Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website http://www.gastrores.org

Original Article

Volume 3, Number 2, April 2010, pages 65-73

Effect of Hospital Characteristics on the Quality of Laparoscopic Gastrectomy in Japan

**Table 1.** Patient or hospital characteristics, care process and outcomes by hospital volume category (n, %).
	LVH	IVH	HVH	P
^†; Compared using analysis of variance. Other comparisons made using Fisher's exact test.
LVH; low volume hospital. IVH; intermediate volume hospital. HVH; high volume hospital.
ASA; American Society Anesthesiologist.
Age (y)	Mean, [SD]	64.2 [11.7]	65.0 [11.5]	64.9 [11.5]	<0.148†
	65≤	658 (51.0)	700 (55.5)	740 (54.3)	0.057
Gender
	Male	804 (62.3)	813 (64.5)	903 (66.3)	0.096
Outcome
	Mortality	5 (0.4)	3 (0.2)	5 (0.4)	0.776
CCI
	1	238 (18.4)	244 (19.3)	177 (13.0)	<0.001
	2	83 (6.4)	99 (7.9)	90 (6.6)
	3≤	39 (3.0)	55 (4.4)	35 (2.6)
Principal diagnosis
	Malignancy	1111 (86.1)	1152 (91.4)	1286 (94.4)	<0.001
ASA
	1	1165 (90.2)	1191 (94.4)	1253 (92.0)	0.001
	2	114 (8.8)	68 (5.4)	103 (7.6)
	3≤	12 (0.9)	2 (0.2)	6 (0.4)
Gastrectomy
	Partial	1206 (93.4)	1134 (89.9)	1158 (85.0)	<0.001
	Total	85 (6.6)	127 (10.1)	204 (15.0)

Complication	136 (10.5)	151 (12.0)	138 (10.1)	0.286
Ownership
	National	212 (16.4)	311 (24.7)	349 (25.6)	<0.001
	Municipal	253 (19.6)	201 (15.9)	219 (16.1)
	Non profit private	487 (37.7)	225 (17.8)	202 (14.8)
	Private for profit	339 (26.3)	524 (41.6)	592 (43.5)
Teaching status
	Community	1020 (79.0)	665 (52.7)	614 (45.1)	<0.001
	Teaching	271 (2.01)	596 (47.3)	748 (54.9)
FY
	2006	323 (25.0)	379 (30.1)	360 (26.4)	0.002
	2007	410 (31.8)	429 (34.0)	467 (34.3)
	2008	558 (43.2)	453 (35.9)	535 (39.3)

Table 1. Patient or hospital characteristics, care process and outcomes by hospital volume category (n, %).

LVH

IVH

HVH

Overall

1291

1261

1362

^†; Compared using analysis of variance. Other comparisons made using Fisher's exact test.

LVH; low volume hospital. IVH; intermediate volume hospital. HVH; high volume hospital.

ASA; American Society Anesthesiologist.

Age (y)

Mean, [SD]

64.2 [11.7]

65.0 [11.5]

64.9 [11.5]

<0.148†

65≤

658 (51.0)

700 (55.5)

740 (54.3)

0.057

Gender

Male

804 (62.3)

813 (64.5)

903 (66.3)

0.096

Outcome

Mortality

5 (0.4)

3 (0.2)

5 (0.4)

0.776

CCI

238 (18.4)

244 (19.3)

177 (13.0)

<0.001

83 (6.4)

99 (7.9)

90 (6.6)

3≤

39 (3.0)

55 (4.4)

35 (2.6)

Principal diagnosis

Malignancy

1111 (86.1)

1152 (91.4)

1286 (94.4)

<0.001

ASA

1165 (90.2)

1191 (94.4)

1253 (92.0)

0.001

114 (8.8)

68 (5.4)

103 (7.6)

3≤

12 (0.9)

2 (0.2)

6 (0.4)

Gastrectomy

Partial

1206 (93.4)

1134 (89.9)

1158 (85.0)

<0.001

Total

85 (6.6)

127 (10.1)

204 (15.0)

Complication

136 (10.5)

151 (12.0)

138 (10.1)

0.286

Ownership

National

212 (16.4)

311 (24.7)

349 (25.6)

<0.001

Municipal

253 (19.6)

201 (15.9)

219 (16.1)

Non profit private

487 (37.7)

225 (17.8)

202 (14.8)

Private for profit

339 (26.3)

524 (41.6)

592 (43.5)

Teaching status

Community

1020 (79.0)

665 (52.7)

614 (45.1)

<0.001

Teaching

271 (2.01)

596 (47.3)

748 (54.9)

2006

323 (25.0)

379 (30.1)

