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Torabi SJ, Nguyen TV, Goshtasbi K, Roman KM, Tjoa T, Haidar YM, Djalilian HR, Kuan EC. The Current State of Regionalization in Otolaryngologic Specialized Tumor Care for Tumor Diagnoses. J Craniofac Surg 2024:00001665-990000000-01840. [PMID: 39190780 DOI: 10.1097/scs.0000000000010554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 07/16/2024] [Indexed: 08/29/2024] Open
Abstract
OBJECTIVE The current extent of otolaryngologic cancer care regionalization is unclear. This study characterizes case volume regionalization patterns for 4 distinct otolaryngologic tumors-head and neck squamous cell carcinomas (HNSCCs), thyroid cancers (TCs), vestibular schwannomas, and pituitary adenomas (PAs). METHODS The 2010-2016 National Cancer Database was queried for patients with HNSCCs, TCs, vestibular schwannomas, and PAs. Facility geographic locations were divided into 4 geographical quadrants. High-volume facilities (HVFs) were defined as top 100 by volume facility for ≥1 pathology. RESULTS A total of 191/1342 facilities (4.2%) were defined as an HVF. Vestibular schwannoma was the most regionalized, with 65.9% of patients treated at an HVF. Thyroid cancer (37.4%) and HNSCC (38.8%) were the least commonly treated at HVFs. Forty-one/191 (21.5%) were classified as HVFs for all 4 pathologies. Factors predictive of treatment at HVFs included age <65, higher income, and private insurance, larger tumor size, and lower American Joint Committee on Cancer stage. CONCLUSION Over 20% of HVFs were considered high-volume for all 4 pathologies. Vestibular schwannomas were the most regionalized compared with PAs, TCs, and HSNCCs.
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Affiliation(s)
- Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA
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Di J, Lu XS, Sun M, Zhao ZM, Zhang CD. Hospital volume-mortality association after esophagectomy for cancer: a systematic review and meta-analysis. Int J Surg 2024; 110:3021-3029. [PMID: 38353697 PMCID: PMC11093504 DOI: 10.1097/js9.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/29/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Postoperative mortality plays an important role in evaluating the surgical safety of esophagectomy. Although postoperative mortality after esophagectomy is partly influenced by the yearly hospital surgical case volume (hospital volume), this association remains unclear. METHODS Studies assessing the association between hospital volume and postoperative mortality in patients who underwent esophagectomy for esophageal cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random effects model. The dose-response association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with PROSPERO. RESULTS Fifty-six studies including 385 469 participants were included. A higher-volume hospital significantly reduced the risk of postesophagectomy mortality by 53% compared with their lower-volume counterparts (odds ratio, 0.47; 95% CI: 0.42-0.53). Similar results were found in subgroup analyses. Volume-outcome analysis suggested that postesophagectomy mortality rates remained roughly stable after the hospital volume reached a plateau of 45 esophagectomies per year. CONCLUSIONS Higher-volume hospitals had significantly lower postesophagectomy mortality rates in patients with esophageal cancer, with a threshold of 45 esophagectomies per year for a high-volume hospital. This remarkable negative correlation showed the benefit of a better safety in centralization of esophagectomy to a high-volume hospital.
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Affiliation(s)
| | | | - Min Sun
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China
| | - Zhe-Ming Zhao
- Department of Surgical Oncology, The Fourth Affiliated Hospital of China Medical University, Shenyang
| | - Chun-Dong Zhang
- Central Laboratory
- Department of Surgical Oncology, The Fourth Affiliated Hospital of China Medical University, Shenyang
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Liu ZY, Zhong Q, Wang ZB, Shang-Guan ZX, Lu J, Li YF, Huang Q, Wu J, Li P, Xie JW, Chen QY, Huang CM, Zheng CH. Appraisal of surgical outcomes and oncological efficiency of intraoperative adverse events in robotic radical gastrectomy for gastric cancer. Surg Endosc 2024; 38:2027-2040. [PMID: 38424283 DOI: 10.1007/s00464-024-10736-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 01/28/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Surgical quality control is a crucial determinant of evaluating the tumor efficacy. OBJECTIVE To assess the ClassIntra grade for quality control and oncological outcomes of robotic radical surgery for gastric cancer (GC). METHODS Data of patients undergoing robotic radical surgery for GC at a high-volume center were retrospectively analyzed. Patients were categorized into two groups, the intraoperative adverse event (iAE) group and the non-iAE group, based on the occurrence of intraoperative adverse events. The iAEs were further classified into five sublevels (ranging from I to V according to severity) based on the ClassIntra grade. Surgical performance was assessed using the Objective Structured Assessment of Technical Skill (OSATS) and the General Error Reporting Tool. RESULTS This study included 366 patients (iAE group: n = 72 [19.7%] and non-iAE group: n = 294 [80.3%]). The proportion of ClassIntra grade II patients was the highest in the iAE group (54.2%). In total and distal gastrectomies, iAEs occurred most frequently in the suprapancreatic area (50.0% and 54.8%, respectively). In total gastrectomy, grade IV iAEs were most common during lymph node dissection in the splenic hilum area (once for bleeding [grade IV] and once for injury [grade IV]). The overall survival (OS) and disease-free survival of the non-iAE group were significantly better than those of the iAE group (Log rank P < 0.001). Uni- and multi-variate analyses showed that iAEs were key prognostic indicators, independent of tumor stage and adjuvant chemotherapy (P < 0.001). CONCLUSION iAEs in patients who underwent robotic radical gastrectomy significantly correlated with the occurrence of postoperative complications and a poor long-term prognosis. Therefore, utilization and inclusion of ClassIntra grading as a crucial surgical quality control and prognostic indicator in the routine surgical quality evaluation system are recommended.
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Affiliation(s)
- Zhi-Yu Liu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qing Zhong
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zeng-Bin Wang
- Department of Immunology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Zhi-Xin Shang-Guan
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jun Lu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Yi-Fan Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Qiang Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Ju Wu
- Department of General Surgery, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Ping Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Jian-Wei Xie
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qi-Yue Chen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China.
| | - Chang-Ming Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China.
| | - Chao-Hui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China.
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Nash S, Weeks K, Kahl AR, Del Vecchio NJ, Gao X, Guyton K, Charlton M. Diagnosing Provider, Referral Patterns, Facility Type, and Patient Satisfaction Among Iowa Rectal Cancer Patients. J Gastrointest Cancer 2024; 55:355-364. [PMID: 37646879 PMCID: PMC11611274 DOI: 10.1007/s12029-023-00963-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Rectal cancer treatment at high-volume centers is associated with higher likelihood of guideline-concordant care and improved outcomes. Whether rectal cancer patients are referred for treatment at high-volume hospitals may depend on diagnosing provider specialty. We aimed to determine associations of diagnosing provider specialty with treating provider specialty and characteristics of the treating facility for rectal cancer patients in Iowa. METHODS Rectal cancer patients identified using the Iowa Cancer Registry completed a mailed survey on their treatment experience and decision-making process. Provider type was defined by provider specialty and whether the provider referred patients elsewhere for surgery. Multivariable-adjusted logistic regression models were used to examine predictors of being diagnosed by a general surgeon who also performed the subsequent surgery. RESULTS Of 417 patients contacted, 381 (76%) completed the survey; our final analytical sample size was 267. Half of respondents were diagnosed by a gastroenterologist who referred them elsewhere; 30% were diagnosed by a general surgeon who referred them elsewhere, and 20% were diagnosed by a general surgeon who performed the surgery. Respondents who were ≥ 65 years old, had less than a college education, and who made < $50,000 per year were more likely to be diagnosed by a general surgeon who performed surgery. In multivariable-adjusted models, respondents diagnosed and treated by the same general surgeon were more likely to have surgery at hospitals with low annual colorectal cancer surgery volume and less likely to be satisfied with their care. CONCLUSIONS Among rectal cancer patients in Iowa, respondents who were diagnosed and treated by the same provider were less likely to get treatment at a high-volume facility. This study informs the importance of provider referral in centralization of rectal cancer care.
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Affiliation(s)
- Sarah Nash
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
| | - Kristin Weeks
- Department of Internal Medicine, The Ohio State University Medical Center, 410 W Tenth Ave, Columbus, OH, 43210, USA
| | - Amanda R Kahl
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA
| | - Natalie J Del Vecchio
- Division of Public Health Science, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Xiang Gao
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr., IA, 52242, Iowa City, USA
| | - Kristina Guyton
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr., IA, 52242, Iowa City, USA
| | - Mary Charlton
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA.
