Hospital-Level Determinants of Mortality After Pancreas Surgery

Abstract

OBJECTIVE: To identify modifiable hospital-level determinants of mortality after pancreas surgery and assess their cumulative protective effects through the development of a Hospital Resource Index (HRI) on a global scale. BACKGROUND: Ninety-day mortality rates after pancreas surgery vary globally (2%-10%); however, institutional factors affecting mortality remain poorly understood. Although caseload volume has driven centralization policies in many health care systems, it is not fully explanatory, and the impact of specific modifiable structural and process-related hospital factors remains unclear. METHODS: We linked patient outcome data from the 2021 PancreasGroup.org global prospective cohort to hospital infrastructure data from the PancreasGroup.org global survey. Binary availability of 20 hospital-level factors was assessed. Factors significantly associated with mortality on univariable multilevel regression were combined into an additive HRI. Multivariable logistic regression evaluated associations between HRI and 90-day mortality. RESULTS: Analyses included 2928 patients from 214 centers across 60 countries. Six hospital factors were significantly associated with lower mortality, including interventional radiology/endoscopy availability, structured nutrition support, evidence-based practice adoption, staff training, equipment maintenance, and favorable nurse-patient ratios. Each additional HRI point was associated with 12% lower mortality odds (OR: 0.88, 95% CI: 0.81-0.95, P=0.001), independent of caseload volume (OR: 0.73, P=0.014, optimal cutoff 55 cases per year), country's development index, and patient and procedural characteristics. Patients at hospitals with all 6 HRI resources had a 54% lower mortality rate compared with those at hospitals with none. CONCLUSIONS: The developed HRI showed cumulative protective effects on mortality after pancreas surgery, with volume remaining independently protective in the adjusted model, providing actionable targets for resource allocation to enhance pancreas surgery outcomes beyond centralization globally.