360 (26.4)

0.002

2007

410 (31.8)

429 (34.0)

467 (34.3)

2008

558 (43.2)

453 (35.9)

535 (39.3)

**Table 2.** Care procedures and resource use by hospital volume category.
	LVH	IVH	HVH	P
SD; standard deviation. *;compared using Fisher's exact test. Other comparisons made using analysis of variance.
Care process
Chemotherapy	29 (2.2)	14 (1.1)	12 (0.9)	0.006*
Blood transfusion
preoperative, n (%)	18 (1.4)	10 (0.8)	19 (1.4)	0.271
preoperative ml, mean [SD]	1611.1 [1365.9]	1520.0 [1174.5]	3010.5 [5019.7]	0.336
operative or postoperative, n (%)	51 (4.0)	40 (3.2)	41 (3.0)	0.363
operative or postoperative ml, mean [SD]	1431.4 [1005.1]	1130.0 [874.2]	2351.2 [3525]	0.027
overall n (%)	62 (4.8)	45 (3.6)	57 (4.2)	0.298
overall ml, mean [SD]	1645.2 [1298.9]	1342.2 [1142.3]	2694.7 [4105.4]	0.022
Postoperative fasting period
days [SD]	5.1 [3.9]	4.7 [3.0]	4.4 [3.3]	<0.001
Use of pain control
n (%)	1024 (79.3)	1015 (80.5)	1017 (74.7)	0.001
day [SD]	3.0 [1.9]	2.7 [1.3]	3.0 [3.1]	<0.001
Use of circular stapling devices n (%)	601 (46.6)	591 (46.9)	660 (48.5)	0.572
Number of circular stapling devices fired	1.1 [0.2]	1.1 [0.2]	1.1 [0.2]	0.829
Use of linear stapling devices n (%)	1057 (81.9)	1042 (82.6)	1196 (87.8)	<0.001
Number of linear stapling devices fired	2.5 [1.1]	2.5 [0.9]	2.5 [1.0]	0.986
Resource use
OT, min [SD]	338.3 [113.1]	361.3 [108.1]	337.3 [97.4]	<0.001
Postoperative LOS, days [SD]	18.4 [11.9]	16.6 [10.9]	15.9 [10.2]	<0.001
LOS, days [SD]	23.3 [15.2]	21.3 [13.0]	20.1 [11.7]	<0.001
Postoperative TC, $ [SD]	4558.5 [4389.5]	4087 [3615]	4204.9 [4843.8]	0.016
TC, $ [SD]	14464.2 [6184.1]	14211 [5026.2]	14527.4 [5934.3]	0.334

Table 2. Care procedures and resource use by hospital volume category.

LVH

IVH

HVH

SD; standard deviation. *;compared using Fisher's exact test. Other comparisons made using analysis of variance.

Care process

Chemotherapy

29 (2.2)

14 (1.1)

12 (0.9)

0.006*

Blood transfusion

preoperative, n (%)

18 (1.4)

10 (0.8)

19 (1.4)

0.271

preoperative ml, mean [SD]

1611.1 [1365.9]

1520.0 [1174.5]

3010.5 [5019.7]

0.336

operative or postoperative, n (%)

51 (4.0)

40 (3.2)

41 (3.0)

0.363

operative or postoperative ml, mean [SD]

1431.4 [1005.1]

1130.0 [874.2]

2351.2 [3525]

0.027

overall n (%)

62 (4.8)

45 (3.6)

57 (4.2)

0.298

overall ml, mean [SD]

1645.2 [1298.9]

1342.2 [1142.3]

2694.7 [4105.4]

0.022

Postoperative fasting period

days [SD]

5.1 [3.9]

4.7 [3.0]

4.4 [3.3]

<0.001

Use of pain control

n (%)

1024 (79.3)

1015 (80.5)

1017 (74.7)

0.001

day [SD]

3.0 [1.9]

2.7 [1.3]

3.0 [3.1]

<0.001

Use of circular stapling devices n (%)

601 (46.6)

591 (46.9)

660 (48.5)

0.572

Number of circular stapling devices fired

1.1 [0.2]

0.829

Use of linear stapling devices n (%)

1057 (81.9)

1042 (82.6)

1196 (87.8)

<0.001

Number of linear stapling devices fired

2.5 [1.1]

2.5 [0.9]

2.5 [1.0]

0.986

Resource use

OT, min [SD]

338.3 [113.1]

361.3 [108.1]

337.3 [97.4]

<0.001

Postoperative LOS, days [SD]

18.4 [11.9]

16.6 [10.9]

15.9 [10.2]

<0.001

LOS, days [SD]

23.3 [15.2]

