Continued Relevance of Minimum Volume Standards for Elective Esophagectomy: A National Perspective.

Background: Despite minimum volume recommendations, the majority of esophagectomies are performed at centers with fewer than 20 annual cases. The present study examined the impact of institutional esophagectomy volume on in-hospital mortality, complications, and resource use after esophageal resection.

Methods: The 2010-2018 Nationwide Readmissions Database was queried to identify all adult patients undergoing esophagectomy for malignancy. Hospitals were categorized as a high-volume hospital (HVH) if performing at least 20 esophagectomies annually and as a low-volume hospital (LVH) if performing fewer than 20 esophagectomies annually. Multivariable models were developed to study the impact of volume on outcomes of interest, which included in-hospital mortality, complications, duration of hospitalization, inflation adjusted costs, readmissions, and nonhome discharge.

Results: Of an estimated 23,176 hospitalizations, 45.6% occurred at HVHs. Incidence of esophagectomy increased significantly along with median institutional caseload over the study period, while the proportion on hospitals considered HVHs remained steady at approximately 7.4%. After adjusting for relevant patient and hospital characteristics, HVH status was associated with decreased mortality (AOR, 0.65), length of stay (β = -1.83), pneumonia (AOR, 0.69), prolonged ventilation (AOR, 0.50), sepsis (AOR, 0.80), and tracheostomy (AOR, 0.66) but increased odds of nonhome discharge (AOR, 1.56; all P < .01), with LVH status as reference.

Conclusions: Many clinical outcomes of esophagectomy are improved with no increment in costs when performed at centers with an annual caseload of at least 20, as recommended by patient advocacy organizations. These findings suggest that centralization of esophageal resections to high-volume centers may be congruent with value-based care models.