© 2005 by the Society forNeuro-Oncology
Surgery for primary supratentorial brain tumors in the United States,1988 to 2000: The effect of provider caseload and centralization of care
Stephen E. and Catherine Pappas Center for Neuro-Oncology,Neurosurgical Service, Massachusetts General Hospital, and Department ofSurgery (Neurosurgery), Harvard Medical School, Boston, MA 02114,USA
1 Address correspondence to Fred G. Barker, Brain Tumor Center — Cox 315,Massachusetts General Hospital, Fruit Street, Boston, MA 02114, USA(barker{at}helix.mgh.harvard.edu).
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Abstract |
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Contemporary reports of patient outcomes after biopsy or resection ofprimary brain tumors typically reflect results at specialized centers. Suchreports may not be representative of practices in nonspecialized settings.This analysis uses a nationwide hospital discharge database to examine trendsin mortality and outcome at hospital discharge in 38,028 admissions for biopsyor resection of supratentorial primary brain tumors in adults between 1988 and2000, particularly in relation to provider caseload. Multivariate analysesshowed that large-volume centers had lower in-hospital postoperative mortalityrates than centers with lighter caseloads, both for craniotomies (odds ratio[OR] 0.75 for a tenfold larger caseload) and for needle (closed) biopsies (OR0.54). Adverse discharge disposition was also less likely at high-volumehospitals, both for craniotomies (OR 0.77) and for needle biopsies (OR 0.67).The annual number of surgical admissions increased by 53% during the 12-yearstudy period, and in-hospital mortality rates decreased during this period,from 4.8% to 1.8%. Mortality rates decreased over time, both for craniotomiesand for needle biopsies. Subgroup analyses showed larger relative mortalityrate reductions at large-volume centers than at small-volume centers (73% vs.43%, respectively). The number of U.S. hospitals performing one or morecraniotomies annually for primary brain tumors decreased slightly, and thenumber performing needle biopsies increased. There was little change in medianhospital annual craniotomy caseloads, but the largest centers haddisproportionate growth in volume. The 100 highest-caseload U.S. hospitalsaccounted for an estimated 30% of the total U.S. surgical primary brain tumorcaseload in 1988 and 41% in 2000. Our findings do not establish minimum volumethresholds for acceptable surgical care of primary brain tumors. However, theydo suggest a trend toward progressive centralization of craniotomies forprimary brain tumor toward large-volume U.S. centers during this interval.
Received February 11, 2004; Accepted July 15, 2004
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