2025 Proffered Presentations
S027: PITUITARY CENTERS OF EXCELLENCE: DISPARITIES AND REGIONALIZATION OF CARE IN CALIFORNIA
Michael G Brandel, MD1; Julia Cochrane, BS1; Chris Reid, MD1; Adam Deconde, MD1; Thomas L Beaumont, MD, PhD1; Alexander A Khalessi, MD1; Robert C Rennert, MD2; 1University of California, San Diego; 2University of Utah
Background: There is an increasing nationwide focus on patient-centered and value-based care. High-volume centers for surgical pituitary care with the presence of the necessary multidisciplinary teams have been designated as Pituitary Centers of Excellence (PCOE). Using a longitudinal large database, we sought to determine the impact of hospital characteristics on surgical outcomes, as well as the demographic or socioeconomic factors that enable care at high-volume centers.
Methods : Patients who had undergone transsphenoidal resection (TSR) of a benign pituitary tumor from 2008 to 2018 were identified in the California Office of Statewide Health Planning and Development database. International Classification of Disease, ninth and tenth revision diagnostic and procedure codes were used to identify candidate admissions. Patient home zip codes and hospital facility addresses were used to determine travel distance ‘as the crow flies.’ Zip codes were also used to determine social deprivation index (SDI) and median incomes. Comorbidities were evaluated using the Elixhauser comorbidity index. Annual hospital TSR volume was calculated. Patients in the bottom half of travel distance and volume (Short travel/Low-Volume: STLV) were compared to patients in the top half of travel distance and volume (Long-travel/High-Volume: LTHV). Outcomes of interest were postoperative cerebrospinal fluid (CSF) leak, any complication, and length of stay (LOS). Binary outcomes were investigated using multivariable logistic regression, and continuous variables were analyzed with generalized linear models with a log link. All analyses were completed using Stata version 18.0, and significance defined as p<0.05.
Results: A total of 8612 patients were identified who underwent TSR at 138 unique facilities in California. The median volume facility performed an average of 21.9 TSRs per year over the 11 years studied (interquartile range [IQR] 6.0-43.2; Figure 1). Patients traveled a median of 26.0 miles (IQR 11.4-67.4) from home to the surgical facility (Figure 2). Median LOS was 3.0 days (IQR 2.0-4.0). CSF leak occurred for 5.5% of all patients. One-year tumor reoperation rate was 2.8%. Assessed as a continuous variable on multivariable analysis, annual hospital volume was associated with reduced odds of a CSF leak (OR=.996, 95% confidence interval [CI] 0.992-0.999, p=0.017) or any complication (OR=0.991, 95% CI 0.987-0.997, p=0.001), as well as a shorter LOS (B= -0.005, 95% CI 0.005-0.003, p<0.001). LTHV patients had shorter LOS (B=-0.28, 95% CI -0.34-0.22, p<0.001) and reduced likelihood of repeat TSR for tumor resection within 1 year (OR=0.53, 95% CI 0.30-0.91), p=0.023).
Conclusions: Hospital volume is associated with improved outcomes for transsphenoidal pituitary surgery. Geographic spread may present a challenge to obtaining care at centers of excellence.
Figure 1. Histogram demonstrating distance (miles) between patient homes and their TSR hospital.
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Figure 2. Map of California demonstrating locations of high-volume TSR centers and locations of patient homes.
