Jha is funded by the Robert Wood Johnson Physician Faculty Scholar Program.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

© 2011 Lippincott Williams & Wilkins, Inc.