21.3 [13.0]

20.1 [11.7]

<0.001

Postoperative TC, $ [SD]

4558.5 [4389.5]

4087 [3615]

4204.9 [4843.8]

0.016

TC, $ [SD]

14464.2 [6184.1]

14211 [5026.2]

14527.4 [5934.3]

0.334

**Table 3.** Factors associated with complication.
	Complication
CI; Confidence interval. ***; not included in the model.
ASA; American Society Anesthesiologist. HL; Hosmer Lemeshow.
Age (y)
<65	1.000
65≤	1.322	[1.072 - 1.632]
Sex
Female	1.000
Male	1.052	[0.845 - 1.311]
CCI
absent	1.000
1	1.654	[1.287 - 2.127]
2	1.304	[0.891 - 1.907]
3≤	2.055	[1.292 - 3.268]
Principal diagnosis
Benign	1.000
Malignancy	0.950	[0.645 - 1.398]
ASA
1	1.000
2	1.244	[0.855 - 1.810]
3≤	1.214	[0.345 - 4.275]
Chemothrapy
absent	1.000
present	0.800	[0.315 - 2.034]
Preoperative blood transfusion
absent	1.000
present	0.792	[0.304 - 2.065]
Gatsrectomy
Partial gastrectomy	1.000
Total gastrectomy	1.188	[0.862 - 1.638]
OT
one more minute	1.002	[1.001 - 1.003]
Postoperative pain control
absent	1.000
present	0.834	[0.654 - 1.062]
Hospital patient volume
one more case	0.997	[0.994 - 0.999]
Ownership
National	1.000
Municipal	1.059	[0.709 - 1.584]
Non profit private	0.963	[0.645 - 1.438]
Private for profit	1.264	[0.945 - 1.690]
Teaching status
Community	1.000
Teaching	1.250	[0.933 - 1.674]
FY
2006	1.000
2007	1.003	[0.761 - 1.322]
2008	1.304	[1.009 - 1.684]
HL goodness of model fit.	0.838

Table 3. Factors associated with complication.

Complication

Odds ratio

[ 95% CI ]

CI; Confidence interval. ***; not included in the model.

ASA; American Society Anesthesiologist. HL; Hosmer Lemeshow.

Age (y)

<65

1.000

65≤

1.322

[1.072 - 1.632]

Sex

Female

1.000

Male

1.052

[0.845 - 1.311]

CCI

absent

1.000

1.654

[1.287 - 2.127]

1.304

[0.891 - 1.907]

3≤

2.055

[1.292 - 3.268]

Principal diagnosis

Benign

1.000

Malignancy

0.950

[0.645 - 1.398]

ASA

1.000

1.244

[0.855 - 1.810]

3≤

1.214

[0.345 - 4.275]

Chemothrapy

absent

1.000

present

0.800

[0.315 - 2.034]

Preoperative blood transfusion

absent

1.000

present

0.792

[0.304 - 2.065]

Gatsrectomy

Partial gastrectomy

1.000

Total gastrectomy

1.188

[0.862 - 1.638]

one more minute

1.002

[1.001 - 1.003]

Postoperative pain control

absent

1.000

present

0.834

[0.654 - 1.062]

Hospital patient volume

one more case

0.997

[0.994 - 0.999]

Ownership

National

1.000

Municipal

1.059

[0.709 - 1.584]

Non profit private

0.963

[0.645 - 1.438]

Private for profit

1.264

[0.945 - 1.690]

Teaching status

Community

1.000

Teaching

1.250

[0.933 - 1.674]

2006

1.000

2007

1.003

[0.761 - 1.322]

2008

1.304

[1.009 - 1.684]

HL goodness of model fit.

