The effect of ICU physician staffing and hospital volume on outcomes after hepatic resection

Outcomes following complex surgical procedures vary between medical centers. High-volume providers demonstrate superior outcomes to low-volume centers. We hypothesize that differences in intensive care unit (ICU) physician staffing are associated with outcomes following hepatic resection. Data on ICU staffing was obtained from a questionnaire and linked to clinical and economic data from the Health Services Cost Review Commission (HSCRC) for all adult patients who had hepatectomy (n = 569) in the state of Maryland from 1994 to 1998. Multivariate regression with hierarchical modeling was used to determine the association between in-hospital mortality, length of stay, postoperative complications, and health care costs with daily rounds by an ICU physician after adjusting for patient and hospital characteristics. The crude in-hospital mortality rate was 1.5% in hospitals that have daily rounds by an ICU physician versus 7.8% in hospitals that did not (p = 0.001). In a multivariate analysis, adjusting for case mix and hospital and surgeon volume, lack of daily rounds by an ICU physician was associated with a fourfold increased in-hospital mortality, [odds ratio (OR) 3.8; 95% confidence interval (CI) 1.4-10.2]. In addition, reintubation (OR 16.2; 95% CI 3.8-67.0), pulmonary insufficiency (OR 8.0; 95% CI 1.8-35.0), pneumonia (OR 3.7; 95% CI 1.2-11.3), and acute renal failure (OR 9.3; 95% CI 1.2-74) were more frequent without daily rounds by an ICU physician. Low-volume hospitals had a 21% (95% CI 2-44%; p = 0.03) increased length of stay and a 22% increased total hospital cost (95% CI 1-48%; p = 0.04) compared with high-volume hospitals. Both daily rounds by an ICU physician and high hospital volume are associated with improved outcomes after hepatic resection. Patients undergoing high-risk surgery should seek referral to centers with both daily rounds by an ICU physician and extensive experience with the operation.