- State Health Registry of Iowa, College of Public Health, University of Iowa, 145 N Riverside Dr., IA, 52242, Iowa City, USA.
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Koh YX, Zhao Y, Tan IEH, Tan HL, Chua DW, Loh WL, Tan EK, Teo JY, Au MKH, Goh BKP. The impact of hospital volume on liver resection: A systematic review and Bayesian network meta-analysis. Surgery 2024; 175:393-403. [PMID: 38052675 DOI: 10.1016/j.surg.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/07/2023] [Accepted: 10/25/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND This study aims to compare the outcomes of high-volume, medium-volume, and low-volume hospitals performing hepatic resections using a network meta-analysis. METHODS A literature search until June 2023 was conducted across major databases to identify studies comparing outcomes in high-volume, medium-volume, and low-volume hospitals for liver resection. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area values, odds ratio, and mean difference with 95% credible intervals were reported for postoperative mortality, failure-to-rescue, morbidity, length of stay, and hospital costs. RESULTS Twenty studies comprising 248,707 patients undergoing liver resection were included. For the primary mortality outcome, overall and subgroup analyses were performed: group I: high-volume = 5 to 20 resections/year; group II: high-volume = 21 to 49 resections/year; group III: high-volume ≥50 resections/year. Results demonstrated a significant association between hospital volume and mortality (overall-high-volume versus medium-volume: odds ratio 0.66, 95% credible interval 0.49-0.87; high-volume versus low-volume: odds ratio 0.52, 95% credible interval 0.41-0.65; group I-high-volume versus low-volume: odds ratio 0.34, 95% credible interval 0.22-0.50; medium-volume versus low-volume: odds ratio 0.56, 95% credible interval 0.33-0.92; group II-high-volume versus low-volume: odds ratio 0.67, 95% credible interval 0.45-0.91), as well as length of stay (high-volume versus low-volume: mean difference -1.24, 95% credible interval -2.07 to -0.41), favoring high-volume hospitals. No significant difference was observed in failure-to-rescue, morbidity, or hospital costs across the 3 groups. CONCLUSION This study supports a positive relationship between hospital volume and surgical outcomes in liver resection. Patients from high-volume hospitals experience superior outcomes in terms of lower postoperative mortality and shorter lengths of stay than medium-volume and low-volume hospitals.
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Affiliation(s)
- Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore.
| | - Yun Zhao
- Group Finance Analytics, Singapore Health Services, Singapore
| | | | - Hwee Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Darren Weiquan Chua
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore
| | - Wei-Liang Loh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Ek Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore
| | - Jin Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore; Finance, SingHealth Community Hospitals, Singapore; Finance, Regional Health System & Strategic Finance, Singapore Health Services, Singapore
| | - Brian Kim Poh Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore
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Chen X, Lu D, Mu Y, Kong L, Zhang L. The clinical significance of intraoperative adverse events in laparoscopic radical hysterectomies for early-stage cervical cancer. BMC Womens Health 2024; 24:1. [PMID: 38167063 PMCID: PMC10763214 DOI: 10.1186/s12905-023-02844-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Surgical quality plays a vital role in the treatment of malignant tumors. We investigated the classification of intraoperative adverse events (iAE) (ClassIntra) in relation to the surgical quality control of laparoscopic radical hysterectomies. METHODS A prospective cohort of 195 patients who had undergone laparoscopic radical hysterectomies for early stage cervical cancer between July 2019 and July 2021 was enrolled. Participants were classified into either an iAE or non-iAE groups in accordance with their intraoperative status. Surgical outcomes, patient satisfaction, and quality of life were compared between the two groups. RESULTS Overall, 48 (24.6%) patients experienced 71 iAE. The iAE group was associated with significantly longer operative times (mean: 270 vs. 245 min, P < 0.001), greater blood loss (mean: 215 vs. 120 mL, P < 0.001), and longer postoperative hospital stays (median: 16 vs. 11 days). Larger tumors and poor technical performance significantly increased the risk of iAE (P < 0.05). Multivariate analysis revealed that iAE were the only independent risk factors for postoperative complications (hazard ratio, 15.100; 95% confidence interval: 4.735-48.158, P < 0.001). Moreover, patients who experienced iAE had significantly lower satisfaction scores and poorer quality of life (P < 0.05). CONCLUSIONS ClassIntra may serve as an effective adjunctive tool for surgical quality control in laparoscopic radical hysterectomies.
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Affiliation(s)
- Xiaolin Chen
- Department of Gynecology, Xingtai Third Hospital, Xingtai, 054000, China.
| | - Dongfang Lu
- Department of Gynecology, Xingtai Third Hospital, Xingtai, 054000, China
| | - Yanmin Mu
- Department of Gynecology, Xingtai Third Hospital, Xingtai, 054000, China
| | - Lingxiao Kong
- Department of Gynecology, Xingtai Third Hospital, Xingtai, 054000, China
| | - Ling Zhang
- Department of Gynecology, Xingtai Third Hospital, Xingtai, 054000, China
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Muslim Z, Stroever S, Poulikidis K, Connery CP, Nitzkorski JR, Bhora FY. Impact of facility type and volume in locally advanced esophageal cancer. Asian Cardiovasc Thorac Ann 2024; 32:19-26. [PMID: 37994000 DOI: 10.1177/02184923231215539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND We hypothesized that academic facilities and high-volume facilities would be independently associated with improved survival and a greater propensity for performing surgery in locally advanced esophageal cancer. METHODS We identified patients diagnosed with stage IB-III esophageal cancer during 2004-2016 from the National Cancer Database. Facility type was categorized as academic or community, and facility volume was based on the number of times a facility's unique identification code appeared in the dataset. Each facility type was dichotomized into high- and low-volume subgroups using the cutoff of 20 esophageal cancers treated/year. We fitted multivariable regression models in order to assess differences in surgery selection and survival between facilities according to type and volume. RESULTS Compared to patients treated at high-volume community hospitals, those at high-volume academic facilities were more likely to undergo surgery (odds ratio: 1.865, p < 0.001) and were associated with lower odds of death (odds ratio: 0.784, p = 0.004). For both academic and community hospitals, patients at high-volume facilities were more likely to undergo surgery compared to those at low-volume facilities, p < 0.05. For patients treated at academic facilities, high-volume facilities were associated with lower odds of death (odds ratio: 0.858, p = 0.02) compared to low-volume facilities, while there was no significant difference in the odds of death between high- and low-volume community hospitals (odds ratio: 1.018, p = 0.87). CONCLUSIONS Both facility type and case volume impact surgery selection and survival in locally advanced esophageal cancer. Compared to community hospitals, academic facilities were more likely to perform surgery and were associated with improved survival.
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Affiliation(s)
- Zaid Muslim
- Division of Thoracic Surgery, Rudy L. Ruggles Biomedical Research Institute, Danbury, CT, USA
| | | | | | - Cliff P Connery
- Division of Thoracic Surgery, Nuvance Health, Poughkeepsie, NY, USA
| | | | - Faiz Y Bhora
- Division of Thoracic Surgery, Rudy L. Ruggles Biomedical Research Institute, Danbury, CT, USA
- Division of Thoracic Surgery, Nuvance Health, Danbury, CT, USA
- Division of Thoracic Surgery, Nuvance Health, Poughkeepsie, NY, USA
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Ramian H, Sun Z, Yabes J, Jacobs B, Sabik LM. Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds. JCO Oncol Pract 2024; 20:123-130. [PMID: 37590899 PMCID: PMC10827295 DOI: 10.1200/op.22.00851] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/08/2023] [Accepted: 07/10/2023] [Indexed: 08/19/2023] Open
Abstract
Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.
