Provider versus patient factors impacting hospital length of stay after pancreaticoduodenectomy Eric B. Schneider, PhD, a Omar Hyder, MD, a Christopher L. Wolfgang, MD, PhD, a Rebecca M. Dodson, MD, a Adil H. Haider, MD, a Joseph M. Herman, MD, b and Timothy M. Pawlik, MD, MPH, PhD, a Baltimore, MD Background. Studies reporting perioperative outcomes after pancreaticoduodenectomy (PD) have focused on morbidity and mortality. Understanding factors that impact hospital duration of stay may have cost- saving implications. We sought to examine variation in duration of stay after PD occurring at the patient, surgeon, and hospital levels. Methods. Year-specific PD volumes for both surgeons and hospitals were determined from the 2003–2009 Nationwide Inpatient Sample and grouped into terciles. Patient age, gender, and comorbidities were examined. Median duration of stay was calculated and modified Poisson regression examined factors associated with duration of stay. Results. Among 5,190 individuals undergoing PD, median age was 65 years and 49.3% were female. Median duration of stay was 13 days (range, 0–234). Older patients and those with comorbid illness were more likely to have duration of stay of $14 days (P < .001). Median annual surgeon volume was 8 (interquartile range [IQR], 2–19; range, 1–54). Annual hospital volume ranged from 1 to 129 (median, 18; IQR, 6–52). Both low surgeon and hospital PD volume were associated with longer du- rations of stay (P < .001). In multivariable modeling, age remained associated with duration of stay (relative risk [RR], 1.007 per year; P < .001); however, comorbidity did not. Patients operated on by high-volume surgeons (RR, 0.67) or at high-volume hospitals (RR, 0.75) had a reduced risk of a prolonged duration of stay of $14 days (both P < .001). Conclusion. PD patients treated by higher volume surgeons and at higher volume hospitals had a shorter duration of stay. Although some patient-level factors impact duration of stay after PD, nonclinical factors such as surgeon and hospital volume were also important contributors to duration of stay. (Surgery 2013;154:152-61.) From the Departments of Surgery a and Radiation Oncology, b Johns Hopkins School of Medicine, Baltimore, MD AS THE COST OF HEALTHCARE continues to rise, there is ongoing interest in identifying ways to streamline certain aspects of healthcare delivery. Specifically, given that a substantial portion of all healthcare expenditures are related to in-hospital patient care, there has been a focus on trying to decrease costly inpatient hospital stay. 1 Some investigators have proposed duration of stay as an indicator of health service efficiency, with a shorter duration of stay possibly associated with improved overall quality. 2 Most initiatives around shortening duration of stay have come from the field of colo- rectal surgery, where enhanced recovery programs have been proposed and implemented with some success. 3 In fact, our group previously reported that patients with a shorter duration of stay after colorectal surgery for colon cancer had better out- comes compared with patients who had a pro- longed duration of stay, because the latter group was much more likely to be readmitted. 4 Despite the high level of interest in duration of stay, few studies have examined which factors specifically impact hospital duration of stay after an operation. 5 Although investigations into duration of stay may not be as relevant to some procedures, understand- ing factors that impact duration of stay for complex operations that have been traditionally associated with long duration of stay is important. Understand- ing factors that impact hospital duration of stay may have cost-saving implications, as well as assist in the Accepted for publication March 28, 2013. Reprint requests: Timothy M. Pawlik, MD, MPH, PhD, Associate Professor of Surgery and Oncology, Chief, Division of Surgical Oncology, Department of Surgery, Blalock 688, 600 N. Wolfe Street, Baltimore, MD 21287. E-mail: tpawlik1@jhmi.edu. 0039-6060/$ - see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2013.03.013 152 SURGERY