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The Impact Of Individual Surgeon On The Likelihood Of Minimal Invasive Surgery Among Medicare Beneficiaries Undergoing Pancreatic Resection
*Qinyu Chen, *Diamantis I Tsilimigras, *Anghela Z Paredes, *J. Madison Hyer, *Mary Dillhoff, *Jordan Cloyd, *Aslam Ejaz, *Allan Tsung, Timothy M Pawlik
The Ohio State University Wexner Medical Center, Columbus, OH

OBJECTIVE(S): Minimal invasive surgery (MIS) has been increasingly utilized for pancreatic resection compared with the conventional open approach. We sought to evaluate individual surgeon variation on the use of MIS among patients undergoing pancreatic resection.
METHODS: The Medicare Provider Analysis and Review (MEDPAR) Standard Analytic Files were reviewed to identify Medicare patients who underwent pancreatic procedures between 2013-2017. Multilevel, multivariable logistic regression was used with odds ratios (OR) to investigate the impact of patient and surgical factors on the likelihood of MIS; median odds ratios (MOR) were used to access the association between a given individual surgeon and use of MIS.
RESULTS: 11,845 (85.1%) patients underwent open pancreatic resection, while MIS was performed in 2,081 (14.9%) patients. In evaluating individual surgeon practices, unadjusted rates of MIS utilization ranged from 0% in the bottom MIS volume tertile of surgeons to 36.4% in the top tertile(Figure 1a). While patients with emergent admission were less likely to undergo MIS pancreatic resection (OR=0.50, 95%CI 0.36-0.69), patients operated on more recently had a higher chance of MIS pancreatectomy (year 2017; OR=1.57, 95%CI 1.32-1.87). On multivariable analysis, after controlling for patient and procedure characteristics, there was considerable variation in the likelihood that a patient would undergo MIS versus open pancreatic resection based on the individual surgeon. Specifically, there was over a three-fold variation in the odds that a patient underwent MIS versus open pancreatic resection based on the individual surgeon (MOR=3.30, 95%CI 3.00-3.60). On multivariate analyses, patients who underwent an MIS pancreatectomy by a low volume MIS surgeon had higher odds of 90-day mortality after surgery (low vs. high tertile MIS surgeons: OR=1.20, 95%CI 1.02-1.40), as well as higher observed/expected mortality(Figure 1b).
CONCLUSIONS: The likelihood of undergoing MIS pancreatic resection among Medicare beneficiaries was markedly influenced by the individual treating surgeon, even after accounting for patient and disease factors. Variation in the use of MIS approach for pancreatic surgery largely depends on the provider, rather than patient- or procedure-level, factors.


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