Secondary Logo

Institutional members access full text with Ovid®

Associations of Surgeon and Hospital Volumes with Outcome for Free Tissue Transfer by Using the National Taiwan Population Health Care Data from 2001 to 2012

Mahmoudi, Elham, Ph.D.; Lu, Yiwen, M.S.; Chang, Shu-Chen, Ph.D.; Lin, Chia-Yu, M.Sc.; Wang, Yi-Chun, M.S.; Chang, Chee Jen, Ph.D.; Cheng, Ming-Huei, M.D., M.B.A.; Chung, Kevin C., M.D., M.S.

Plastic and Reconstructive Surgery: September 2017 - Volume 140 - Issue 3 - p 455e-465e
doi: 10.1097/PRS.0000000000003593
Reconstructive: Trunk: Outcomes Article

Background: Greater hospital case volumes are associated with improved outcomes for high-risk procedures. The hospital-outcome association for complex but low-mortality procedures and the association between surgeon versus hospital case volume and surgical outcomes have been less explored. The authors examined the association between surgeon and hospital volume and the success for free tissue transfer (free flap) surgery. The authors hypothesized that there would be positive associations between hospital and surgeon volume and the success of free flap surgery.

Methods: The study design was a cross-sectional analysis of adults aged 18 to 64 years who underwent free flap surgery. The authors used 100 percent of all free flap operations between 2001 and 2012 using Taiwan’s national data that cover the entire population of 23 million in the country. The authors applied hierarchical regression modeling to analyze volume-outcome associations.

Results: The association between hospital volume and free flap success was small but positive (OR, 1.007; 95 percent CI, 1.00 to 1.01). For surgeons, their years of experience had a positive association with success of the operation (OR, 1.04; 95 percent CI, 1.02 to 1.06) rather than their annual case volume. Compared with low-volume surgeons (<11 annual cases) working in low-volume hospitals (<95 annual cases), high-volume surgeons (>25 annual cases) working in high-volume hospitals (>156 annual cases) showed greater odds of operation success (OR, 2.97; 95 percent CI, 1.21 to 7.29).

Conclusions: Higher volume hospitals and more experienced surgeons, regardless of their annual volume, showed better outcomes. Increasing demand for high-quality care and Taiwan’s national policies toward centralization of complex surgical procedures have increased competition among hospitals.


Ann Arbor, Mich.; and Taoyuan, Taiwan

From the Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School; the Research Services Center for Health Information and Graduate Institute of Clinical Medicine, Chang Gung University; and the Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Department of Cardiovascular Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University.

Received for publication November 21, 2016; accepted February 2, 2017.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (

This work was supported by THE PLASTIC SURGERY FOUNDATION.

Elham Mahmoudi, Ph.D., University of Michigan North Campus Research Complex, 2800 Plymouth Road, Building 14, Room G234, Ann Arbor, Mich. 48109,

Ming-Huei Cheng, M.D., M.B.A., Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5 Fu-Hsing Street, Kueishan, Taoyuan 333, Taiwan,

Copyright © 2017 by the American Society of Plastic Surgeons