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Affiliation(s)
- Haleh Ramian
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Zhaojun Sun
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Jonathan Yabes
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce Jacobs
- Department of Urology, Division of Health Services Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA
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Song JH, Shin HJ, Hyung WJ, Yang HK, Han SU, Park YK, Lee HJ, An JY, Kim W, Kim HH, Ryu SW, Hur H, Kim MC, Kong SH, Kim JJ, Park DJ, Kim YW, Ryu KW, Kim JW, Lee JH, Kim HI. Predictive Value of KLASS-02-QC Assessment Score on KLASS-02 Surgical Outcomes: Validation of Surgeon Quality Control and Standardization for D2 Lymphadenectomy. Ann Surg 2023; 278:e1011-e1017. [PMID: 36727760 DOI: 10.1097/sla.0000000000005810] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to audit the 22 items and assessed each item's predictive value on surgical outcomes. BACKGROUND The KLASS-02 trial revealed that the oncologic outcomes of laparoscopic distal gastrectomy are not inferior to open distal gastrectomy in patients with advanced gastric cancer. The surgeons participating in this trial were chosen based on the assessment scores from the KLASS-02-QC trial, which used 22 items for standardization of D2 lymphadenectomy and quality control. METHODS We reviewed proficiency scores (PSs) for 22 items for 20 surgeons who participated in KLASS-02. The surgeons were divided into 2 groups according to PS, and the perioperative outcomes of 924 patients enrolled in KLASS-02 were compared between groups. Each item's predictive value for perioperative outcome was then assessed using multivariable regression models. RESULTS Of the total 924 patients, 529 were operated on by high-score surgeons (high PS) and 395 were operated on by low-score surgeons (low-PS). High-PS group had less intraoperative blood loss, longer operation times, and fewer complications, major complications, reoperations, and shorter first flatus and hospital stay than low-PS group ( P =0.006, P <0.001, P <0.001, P <0.001, P =0.042, P =0.013, and P <0.001, respectively). Some items used in KLASS-02-QC predicted perioperative outcomes, such as intraoperative blood loss, major complications, reoperation, and hospital stay. CONCLUSIONS Although this study only analyzed data associated with qualified surgeons, the 22 items effectively assessed the surgeons based on PS. A high score was associated with longer operation times, but better perioperative outcomes.
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Affiliation(s)
- Jeong Ho Song
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Hye Jung Shin
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Han-Kwang Yang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Young-Kyu Park
- Department of Surgery, Chonnam National University Medical School, Gwangju, South Korea
| | - Hyuk-Joon Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji Yeong An
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wook Kim
- Department of Surgery, Yeouido St Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Seung Wan Ryu
- Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Hoon Hur
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Min-Chan Kim
- Department of Surgery, Dong-A University Hospital, Busan, South Korea
| | - Seong-Ho Kong
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin-Jo Kim
- Department of Surgery, Incheon St Mary's Hospital, The Catholic University of Korea, Incheon, South Korea
| | - Do Joong Park
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Young Woo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Jong Won Kim
- Department of Surgery, Chung-Ang University Hospital, Seoul, South Korea
| | - Joo-Ho Lee
- Department of Surgery, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
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Liu ZY, Chen QY, Zhong Q, Li P, Xie JW, Wang JB, Lin JX, Lu J, Cao LL, Lin M, Huang CM, Zheng CH. Intraoperative Adverse Events, Technical Performance, and Surgical Outcomes in Laparoscopic Radical Surgery for Gastric Cancer: A Pooled Analysis From 2 Randomized Trials. Ann Surg 2023; 278:222-229. [PMID: 36250322 DOI: 10.1097/sla.0000000000005727] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To verify an intraoperative adverse event (iAE) classification (ClassIntra grade) to evaluate quality control and to predict the prognostic performance of laparoscopic radical surgery for gastric cancer. BACKGROUND Surgical quality control is a key factor in the evaluation of surgical treatment for tumors. And, there is no recognized iAE classification for gastric cancer. METHODS We performed a retrospective post hoc analysis of previously collected data from the FUGES-001 study (NCT02327481) and a subset of the CLASS-01 study (NCT01609309). Patients were classified into the iAE and non-iAE groups. And iAE was further classified into 5 subgrades according to the ClassIntra grade (with I-V severity categories). Technical performance was evaluated using the Objective Structured Assessment of Technical Skills tool and the Generic Error Rating Tool. RESULTS Overall, 528 gastric cancer patients were included in this study, with 105 patients (19.9%) in the iAE group and 423 (80.1%) in the non-iAE group. The survival curve showed that the overall, disease-specific, and recurrence-free survival of the non-iAE group were significantly better than those of the iAE group ( P =0.001). The prognosis of patients with ClassIntra grade ≥II was significantly worse than that of patients with ClassIntra grade ≤I. A higher ClassIntra grade, lower Objective Structured Assessment of Technical Skills score, and total gastrectomy were independent risk factors for severe postoperative complications. There was a significant increase in bleeding (grade IV) and injury with splenic hilar lymph node dissection during total gastrectomy. CONCLUSIONS The ClassIntra grade is an effective prognostic and surgical quality control index for laparoscopic radical surgery for gastric cancer; therefore, it could be included in routine hospital care and surgical quality control.
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Affiliation(s)
- Zhi-Yu Liu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Qi-Yue Chen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Qing Zhong
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Ping Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Jian-Wei Xie
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Jia-Bin Wang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Jian-Xian Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Jun Lu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Long-Long Cao
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Mi Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Chang-Ming Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
| | - Chao-Hui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
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11
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Endo Y, Sasaki K, Moazzam Z, Woldesenbet S, Yang J, Araujo Lima H, Alaimo L, Munir MM, Shaikh CF, Schenk A, Kitago M, Pawlik TM. The Impact of a Liver Transplant Program on the Outcomes of Hepatocellular Carcinoma. Ann Surg 2023; 278:230-238. [PMID: 36994716 DOI: 10.1097/sla.0000000000005849] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE We sought to evaluate the impact of liver transplantation (LT) programs on the prognosis of hepatocellular carcinoma (HCC) patients who underwent liver resection (LR) and noncurative intent treatment. BACKGROUND LT programs have an array of resources and services that would positively affect the prognosis of patients with HCC. METHODS Patients who underwent LT, LR, radiotherapy (RT), or chemotherapy (CTx) for HCC between 2004 and 2018 were included in the National Cancer Database. Institutions with LT programs were defined as those that performed 1 or more LT for at least 5 years. Centers were stratified by hospital volume. The impact of LT programs was assessed after propensity score matching to achieve covariate balance. RESULTS A total of 71,735 patients were identified, of which 7997 received LT (11.1%), 12,683 LR (17.7%), 15,675 RT (21.9%), and 35,380 CTx (49.3%). Among a total of 1267 distinct institutions, 94 (7.4%) were categorized as LT programs. Designation as an LT program was also associated with a high volume of LR and noncurative intent treatment (both P <0.001). After propensity score matching, LT programs were associated with better survival among LR and noncurative intent treatment patients. Although hospital volume was also associated with improved prognosis, LT programs were associated with additional survival benefits in noncurative intent treatment. On the other hand, no such benefit was noted in patients who underwent LR. CONCLUSIONS The presence of an LT program was associated with a higher volume of LR and noncurative intent treatment. Furthermore, designation as an LT program had a "halo effect" on the prognosis of patients undergoing RT/CTx that went beyond the procedure-volume effect.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | | | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Jason Yang
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Henrique Araujo Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Chanza F Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Austin Schenk
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Minoru Kitago
- Department of Surgery, Keio University, Tokyo, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
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12
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Blum TG, Morgan RL, Durieux V, Chorostowska-Wynimko J, Baldwin DR, Boyd J, Faivre-Finn C, Galateau-Salle F, Gamarra F, Grigoriu B, Hardavella G, Hauptmann M, Jakobsen E, Jovanovic D, Knaut P, Massard G, McPhelim J, Meert AP, Milroy R, Muhr R, Mutti L, Paesmans M, Powell P, Putora PM, Rawlinson J, Rich AL, Rigau D, de Ruysscher D, Sculier JP, Schepereel A, Subotic D, Van Schil P, Tonia T, Williams C, Berghmans T. European Respiratory Society guideline on various aspects of quality in lung cancer care. Eur Respir J 2023; 61:13993003.03201-2021. [PMID: 36396145 DOI: 10.1183/13993003.03201-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.
