Association between institutional procedural preference and in-hospital outcomes in laparoscopic surgeries; Insights from a retrospective cohort analysis of a nationwide surgical database in Japan

OBJECTIVE: To assess the use of laparoscopic surgeries (LS) and the association between its performance and hospitals’ preference for LS over open surgeries. SUMMARY BACKGROUND DATA: LS is increasingly used in many abdominal surgeries, albeit both with and without solid guideline recommendations. To date, the hospitals’ preference (LS vs. open surgeries) and its association with in-hospital outcomes has not been evaluated. METHODS: We enrolled patients undergoing 8 types of gastrointestinal surgeries in 2011–2013 in the Japanese National Clinical Database. We assessed the use of LS and the occurrences of surgery-related morbidity and mortality during the study period. Further, for 4 typical LS procedures, we assessed the hospitals’ preference for LS by modeling the propensity to perform LS (over open surgeries) from patient-level factors, and estimating each institution’s observed/expected (O/E) ratio for LS use. Institutions with O/E>2 were defined as LS-dominant. Using hierarchical logistic regression models, we assessed the association between LS preference and in-hospital outcomes. RESULTS: Among 1,377,118 patients undergoing gastrointestinal procedures in 2,336 participating hospitals, use of LS increased in all 8 procedures (35.1% to 44.7% for distal gastrectomy (DG), and 27.5% to 43.2% for right hemi colectomy (RHC)). Those operated at LS-dominant hospitals were at an increased risk of operative death (OR 1.83 [95%CI, 1.37–2.45] for DG, 1.79 [95%CI, 1.43–2.25] for RHC) compared to standard O/E level hospitals (0.5≤O/E<2.0). CONCLUSIONS: LS use widely increased during 2011–2013 in Japan. Facilities with higher than expected LS use had higher mortality compared to other hospitals, suggesting a need for careful patient selection and dissemination of the procedure.