0.838

**Table 4.** Factors associated with operating time (OT), length of stay (LOS) and total charge (TC).
	OT (min)	LOS	TC
F test for the model. P<0.001. Coefficient of determination; OT 0.207, LOS 0.207, TC 0.297.
^†; operative blood transfusion in operating day. ***; not included in the regression model. ASA; American Society Anesthesiologist.
Intercept	234.3	8.0	<0.001	18.1	1.0	<0.001	9724	406	<0.001
Age	-4.9	3.1	0.117	2.3	0.4	<0.001	828	157	<0.001
Male	25.1	3.2	<0.001	1.1	0.4	0.006	805	163	<0.001
CCI (for zero)
1	8.3	4.2	0.048	2.8	0.5	<0.001	715	212	0.001
2	18.5	6.1	0.003	2.6	0.8	0.001	982	311	0.002
3 ≤	24.2	8.7	0.005	3.3	1.1	0.002	1572	439	<0.001
Principal diagnosis
Malignancy	116.0	5.4	<0.001	1.8	0.7	0.009	2132	272	<0.001
ASA (for 1)
2	5.9	6.0	0.326	0.9	0.8	0.244	287	306	0.348
3–5	4.7	21.5	0.826	-4	2.7	0.142	-786	1090	0.471
Chemotherapeutic agent
administered	12.6	13.0	0.331	14.6	1.6	<0.001	4444	659	<0.001
Preoperative blood transfusion
Present	-21.4	14.3	0.135	20.6	1.8	<0.001	7490	725	<0.001
Gastrectomy (for partial gastrectomy)
Total gastrectomy	74.2	5.0	0.000	5.3	0.6	<0.001	4843	254	<0.001
Postoperative pain control
Present	4.0	3.8	0.283	-0.6	0.5	0.207	311	191	0.103
Complication
Present	***	7.0	0.6	<0.001	2535	250	<0.001
Operative/postoperative blood transufusion†
Present	71.1	11.4	<0.001	16.2	1.1	<0.001	9728	439	<0.001
Hospital patient volume
one more case	-0.251	0.050	<0.001	-0.034	0.006	<0.001	-6	3	0.015
Ownership (for national)
Municipal	-31.7	6.0	<0.001	-1.5	0.8	0.050	-726	306	0.018
Non profit private	-21.8	5.9	<0.001	-0.1	0.7	0.938	-104	301	0.729
Private for profit	-17.8	4.5	<0.001	-1.5	0.6	0.007	-157	229	0.494
Teaching status
Academic	5.8	4.6	0.203	1.8	0.6	0.002	851	232	<0.001
FY (for 2006)
2007	4.3	3.9	0.274	-0.9	0.5	0.058	111	200	0.579
2008	-1.5	3.8	0.696	-2.6	0.5	<0.001	196	193	0.311

Table 4. Factors associated with operating time (OT), length of stay (LOS) and total charge (TC).

OT (min)

LOS

Estimation

95% CI

Estimation

95% CI

Estimation

95% CI

F test for the model. P<0.001. Coefficient of determination; OT 0.207, LOS 0.207, TC 0.297.

^†; operative blood transfusion in operating day. ***; not included in the regression model. ASA; American Society Anesthesiologist.

Intercept

234.3

8.0

<0.001

18.1

1.0

<0.001

9724

406

<0.001

Age

-4.9

3.1

0.117

2.3

0.4

<0.001

828

157

<0.001

Male

25.1

3.2

<0.001

1.1

0.4

0.006

805

163

<0.001

CCI (for zero)

8.3

4.2

0.048

2.8

0.5

<0.001

715

212

0.001

18.5

6.1

0.003

2.6

0.8

0.001

982

311

0.002

3 ≤

24.2

8.7

0.005

3.3

1.1

0.002

1572

439

<0.001

Principal diagnosis

Malignancy

116.0

5.4

<0.001

1.8

0.7

0.009

2132

272

<0.001

ASA (for 1)

5.9

6.0

0.326

0.9

0.8

0.244

287

306

0.348

3–5

4.7

21.5

0.826

-4

2.7

0.142

-786

1090

0.471

Chemotherapeutic agent

administered

12.6

13.0

0.331

14.6

1.6

<0.001

4444

659

<0.001

Preoperative blood transfusion

Present

-21.4

14.3

0.135

20.6

1.8

<0.001

7490

725

<0.001

Gastrectomy (for partial gastrectomy)

Total gastrectomy

74.2

5.0

0.000

5.3

0.6

<0.001

4843

254

<0.001

Postoperative pain control

Present

4.0

3.8

0.283

-0.6

0.5

0.207

311

191

0.103

Complication

Present

***

7.0

0.6

<0.001

2535

250

<0.001

Operative/postoperative blood transufusion†

Present

71.1

11.4

<0.001

16.2

1.1

<0.001

9728

439

<0.001

Hospital patient volume

one more case

-0.251

0.050

<0.001

-0.034

0.006

<0.001

-6

0.015

Ownership (for national)

Municipal

-31.7

6.0

<0.001

-1.5

0.8

0.050

-726

306

0.018

Non profit private

-21.8

5.9

<0.001

-0.1

0.7

0.938

-104

301

0.729

Private for profit

-17.8

4.5

<0.001

-1.5

0.6

0.007

-157

229

0.494

Teaching status

Academic

5.8

4.6

0.203

1.8

0.6

0.002

851

232

<0.001

FY (for 2006)

2007

4.3

3.9

0.274

-0.9

0.5

0.058

111

200

0.579

2008

-1.5

3.8

0.696

-2.6

0.5

<0.001

196

193

0.311