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Affiliation(s)
- Torsten Gerriet Blum
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - David R Baldwin
- Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
| | | | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | | | | | - Bogdan Grigoriu
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Georgia Hardavella
- Department of Respiratory Medicine, King's College Hospital London, London, UK
- Department of Respiratory Medicine and Allergy, King's College London, London, UK
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Neuruppin, Germany
| | - Erik Jakobsen
- Department of Thoracic Surgery, Odense University Hospital, Odense, Denmark
| | | | - Paul Knaut
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Gilbert Massard
- Faculty of Science, Technology and Medicine, University of Luxembourg and Department of Thoracic Surgery, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - John McPhelim
- Lung Cancer Nurse Specialist, Hairmyres Hospital, NHS Lanarkshire, East Kilbride, UK
| | - Anne-Pascale Meert
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Robert Milroy
- Scottish Lung Cancer Forum, Glasgow Royal Infirmary, Glasgow, UK
| | - Riccardo Muhr
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Luciano Mutti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- SHRO/Temple University, Philadelphia, PA, USA
| | - Marianne Paesmans
- Data Centre, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Paul Martin Putora
- Departments of Radiation Oncology, Kantonsspital St Gallen, St Gallen and University of Bern, Bern, Switzerland
| | | | - Anna L Rich
- Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | - Dirk de Ruysscher
- Maastricht University Medical Center, Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
- Erasmus Medical Center, Department of Radiation Oncology, Rotterdam, The Netherlands
| | - Jean-Paul Sculier
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Arnaud Schepereel
- Pulmonary and Thoracic Oncology, Université de Lille, Inserm, CHU Lille, Lille, France
| | - Dragan Subotic
- Clinic for Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Thierry Berghmans
- Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
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13
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Abiri A, Pang JC, Roman K, Goshtasbi K, Birkenbeuel JL, Kuan EC, Tjoa T, Haidar YM. Facility Volume as a Prognosticator of Survival in Locally Advanced Papillary Thyroid Cancer. Laryngoscope 2023; 133:443-450. [PMID: 35822421 PMCID: PMC9837308 DOI: 10.1002/lary.30280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/26/2022] [Accepted: 06/13/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To evaluate the influence of facility case-volume on survival in patients with locally advanced papillary thyroid cancer (PTC), and to identify prognostic case-volume thresholds for facilities managing this patient population. STUDY DESIGN Retrospective database study. METHODS The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for locally advanced PTC. Using K-means clustering and multivariable Cox proportional-hazards (CPH) regression, two groups with distinct spectrums of facility case-volumes were generated. Multivariable CPH regression and Kaplan-Meier analysis assessed for the influence of facility case-volume and the prognostic value of its stratification on overall survival (OS). RESULTS Of 48,899 patients treated at 1304 facilities, there were 34,312 (70.2%) females and the mean age was 48.0 ± 16.0 years. Increased facility volume was significantly associated with reduced all-cause mortality (HR 0.996; 95% CI, 0.992-0.999; p = 0.008). Five facility clusters were generated, from which two distinct cohorts were identified: low (LVF; <27 cases/year) and high (HVF; ≥27 cases/year) facility case-volume. Patients at HVFs were associated with reduced mortality compared to those at LVFs (HR 0.791; 95% CI, 0.678-0.923, p = 0.003). Kaplan-Meier analysis of propensity score-matched N0 and N1 patients demonstrated higher OS in HVF cohorts (all p < 0.001). CONCLUSIONS Facility case-volume was an independent predictor of improved OS in locally advanced PTC, indicating a possible survival benefit at high-volume medical centers. Specifically, independent of a number of sociodemographic and clinical factors, facilities that treated ≥27 cases per year were associated with increased OS. Patients with locally advanced PTC may, therefore, benefit from referrals to higher-volume facilities. LEVEL OF EVIDENCE 4 Laryngoscope, 133:443-450, 2023.
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Affiliation(s)
- Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Jonathan C Pang
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Kelsey Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Jack L Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Tjoson Tjoa
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
| | - Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, U.S.A
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14
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Roman KM, Torabi SJ, Bitner BF, Goshtasbi K, Haidar YM, Tjoa T, Kuan EC. The Impact of Facility Type and Volume on Outcomes in Head and Neck Mucosal Melanoma. Otolaryngol Head Neck Surg 2023; 168:1079-1088. [PMID: 36939581 DOI: 10.1002/ohn.173] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/11/2022] [Accepted: 09/15/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate differences in treatment outcomes for head and neck mucosal melanoma (HNMM) patients seen at academic versus nonacademic centers and high versus low volume facilities. STUDY DESIGN Retrospective cohort study. SETTING National Cancer Database. METHODS Differences in treatment course and overall survival (OS) by facility type and volume were assessed for 2772 HNMM cases reported by the 2004 to 2017 National Cancer Database. A subgroup analysis was performed with a smaller cohort containing staging data. The analysis employed Kaplan-Meier and Cox proportional hazards models. RESULTS A higher proportion of patients treated at academic centers within the HNMM cohort waited longer for surgery after diagnosis (p < .001), had negative surgical margins (p < .001), and were readmitted to the hospital within 30 days of surgery (p = .001); these relationships remained significant when controlling for cancer stage. Kaplan-Meier analysis demonstrated higher 5-year OS for patients treated at academic versus nonacademic facilities within the main cohort (32.5% ± 1.3% vs 27.3% ± 1.5%; p = .006) and within the stage-controlled subgroup (34.8% ± 2.1% vs 27.2% ± 2.6%; p = .003). Treatment at high volume versus low volume facilities was associated with improved 5-year OS for main cohort patients (33.5% ± 1.7% vs 28.8% ± 1.2%; p = .016) but not for subgroup patients (35.3% ± 2.7% vs 30.1% ± 2.1%; p = .100). Upon multivariate analysis controlling for demographic and oncologic factors, there was no significant difference in OS by facility type (main cohort: odds ratio [OR] = 1.07, 95% confidence interval [CI] = 1.01-1.21; subgroup: OR = 1.13, 95% CI = 0.97-1.32). CONCLUSION Neither facility type nor surgical volume predicts overall survival in HNMM.
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Affiliation(s)
- Kelsey M Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Benjamin F Bitner
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Tjoson Tjoa
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
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15
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Cawich SO, Pearce NW, Naraynsingh V, Shukla P, Deshpande RR. Whipple’s operation with a modified centralization concept: A model in low-volume Caribbean centers. World J Clin Cases 2022; 10:7620-7630. [PMID: 36158490 PMCID: PMC9372853 DOI: 10.12998/wjcc.v10.i22.7620] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 05/05/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors’ opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.
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Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Neil W Pearce
- University Surgical Unit, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Parul Shukla
- Department of Surgery, Weill Cornell Medical College, New York, NY 10065, United States
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
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16
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Roman KM, Torabi SJ, Goshtasbi K, Kuan EC, Tjoa T, Haidar YM. Case volume regionalization and volume-based outcome differences in cutaneous head and neck melanoma. Head Neck 2022; 44:2428-2436. [PMID: 35903986 DOI: 10.1002/hed.27150] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 06/06/2022] [Accepted: 07/07/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Hospital volume has emerged as a prognostic factor in oncology but is not currently known whether volume is associated with improved outcomes for cutaneous head and neck (HN) melanoma. METHODS A total of 556 079 cutaneous melanoma cases reported by the 2004-2016 National Cancer Database were separated into two cohorts (HN and non-HN) and facilities within each cohort were classified by case volume. Analysis employed chi-square, analysis of variance, Kaplan-Meier, and Cox proportional hazards models. RESULTS Only 41 facilities (3.1% of 1326) treating HN melanoma and 50 facilities (3.7% of 1344) treating non-HN melanoma were classified as high-volume facilities (HVFs). The estimated 5-year overall survival (OS) was 62.7% (standard error [SE]: 0.4%) for patients with HN at low-volume facilities (LVFs), 69.3% (SE: 0.4%) at IVFs, and 71.8% (SE 0.4%) at HVFs (p < 0.001). Differences in OS remained significant between HVFs versus LVFs after adjusting for confounders. CONCLUSION Volume is independently associated with OS and improved surgical outcomes for HN melanoma.
