ORIGINAL ARTICLE Hospital Volume and the Costs Associated with Surgery for Pancreatic Cancer Faiz Gani 1 & Fabian M Johnston 1 & Howard Nelson-Williams 1 & Marcelo Cerullo 1 & Mary E Dillhoff 2 & Carl R Schmidt 2 & Timothy M. Pawlik 2,3 Received: 2 May 2017 /Accepted: 14 June 2017 # 2017 The Society for Surgery of the Alimentary Tract Abstract Background Data evaluating the financial implications of volume-based referral are lacking. This study sought to compare in- hospital costs for pancreatic surgery by annual hospital volume. Methods Eleven thousand and eighty-one patients aged ≥18 years undergoing an elective pancreatic resection for cancer were identified using the Nationwide Inpatient Sample 2002–2011. Multivariable regression analysis was performed to compare length-of-stay (LOS), postoperative morbidity and mortality, failure-to-rescue (FTR), and inpatient costs by annual hospital volume group. Results Patients undergoing surgery at high-volume hospitals (HVH) demonstrated 23% lower odds (odds ratio [OR] = 0.77, 95% confidence interval [95%CI] 0.63–0.95) of developing a postoperative complication, 59% lower odds of experiencing an LOS > 14 days (OR = 0.41, 95%CI 0.34–0.50), 51% lower odds of postoperative mortality (OR = 0.49, 95%CI 0.34–0.71), and 47% lower odds of FTR (OR = 0.53, 95%CI 0.37–0.76; all p<0.05). The overall mean in-hospital cost was $39,012 (SD = $15,214) with minimal differences observed across hospital volume groups. Rather, postoperative complications (no complication vs. complication $26,686 [SD = $5762] vs. $44,633 [SD = $11,637]) and FTR (rescue vs. FTR $42,413 [SD = $8481] vs. $69,546 [SD = $13,131]) were determinant of higher in-hospital costs. While this pattern was observed at all hospital volume groups, costs varied minimally between hospital volume groups after this stratification. Conclusions Annual hospital surgical volume was not associated with in-hospital costs among patients undergoing pancreatic surgery. Keywords Pancreas . Cost . Volume-outcome . Selective-referral Introduction The volume-outcome relationship was initially described in 1979 by Luft and colleagues. 1 In their seminal work, the authors dem- onstrated an association between increasing hospital volume and improved postoperative mortality. 1 Since then, a large body of literature has similarly described an inverse relationship between hospital volume and postoperative clinical outcomes, resulting in the regionalization of complex, high-risk operations to high- volume hospitals. 2–6 Although the volume-outcome relationship is well-established and has remained consistent over time, the financial implications associated with the volume-based referral of patients remain largely unexplored. 7–11 Referral to high- This study was presented as an oral presentation at the American College of Surgeons, Clinical Congress held in Washington D.C., between October 16 and 20, 2016. Electronic supplementary material The online version of this article (doi:10.1007/s11605-017-3479-x) contains supplementary material, which is available to authorized users. * Timothy M. Pawlik tim.pawlik@osumc.edu 1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA 2 Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA 3 Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center at The Ohio State University, 395 W. 12th Avenue, Suite 670, Columbus, OH 43210, USA J Gastrointest Surg DOI 10.1007/s11605-017-3479-x