Does the Annual Hospital Admission Volume of Patients with Acute Necrotising Pancreatitis Really Matter?

OBJECTIVE The objective of the study was to examine the impact of hospital volume on mortality and healthcare utilisation in patients admitted with acute necrotising pancreatitis (ANP). SUMMARY Acute pancreatitis (AP) is one of the leading causes of hospitalisation in the United States and is responsible for major life and financial loss. The rate of progression of pancreatitis to ANP is around ~ 20% and 50% of these have infected ANP.[1] ANP is associated with high morbidity and mortality. Upfront surgical necrosectomy was the norm in the past and was associated with high complication and mortality rates but the landmark PANTER trial introduced the concept of a ‘Step-up approach’ in which initial medical management formed the core.[2] This has caused a paradigm shift in the management of the disease with minimally invasive procedures dominating the major proportion of the initial management and surgery being only used as a last resort. The above changes in paradigm, although they may have slightly improved the outcomes, have made the management of ANP more complicated and require multidisciplinary involvement in well-equipped hospitals. The present study was based on the hypothesis that ANP patients have better outcomes if managed in high-volume centres. The authors retrospectively analysed data from a United States Nationwide Readmissions Database from 2016 to 2019. They stratified procedural interventions into percutaneous drainage only, endoscopic drainage/debridement only, percutaneous and endoscopic drainage, minimally invasive pancreatic surgery and open pancreatic resection/drainage. Inhospital mortality (defined as mortality within 30 days of initial discharge) was taken as the primary outcome while the length of hospital stay, discharge disposition, 30-day unplanned readmission and total healthcare costs in US dollars were taken as secondary outcomes. Appropriate statistical tests were applied by the authors. The study population consisted of a total 25,483 patients out of which 19,878 (78%) had uninfected ANP of unknown aetiology. Mostly, patients were admitted to teaching (n = 20,339/79.8%) and private (n = 20,544/80.6%) hospitals. Overall, 31.5% (n = 8022) of ANP patients were admitted to low-volume hospitals, 36.3% (n = 9250) to medium-volume hospitals and 32.2% (n = 8211) to high-volume hospitals. The median hospital admission volume was 13 (1–171). Patients admitted to high-volume centres had higher comorbidity (index >3) (54.6% vs. 47.5% vs. 40.5%, P < 0.0001). High-volume centres were usually teaching hospitals (98.6% vs. 84.6% vs. 55.1%, P < 0.001) and had patients transferred from other hospitals (15.6% vs. 6.1% vs. 1.9%, P < 0.0001). Patients in high-volume centres had more severe disease (38.3% vs. 32.4% vs. 28.1%, P < 0.001) and infected necrosis (24.5% vs. 21.85 vs. 19.6%, P < 0.001) and were more likely to undergo a procedural intervention (21.0% vs. 14.0% vs. 7.7%, P < 0.001). The intervention was performed in 14.3% patients out of which the majority underwent open necrosectomy (n = 1269, 34.9%). High-volume centres performed more minimally invasive surgery (22.7% vs. 15.7% vs. 12.8%, P < 0.001) and endoscopic management (29.4% vs. 20.7% vs. 17.6%, P < 0.001) while open necrosectomy and percutaneous drainage were done mostly in mid-or low-volume centres. High-volume centres overall had a higher inhospital mortality, hospital stay, unplanned readmission and healthcare cost but when the authors applied multiple logistic regression analysis to those who underwent intervention, high-volume centres had a lower inhospital mortality (odds ratio [OR] =0.7), shorter hospital stay (OR = 0.73) and reduced healthcare costs (OR = 0.84) albeit higher unplanned readmission (OR = 1.12). Similar findings were also seen by performing sensitivity analyses while excluding patients who were transferred to high-volume centres. COMMENTARY ANP has a multi-pathway disease progression which makes its management complex and needs multidisciplinary involvement. The high morbidity and mortality rates associated with upfront traditional open necrosectomy paved the way for minimally invasive approach with fewer complications and mortality (PANTER TRIAL).[2] Although it has been proven that higher hospital volumes are associated with better outcomes in complex pancreatic, oesophageal and colorectal surgeries,[3,4] there have been no such well-conducted studies available for ANP. The initial few studies had shown an inverse volume-outcome relationship but were flawed by the lack of adjusted disease severity scores.[5,6] The first proper study was performed by Hamada et al. in 17,415 patients in Japan but failed to find an association between volume and outcome.[7] Similar outcomes were also reported by Santillan et al. in the western hemisphere.[8] A proper understanding of volume outcome in ANP serves several purposes. First, owing to the rising incidence of the disease and its association with very high treatment costs, it may help in optimising medical care and proper resource utilisation. It can also help in early referral of ANP patients and future policy planning. Similarly, the plausible explanations behind better outcomes in patients treated at high-volume centres are few. First, the ever-evolving field of management of ANP including aggressive fluid resuscitation, enteral nutrition along with various procedural interventions and these are performed better in high-volume centres. Second, high-volume hospitals are usually tertiary care, teaching hospitals with experienced staff, greater intensive care facilities and proper institutional protocols. AP poses a major burden on healthcare services worldwide. With its rise in incidence, the cost involved is also increasing. Fagenholz et al. showed the total annual cost of hospitalisation in the USA was 2.2 billion dollars.[9] The current study showed a clear-cut difference in expenditure incurred in different strata of hospitals with high-volume centres showing lower costs involved in patients who underwent procedure-related interventions. In a developing country like India, ANP poses a significant challenge in terms of its clinical and financial aspects. Although the accessibility to health care has improved in the last few years, the accessibility to quality health care still remains a distant dream for many. ANP not only demands quality health care but also requires precise management. Although standardisation of the management of ANP has improved its outcome in recent years, only a few centres follow protocol-based management of ANP. So, stratifying the centres as per their ANP patient volume may help in improving outcomes. The minimally invasive aspect of the management of ANP is available in few apex healthcare institutes and private institutions. Similarly, open necrosectomy is only being practised in a few specialised centres. Hence, high-volume centres can provide a better algorithm-based management of ANP. One of the issues in developing countries is patients usually pay from their pocket for hospital care which acts as a barrier to assess quality health care from private institutions. Although the step-up approach by the Dutch group did not show any significant difference in mortality rate compared to open necrosectomy (16% vs. 19%, P = 0.70), it should be kept in mind that the result may not have achieved statistical significance owing to small sample size. In that case, the step-up approach may not hold any advantage over open necrosectomy. We must remember that the step-up approach requires more frequent interventions and higher costs whereas an upfront open necrosectomy is associated with only a slightly increased mortality and should perhaps be continued in hospitals which have inadequate support systems.[10] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Article Information Nzenwa IC, Panossian VS, DeWane MP, Albutt KH, Hernandez-Barco YG, Fernandez-del Castillo CF, et al. Volume Matters: Examining The Management Of Necrotizing Pancreatitis In The United States. Annals of Surgery. 2025:10-97.