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Affiliation(s)
- Kelsey M Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Tjoson Tjoa
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
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17
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Park M, Verma A, Madrigal J, Lee C, Koshki J, Festekjian J, Benharash P. Cost-volume analysis of deep inferior epigastric artery perforator flaps for breast reconstruction in the United States. Surgery 2022; 172:838-843. [PMID: 35710535 DOI: 10.1016/j.surg.2022.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/09/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Deep inferior epigastric artery perforator flaps are increasingly utilized over other autologous methods of breast reconstruction. We evaluated the relationship between annual hospital volume and costs after breast reconstruction with the deep inferior epigastric artery perforator flap. METHODS All female patients undergoing elective implant or autologous tissue breast reconstruction were identified using the 2016-2019 Nationwide Readmission Database. Annual hospital volume of deep inferior epigastric artery perforator reconstructions was tabulated and modeled using restricted cubic splines. Institutions were categorized into high- and low-volume based on the inflection point of the spline between annual caseload and costs. The association between high volume status and costs, complications, length of stay, and 30-day nonelective readmission was assessed using multivariable regression. RESULTS Of an estimated 94,524 patients meeting inclusion criteria, 33,046 (34.6%) underwent deep inferior epigastric artery perforator flap reconstruction. Deep inferior epigastric artery perforator flap utilization increased from 31% in 2016 to 40% in 2019 (P < .001) among inpatient breast reconstructions. High-volume hospitals more frequently performed bilateral reconstructions (43.3 vs 37.7%, P = .021) but had similar rates of concurrent mastectomy (28.7 vs 30.6%, P = .46), relative to low-volume hospitals. The median cost of deep inferior epigastric artery perforator reconstruction was lower ($29,900 [interquartile range: 22,400-37,400] vs $31,600 [interquartile range: 22,500-44,900], P = .036) at high-volume hospitals compared to low-volume. On adjusted analysis, high-volume status was associated a $3,800 (95% confidence interval: -6,200 to -1,400) decrement in hospitalization costs, and reduced odds of perioperative complications (adjusted odd ratio: 0.68 95% confidence interval: 0.54-0.86). High-volume status was not associated with length of stay or likelihood of unplanned readmission. CONCLUSION The present study demonstrated an inverse cost-volume relationship in deep inferior epigastric artery perforator flap breast reconstruction. In line with goals of value-based health care delivery, our findings may inform referral patterns to suitable centers for deep inferior epigastric artery perforator breast reconstruction.
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Affiliation(s)
- Mina Park
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Josef Madrigal
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Cory Lee
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jessica Koshki
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jaco Festekjian
- Division of Plastic and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Hunger R, Seliger B, Ogino S, Mantke R. Mortality factors in pancreatic surgery: A systematic review. How important is the hospital volume? Int J Surg 2022; 101:106640. [PMID: 35525416 PMCID: PMC9239346 DOI: 10.1016/j.ijsu.2022.106640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND How the extent of confounding adjustment impact (hospital) volume-outcome relationships in published studies on pancreatic cancer surgery is unknown. METHODS A systematic literature search was conducted for studies that investigated the relationship between volume and outcome using a risk adjustment procedure by querying the following databases: PubMed, Cochrane Central Register of Controlled Trials, Livivo, Medline and the International Clinical Trials Registry Platform (last query: 2020/09/16). Importance of risk-adjusting covariates were assessed by effect size (odds ratio, OR) and statistical significance. The impact of covariate adjustment on hospital (or surgeon) volume effects was analyzed by regression and meta-regression models. RESULTS We identified 87 studies (75 based on administrative data) with nearly 1 million patients undergoing pancreatic surgery that included in total 71 covariates for risk adjustment. Of these, 33 (47%) had statistically significant effects on short-term mortality and 23 (32%) did not, while for 15 (21%) factors neither effect size nor statistical significance were reported. The most important covariates for short term mortality were patient-specific factors. Concerning the covariates, single comorbidities (OR: 4.6, 95% CI: 3.3 to 6.3) had the strongest impact on mortality followed by hospital volume (OR: 2.9, 95% CI: 2.5 to 3.3) and the procedure (OR: 2.2, 95% CI: 1.9 to 2.5). Among the single comorbidities, coagulopathy (OR: 4.5, 95% CI: 2.8 to 7.2) and dementia (OR: 4.2, 95% CI: 2.2 to 8.0) had the strongest influence on mortality. The regression analysis showed a significant decrease hospital volume effect with an increasing number of covariates considered (OR: 0.06, 95% CI: 0.10 to -0.03, P < 0.001), while such a relationship was not observed for surgeon volume (P = 0.35). CONCLUSIONS This analysis demonstrated a significant inverse relationship between the extent of risk adjustment and the volume effect, suggesting the presence of unmeasured confounding and overestimation of volume effects. However, the conclusions are limited in that only the number of included covariates was considered, but not the effect size of the non-included covariates.
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Affiliation(s)
- Richard Hunger
- Faculty of Medicine, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Barbara Seliger
- Martin Luther University Halle-Wittenberg, Institute of Medical Immunology, Halle, Germany; Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Shuji Ogino
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA; Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Rene Mantke
- Faculty of Medicine, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany; Faculty of Health Sciences, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany.
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19
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Fournier FR, Brown CJ. Transanal Endoscopic Surgery: Who Should Be Doing This Procedure? Clin Colon Rectal Surg 2022; 35:99-105. [PMID: 35237104 PMCID: PMC8885151 DOI: 10.1055/s-0041-1742109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Transanal endoscopic surgery (TES) was introduced in the 1980s, but more widely adopted in the late 2000s with innovations in instrumentation and training. Moreover, the global adoption of minimally invasive approaches to abdominal procedures has led to translatable skills for TES among colorectal and general surgeons. While there are similarities to laparoscopic surgery, TES has unique challenges related to the narrow confines of intraluminal surgery, angled instrumentation, and relatively uncommon indications limiting the opportunity to practice. The following review discusses the current evidence on TES learning curves, including potential limitations related to the broad adoption of TES by general surgeons. This article aims to provide general recommendations for the safe expansion of TES.
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Affiliation(s)
- François Rouleau Fournier
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carl James Brown
- Department of Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada,Address for correspondence Carl James Brown, MD, MSc, FACS, FRCSC Department of Surgery, St. Paul's Hospital, University of British Columbia1081 Burrard Street, Room C310, Third Floor, Burrard Building, Vancouver, BCCanada V6Z 1Y6
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20
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Goshtasbi K, Vasudev M, Torabi SJ, Roman K, Abiri A, Lehrich BM, Hsu FPK, Kuan EC. The influence of facility volume and type on esthesioneuroblastoma treatment and outcomes. Int Forum Allergy Rhinol 2021; 12:1056-1059. [PMID: 34908249 DOI: 10.1002/alr.22948] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Milind Vasudev
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Kelsey Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA, USA
| | - Brandon M Lehrich
- Medical Scientist Training Program, University of Pittsburgh and Carnegie Mellon University, Pittsburgh, PA, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, CA, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA, USA
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21
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Merritt RE, Abdel-Rasoul M, Fitzgerald M, D'Souza DM, Kneuertz PJ. The Academic Facility Is Associated with Higher Utilization of Esophagectomy and Improved Overall Survival for Esophageal Carcinoma. J Gastrointest Surg 2021; 25:1677-1689. [PMID: 33025288 DOI: 10.1007/s11605-020-04817-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/30/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Operable esophageal carcinoma is potentially curable with surgical resection. The short-term outcomes and overall survival rate for operable esophageal carcinoma may be impacted by the healthcare facility type where patients receive care. METHODS A total of 37, 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Data Base at over 12,721 facilities were analyzed. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazard models were used to evaluate differences in overall survival between facility types, which accounted for facility esophageal cancer volume. Propensity score methodology with inverse probability of treatment weighting was used to adjust for patient related baseline differences between facility types. RESULTS Patients with clinical stage I-III esophageal carcinoma who underwent esophagectomy at academic healthcare facilities had a significantly better overall survival compared with patients who underwent esophagectomy at community healthcare facilities [HR = 0.89: CI [0.84-0.95] (p = 0.0005)]. The rate of esophagectomy was significantly higher at the academic facilities (49.0% versus 26.5%; p < 0.0001). The 30-day and 90-day mortality rates for esophagectomy were significantly better for patients who underwent esophagectomy for esophageal cancer at the academic facility types. CONCLUSION Patients with clinical stage I-III esophageal carcinoma who received care at academic facility types had significantly better overall survival compared with community facility types. The utilization of esophagectomy was significantly higher and the short-term surgical outcomes were better for patients treated at academic facility types.
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Affiliation(s)
- Robert E Merritt
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA.
