Pancreatic Resection Results in a Statewide Surgical Collaborative

Pancreatic resection is a complex surgical procedure. Although its associated mortality has decreased significantly over time, morbidity remains high. A strong volume–outcome relation has been demonstrated for pancreatic resection, with decreases in the mortality, hospital length of stay, and cost when performed in high-volume hospitals. Despite these compelling data, complete regionalization of pancreatectomy to high-volume centers has not been achieved, with 20–40 % of pancreatic resections still being performed at low-volume centers. There is evidence that failure of regionalization is driven, in part, by patient preferences and physician referral patterns. In Texas, 19 % of patients traveled a distance farther than the distance to the nearest high-volume hospital to have their operation performed at a low-volume hospital. Finlayson and colleagues found that only 55 % of patients were willing to travel to a high-volume center even if told that their mortality risk was double at their local facility. Also, only 82 % were willing to travel if told that their mortality risk was sixfold higher at their local facility. Even across high-volume centers, there is significant variability in outcomes. Given the wide variability in outcomes and the challenges and reality of regionalization, it is critical to explore alternative approaches to improving overall outcomes as well as closing the ‘‘quality gap’’ observed between highand low-volume providers. Healy et al. provide data to suggest that participation in a regional quality improvement collaborative may provide an alternative model to improving outcomes for patients undergoing pancreatic resection. Leveraging data from an already existing statewide surgical quality collaborative, the authors demonstrate improvement in risk-adjusted morbidity, mortality, and failure to rescue rates for pancreatectomy between two time periods, 2008–2010 and 2011–2013. Importantly, the majority of the observed improvement in outcomes was due to attenuation of the variation in outcomes across lowand high-volume hospitals. Adjusted mortality rates (from 6.2 to 3.3 %) and major complication rates (from 27.8 to 22.2 %) improved over time in low-volume hospitals. However, there was a slight increase in the mortality rate (from 0.8 to 1.1 %) and morbidity rate (from 17.8 to 20.0 %) at high-volume hospitals, although this increase is likely not statistically or clinically significant. When evaluating these outcomes, the reader should understand that this collaborative effort was not procedure-specific. It did not assess pancreatectomyspecific outcomes across institutions, nor was it a true collaboration between centers to learn from each other and drive further improvement. Regardless of these drawbacks, the data suggest that a collaborative approach to quality improvement could provide another important piece of the puzzle. Pancreatectomyspecific improvement occurred even when it was not the primary goal of the collaborative design. Therefore, it is reasonable to extrapolate that a procedure-specific collaborative could help hospitals and physicians improve outcomes for complex procedures. Ideally, collaboratives would provide benefit beyond the outcomes reporting by learning from one another and implementing strategic interventions, ultimately improving global outcomes. These results, in turn, could lead to a reduction in the variation between lowand high-volume providers as well as improved outcomes at all centers. For example, instead of improving overall pancreatic fistula rates by bringing the low-volume centers to the current level of the high-volume Society of Surgical Oncology 2015