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Morgan Fitzgerald
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Desmond M D'Souza
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Peter J Kneuertz
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA
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22
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Goshtasbi K, Abiri A, Lehrich BM, Haidar YM, Tjoa T, Kuan EC. The influence of facility volume on patient treatments and survival outcomes in nasopharyngeal carcinoma. Head Neck 2021; 43:2755-2763. [PMID: 33998094 DOI: 10.1002/hed.26739] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/15/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study evaluates the influence of facility case-volume on nasopharyngeal carcinoma (NPC) treatments and overall survival (OS). METHODS The 2004-2015 National Cancer Database was queried for patients with NPC receiving definitive treatment. RESULTS A total of 8260 patients (5-year OS: 63.4%) were included. The 1114 unique facilities were categorized into 854 low-volume (treating 1-8 patients), 200 intermediate-volume (treating 9-23 patients), and 60 high-volume (treating 24-187 patients) facilities. Kaplan-Meier log-rank analysis demonstrated significantly improved OS with high-volume facilities (p < 0.001). On cox proportional-hazard multivariate regression after adjusting for age, sex, income, insurance, comorbidity index, histology, AJCC clinical stage, and treatment type, high-volume facilities were associated with lower mortality risk than low-volume (HR = 0.865, p = 0.019) and intermediate-volume facilities (HR = 0.916, p = 0.004). Propensity score matching analysis confirmed this association (p < 0.001). CONCLUSION Higher facility volume was an independent predictor of improved OS in NPC, suggesting a possible survival benefit of referrals to high-volume medical centers.
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Affiliation(s)
- Khodayar Goshtasbi
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, USA
| | - Arash Abiri
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, USA
| | - Brandon M Lehrich
- Medical Scientist Training Program, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yarah M Haidar
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, USA
| | - Tjoson Tjoa
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, USA
| | - Edward C Kuan
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, USA
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23
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Han SU, Hur H, Lee HJ, Cho GS, Kim MC, Park YK, Kim W, Hyung WJ. Surgeon Quality Control and Standardization of D2 Lymphadenectomy for Gastric Cancer: A Prospective Multicenter Observational Study (KLASS-02-QC). Ann Surg 2021; 273:315-324. [PMID: 33064386 DOI: 10.1097/sla.0000000000003883] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To qualify surgeons to participate in a randomized trial comparing laparoscopic and open distal D2 gastrectomy for advanced gastric cancer. SUMMARY OF BACKGROUND DATA No studies have sought to qualify surgeons for a randomized trial comparing laparoscopic and open D2 gastrectomy for advanced gastric cancer. METHODS We conducted a multicenter prospective observational study evaluating unedited videos of laparoscopic and open D2 gastrectomy performed by 27 surgeons. Surgeons performed 3 of each laparoscopic and open distal gastrectomies with D2 lymphadenectomy for gastric cancer. Five peers reviewed each unedited video using a video assessment form. Based on experts' review of videos, a separate review committee decided surgeons as "Qualified" or "Not-qualified." RESULTS Twelve surgeons (44.4%) were qualified on initial evaluation whereas the other 15 surgeons were not. Another 9 surgeons were finally qualified after re-evaluation. The median score for Qualified was significantly higher than Not-qualified (P < 0.001).Significant differences between Qualified and Not-qualified were noted both in operation type and in all evaluation area of surgical skill, perigastric, and extra-perigastric lymphadenectomy, although the inter-rater variability of the assessment score was low (kappa = 0.285). However, Not-qualified surgeons' scores improved upon re-evaluation of resubmitted videos.When compared laparoscopy with open surgery, median scores were similar between the 2 groups (P = 0.680). However, open gastrectomy scores for surgical skills were significantly higher than for laparoscopic surgery (P = 0.016). CONCLUSIONS Our surgeon quality control study for gastrectomy represents a milestone in surgical standardization for surgical clinical trials. Our methods could also serve as a system for educating surgeons and assessing surgical proficiency.
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Affiliation(s)
- Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hoon Hur
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gyu Seok Cho
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Min-Chan Kim
- Department of Surgery, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Young Kyu Park
- Department of Surgery, Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Wook Kim
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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24
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Reynolds JV, Donlon N, Elliott JA, Donohoe C, Ravi N, Kuppusamy MK, Low DE. Comparison of Esophagectomy outcomes between a National Center, a National Audit Collaborative, and an International database using the Esophageal Complications Consensus Group (ECCG) standardized definitions. Dis Esophagus 2021; 34:5863448. [PMID: 32591791 DOI: 10.1093/dote/doaa060] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/19/2020] [Accepted: 05/28/2020] [Indexed: 12/11/2022]
Abstract
The ECCG developed a standardized platform for reporting operative complications, with consensus definitions. The Dutch Upper Gastrointestinal Cancer Audit (DUCA) published a national comparison against these benchmarks. This study compares ECCG data from the Irish National Center (INC) with both published benchmark studies. All patients undergoing multimodal therapy or surgery with curative intent from 2014 to 2018 inclusive were studied, with data recorded prospectively and entered onto a secure online database (Esodata.org). 219 patients (mean age 67; 77% male) underwent open resection, 66.6% via transthoracic en bloc resection. 30-day and 90-day mortality were 0.0 and 0.9%,nrespectively. Anastomotic leak rate was 5.4%, pneumonia 18.2%, respiratory failure 10%, ARDS 2.7%, atrial dysrhythmia 22.8%, recurrent nerve injury 3%, and delirium in 5% of patients. Compared with both ECCG and DUCA, where MIE constituted 47 and 86% of surgical approaches, respectively, overall complications were similar, as were severity of complications; however, anastomotic leak rate was several-fold less, and mortality was significantly lower (P < 0.001). In this consecutive series and comparative audit with benchmark averages from the ECCG and DUCA publications, a low mortality and anastomotic leak rate were the key differential findings. Although not risk stratified, the severity of complications from this 'open' series is consistent with series containing large numbers of total or hybrid MIE, highlighting a need to adhere to these strictly defined definitions in further prospective research and randomized studies.
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Affiliation(s)
- John V Reynolds
- National Esophageal and Gastric Cancer Center, St James's Hospital and Trinity College, Dublin, Ireland
| | - Noel Donlon
- National Esophageal and Gastric Cancer Center, St James's Hospital and Trinity College, Dublin, Ireland
| | - Jessie A Elliott
- National Esophageal and Gastric Cancer Center, St James's Hospital and Trinity College, Dublin, Ireland
| | - Claire Donohoe
- National Esophageal and Gastric Cancer Center, St James's Hospital and Trinity College, Dublin, Ireland
| | - Narayanasamy Ravi
- National Esophageal and Gastric Cancer Center, St James's Hospital and Trinity College, Dublin, Ireland
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25
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Impact of payer status and hospital volume on outcomes after head and neck oncologic reconstruction. Am J Surg 2020; 222:173-178. [PMID: 33223075 DOI: 10.1016/j.amjsurg.2020.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/28/2020] [Accepted: 11/11/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND High-volume centers improve outcomes in head and neck cancer (HNCA) reconstruction, yet it is unknown whether patients of all payer status benefit equally. METHODS We identified patients undergoing HNCA surgery between 2002 and 2015 using the National Inpatient Sample. Outcomes included receipt of care at high-volume centers, receipt of reconstruction, and post-operative complications. Multivariate regression analysis was stratified by payer status. RESULTS 37,442 patients received reconstruction out of 101,204 patients who underwent HNCA surgery (37.0%). Privately-insured and Medicaid patients had similar odds of receiving high-volume care (OR = 0.99, 95% CI = 0.87-1.11) and undergoing reconstruction (OR = 0.96, 95% CI = 0.86-1.05). Medicaid beneficiaries had higher odds of complication (OR = 1.36, 95% CI = 1.22-1.51). The discrepancy in complication odds was significant at low-volume (OR = 1.44, 95% CI = 1.12-1.84) and high-volume centers (OR = 1.30, 95% CI = 1.15-1.47). CONCLUSIONS Medicaid beneficiaries are as likely to receive care at high-volume centers and undergo reconstruction as privately-insured individuals. However, they have poorer outcomes than privately-insured individuals at both low- and high-volume centers.
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26
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Papageorge MV, Resio BJ, Monsalve AF, Canavan M, Pathak R, Mase VJ, Dhanasopon AP, Hoag JR, Blasberg JD, Boffa DJ. Navigating by Stars: Using CMS Star Ratings to Choose Hospitals for Complex Cancer Surgery. JNCI Cancer Spectr 2020; 4:pkaa059. [PMID: 33134834 PMCID: PMC7583163 DOI: 10.1093/jncics/pkaa059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/30/2020] [Accepted: 06/26/2020] [Indexed: 11/16/2022] Open
Abstract
Background The Centers for Medicare and Medicaid Services (CMS) developed risk-adjusted “Star Ratings,” which serve as a guide for patients to compare hospital quality (1 star = lowest, 5 stars = highest). Although star ratings are not based on surgical care, for many procedures, surgical outcomes are concordant with star ratings. In an effort to address variability in hospital mortality after complex cancer surgery, the use of CMS Star Ratings to identify the safest hospitals was evaluated. Methods Patients older than 65 years of age who underwent complex cancer surgery (lobectomy, colectomy, gastrectomy, esophagectomy, pancreaticoduodenectomy) were evaluated in CMS Medicare Provider Analysis and Review files (2013-2016). The impact of reassignment was modeled by applying adjusted mortality rates of patients treated at 5-star hospitals to those at 1-star hospitals (Peters-Belson method). Results There were 105 823 patients who underwent surgery at 3146 hospitals. The 90-day mortality decreased with increasing star rating (1 star = 10.4%, 95% confidence interval [CI] = 9.8% to 11.1%; and 5 stars = 6.4%, 95% CI = 6.0% to 6.8%). Reassignment of patients from 1-star to 5-star hospitals (7.8% of patients) was predicted to save 84 Medicare beneficiaries each year. This impact varied by procedure (colectomy = 47 lives per year; gastrectomy = 5 lives per year). Overall, 2189 patients would have to change hospitals each year to improve outcomes (26 patients moved to save 1 life). Conclusions Mortality after complex cancer surgery is associated with CMS Star Rating. However, the use of CMS Star Ratings by patients to identify the safest hospitals for cancer surgery would be relatively inefficient and of only modest impact.
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Affiliation(s)
- Marianna V Papageorge
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Benjamin J Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Andres F Monsalve
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Maureen Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
| | - Ranjan Pathak
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Vincent J Mase
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Andrew P Dhanasopon
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, USA
| | - Justin D Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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27
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Hull R, Mbele M, Makhafola T, Hicks C, Wang SM, Reis RM, Mehrotra R, Mkhize-Kwitshana Z, Hussain S, Kibiki G, Bates DO, Dlamini Z. A multinational review: Oesophageal cancer in low to middle-income countries. Oncol Lett 2020; 20:42. [PMID: 32802164 PMCID: PMC7412736 DOI: 10.3892/ol.2020.11902] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 10/08/2019] [Indexed: 12/12/2022] Open
Abstract
Oesophageal cancer (OC) is an aggressive neoplasm that manifests in the gastrointestinal tract and is the result of numerous factors that can contribute to the development of the disease. These may include old age, nutritional deficiencies, oesophageal obstruction and food ingestion difficulties. Environmental factors serve a large role in increasing the risk of developing OC. Two factors that serve an increasing risk of developing OC are the use of tobacco and the consumption of alcohol. Genetic factors also exhibit a large effect on the risk of developing OC, for example, the causative genes in Black Africans differ from other races. OC is 3-4 times more common among men than women. OC has been previously reported in >450 000 individuals worldwide, and its incidence is increasing. The current review compares OC in low to middle-income countries with developed countries. The incidence of OC, particularly squamous cell carcinoma (SCC) is high in low and middle-income countries. In developed countries, the incidence of SCC is low compared with adenocarcinoma. The majority of OC cases are diagnosed in the late stages of the disease, leading to high mortality rates. The current review aimed to discuss factors that contribute to the development of this disease in different geographical areas and genetic mechanisms governing these findings. The current review also aims to discuss the preventative treatment options for the disease, and also discusses the diagnosis and surveillance in five LMICs, including South Africa, China, Tanzania, India and Brazil.
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Affiliation(s)
- Rodney Hull
- South African-Medical Research Council/University of Pretoria Precision, Prevention and Novel Drug Targets for HIV-Associated Cancers Extramural Unit, Cancer Research Institute, University of Pretoria, Faculty of Health Sciences, Pretoria, Gauteng 0028, South Africa
| | - Mzwandile Mbele
- South African-Medical Research Council/University of Pretoria Precision, Prevention and Novel Drug Targets for HIV-Associated Cancers Extramural Unit, Cancer Research Institute, University of Pretoria, Faculty of Health Sciences, Pretoria, Gauteng 0028, South Africa
| | - Tshepiso Makhafola
- South African-Medical Research Council/University of Pretoria Precision, Prevention and Novel Drug Targets for HIV-Associated Cancers Extramural Unit, Cancer Research Institute, University of Pretoria, Faculty of Health Sciences, Pretoria, Gauteng 0028, South Africa
| | - Chindo Hicks
- Louisiana State University, School of Medicine, Department of Genetics, Bioinformatics and Genomics Centre, LA 70112, USA
| | - Shao Ming Wang
- National Cancer Centre, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, P.R. China
| | - Rui Manuel Reis
- Molecular Oncology Research Centre, Barretos Cancer Hospital, CEP 14784 400, Sao Paulo, Brazil
| | - Ravi Mehrotra
- Indian Council of Medical Research, 110029 New Delhi, India
| | | | - Showket Hussain
- East African Health Research Commission, East African Community, Quartier Kigobe, 1096 Arusha, United Republic of Tanzania
| | - Gibson Kibiki
- East African Health Research Commission, East African Community, Quartier Kigobe, 1096 Arusha, United Republic of Tanzania
| | - David O. Bates
- University of Nottingham, Queens Medical Centre, Cancer Biology, NG7 2UH Nottingham, UK
| | - Zodwa Dlamini
- South African-Medical Research Council/University of Pretoria Precision, Prevention and Novel Drug Targets for HIV-Associated Cancers Extramural Unit, Cancer Research Institute, University of Pretoria, Faculty of Health Sciences, Pretoria, Gauteng 0028, South Africa
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28
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Hadaya J, Dobaria V, Aguayo E, Mandelbaum A, Sanaiha Y, Revels SL, Benharash P. Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States. Ann Thorac Surg 2020; 110:1874-1881. [PMID: 32553767 DOI: 10.1016/j.athoracsur.2020.04.115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 04/06/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual institutional volume of anatomic lung resections on outcomes after elective pneumonectomy. METHODS We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Patients less than 18 years of age, or with trauma-related diagnoses, mesothelioma, or a nonelective admission were excluded. Hospitals were divided into volume quartiles based on annual institutional anatomic lung resection caseload. We studied the effect of institutional volume on inhospital mortality, complications, and failure to rescue, as well as costs and length of stay. RESULTS During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P trend = .045). Compared with the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% confidence interval, 1.14 to 2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure to rescue rates (18.3% vs 12.7%, P = .024) and adjusted odds of mortality (1.70; 95% confidence interval, 1.09 to 2.64) after any complication. CONCLUSIONS High volume hospital status is strongly associated with reduced mortality and failure to rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.
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Affiliation(s)
- Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Esteban Aguayo
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Sha'Shonda L Revels
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California.
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Reid CM, Parmeshwar N, Brandel MG, Crisera CA, Herrera FA, Suliman AS. Detailed analysis of the impact of surgeon and hospital volume in microsurgical breast reconstruction. Microsurgery 2020; 40:670-678. [PMID: 32304337 DOI: 10.1002/micr.30591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/13/2020] [Accepted: 04/02/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Prior investigations of microsurgical breast reconstruction have not distinguished the effects of surgeon versus hospital volume and failed to address the effect of patient clustering. Our data-driven analysis aims to determine the impacts of surgeon and hospital volume on outcomes of microsurgical breast reconstruction. METHODS Nationwide Inpatient Sample (NIS) data from 2008 to 2011 was analyzed for patients who underwent microsurgical breast reconstruction. Volume-outcome relationships were analyzed with restricted cubic spline analysis. A multivariable mixed-effects logistic regression was used to account for patient clustering effect. RESULTS A total of 5,404 NIS patients met inclusion criteria. High-volume (HV) surgeons had a 59% decrease in the risk of inpatient complications, which became non-significant after clustering correction. For HV hospitals, there was a 47% decrease in the risk of inpatient complications (odds ratio = 0.53; 95% confidence intervals 0.30, 0.91; p = 0.021) that was statistically significant with the clustering adjustment. Neither the volume-cost relationship for surgeons nor hospitals remained statistically significant after accounting for clustering. CONCLUSIONS Hospital volume plays a significant impact on outcomes in microsurgical breast reconstruction, while surgeon volume has comparatively not shown to be similarly impactful. The complexity of care related to microsurgical breast reconstruction warrants equally complex and engineered health systems.
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Affiliation(s)
- Chris M Reid
- Division of Plastic Surgery, Department of Surgery, University of California, San Diego, California, USA.,Section of Plastic & Reconstructive Surgery, VA San Diego Healthcare System, San Diego, California, USA
| | - Nisha Parmeshwar
- Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, California, USA
| | - Michael G Brandel
- Division of Plastic Surgery, Department of Surgery, University of California, San Diego, California, USA
| | - Christopher A Crisera
- Division of Plastic Surgery, Department of Surgery, University of California, Los Angeles, California, USA
| | - Fernando A Herrera
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ahmed S Suliman
- Division of Plastic Surgery, Department of Surgery, University of California, San Diego, California, USA.,Section of Plastic & Reconstructive Surgery, VA San Diego Healthcare System, San Diego, California, USA
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Effect of Hospital Volume With Respect to Performing Gastric Cancer Resection on Recurrence and Survival: Results From the CRITICS Trial. Ann Surg 2020; 270:1096-1102. [PMID: 29995679 DOI: 10.1097/sla.0000000000002940] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE We examined the association between surgical hospital volume and both overall survival (OS) and disease-free survival (DFS) using data obtained from the international CRITICS (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach) trial. SUMMARY BACKGROUND DATA In the CRITICS trial, patients with resectable gastric cancer were randomized to receive preoperative chemotherapy followed by adequate gastrectomy and either chemotherapy or chemoradiotherapy. METHODS Patients in the CRITICS trial who underwent a gastrectomy with curative intent in a Dutch hospital were included in the analysis. The annual number of gastric cancer surgeries performed at the participating hospitals was obtained from the Netherlands Cancer Registry; the hospitals were then classified as low-volume (1-20 surgeries/year) or high-volume (≥21 surgeries/year) and matched with the CRITICS trial data. Univariate and multivariate analyses were then performed to evaluate the hazard ratio (HR) between hospital volume and both OS and DFS. RESULTS From 2007 through 2015, 788 patients were included in the CRITICS trial. Among these 788 patients, 494 were eligible for our study; the median follow-up was 5.0 years. Five-year OS was 59.2% and 46.1% in the high-volume and low-volume hospitals, respectively. Multivariate analysis revealed that undergoing surgery in a high-volume hospital was associated with higher OS [HR = 0.69, 95% confidence interval (CI) = 0.50-0.94, P = 0.020] and DFS (HR = 0.73, 95% CI: 0.54-0.99, P = 0.040). CONCLUSIONS In the CRITICS trial, hospitals with a high annual volume of gastric cancer surgery were associated with higher overall and DFS. These findings emphasize the value of centralizing gastric cancer surgeries in the Western world.
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Hayanga JWA, Chan EG, Musgrove K, Leung A, Shigemura N, Hayanga HK. Extracorporeal Membrane Oxygenation in the Perioperative Care of the Lung Transplant Patient. Semin Cardiothorac Vasc Anesth 2020; 24:45-53. [PMID: 31893982 DOI: 10.1177/1089253219896123] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lung transplantation (LT) is definitive therapy for end-stage lung disease. Donor allocation based on medical urgency has led to an increased trend in the transplantation of sicker and older patients. Mechanical ventilation (MV) formerly was the only method of bridging high-acuity patients to LT. When the physiological demands of ventilatory support exceeds the capability of MV, extracorporeal membrane oxygenation (ECMO) may become necessary. Recent improvements in ECMO technology and component design have led to a resurgence of interest in its use before, during, and after LT. Survival with ECMO as a bridge to LT has improved over time, now with many centers reporting little or no difference in outcomes, and some even reporting better outcomes, as compared with MV. Extracorporeal life support may also be used intraoperatively. In many studies to date, ECMO or cardiopulmonary bypass (CPB) has been reserved for patients who became hemodynamically unstable during the procedure or patients who could not tolerate single-lung ventilation. Both methods of support are fraught with potential complications. However, multiple studies comparing ECMO with CPB have shown that intraoperative use of ECMO resulted in improved outcomes and overall survival as well as lower rates of bleeding complications. In order to further reduce complications associated with ECMO, planned intraoperative ECMO use is occasionally reserved for high-risk patients who might otherwise require CPB. Future studies will need to improve patient selection to fully take advantage of the use of ECMO in LT while minimizing its costs.
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Affiliation(s)
| | - Ernest G Chan
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Chang SH. One hundred sixty pancreaticoduodenectomies for periampullary cancers in a growing-volume setting: a single-institution and a single-surgeon's experience. Ann Surg Treat Res 2019; 97:130-135. [PMID: 31508393 PMCID: PMC6722292 DOI: 10.4174/astr.2019.97.3.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/07/2019] [Accepted: 07/10/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Many studies have concluded that cancer patients may have better outcomes when their surgery is performed in high-volume centers, especially when the procedure is pancreaticoduodenectomy (PD). However, some studies concluded that experienced surgeons or incorporation of expertise from high-volume centers may achieve satisfactory outcomes after PD in low-volume centers. Methods I retrospectively collected and analyzed the outcomes of PD for periampullary cancers treated with curative intent in my center. Results From August 2, 2005 to December 10, 2018, 160 pancreatic resections were done with curative intent in my center. The number of operations per year was 1 in 2005 and gradually increased to 21 in 2018. Thirty-day mortality was 0, and 90-day mortality was 1 (0.6%). Morbidity was found in 65 cases (40.6%). The median follow-up period was 23.2 months and 5-year survival rates were 28.5% for pancreas head cancer, 48.2% for distal CBD cancer, and 72.6% for AOV cancer. I divided patients into 2 groups by the number of annual operations, which is more than 21 per 2 years. The 2 groups showed no differences in terms of morbidity and mortality. Conclusion A well-trained low-volume surgeon may perform PD safely at a well-equipped low-volume center.
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Affiliation(s)
- Seong-Hwan Chang
- Department of Surgery, Konkuk University School of Medicine, Seoul, Korea
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Wilson GC, Geller DA. Facility Type is Another Factor in the Volume-Outcome Relationship for Complex Hepatopancreatobiliary Procedures. Ann Surg Oncol 2019; 26:3811-3812. [PMID: 31372869 DOI: 10.1245/s10434-019-07668-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Indexed: 01/07/2023]
Affiliation(s)
- Gregory C Wilson
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David A Geller
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Liu N, Vigod SN, Farrugia MM, Urquia ML, Ray JG. Physician procedure volume and related adverse events after surgically induced abortion: a population-based cohort study. CMAJ 2019; 191:E519-E528. [PMID: 31085561 DOI: 10.1503/cmaj.181288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2019] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Induced abortion is a common procedure performed by physicians with varying degrees of clinical experience. We aimed to determine whether a physician's procedure volume influences complications after induced abortion. METHODS We obtained population-based retrospective data on surgically induced abortion procedures in Ontario between 2003 and 2015 from Ontario health administrative databases held at ICES. Physician procedure volume was defined as the number of surgically induced abortions performed in the 1-year period preceding the index procedure date, categorized as low (< 10th percentile of yearly volume) or higher (≥ 10th percentile). The primary outcome was a severe adverse event (maternal end organ damage, severe maternal morbidity, intensive care unit admission or death) within 42 days after an induced abortion. The secondary outcome was any adverse event within 42 days. RESULTS Among 529 141 surgical abortion procedures, we found 850 severe adverse events (1.6 per 1000 procedures, 95% confidence interval [CI] 1.5-1.7), and 5664 any adverse events (10.7 per 1000 procedures, 95% CI 10.4-11.0). Severe adverse events occurred in 194 out of 52 889 procedures in the low-volume group (3.7 per 1000 procedures, 95% CI 3.2-4.2) compared with 656 out of 476 252 procedures in the higher-volume group (1.4 per 1000 procedures, 95% CI 1.3-1.5), an adjusted odds ratio (OR) of 1.91 (95% CI 1.41-2.59). The odds of any adverse event were also higher in the low-volume versus higher-volume group (adjusted OR 1.19, 95% CI 1.02-1.40). INTERPRETATION Low physician procedure volumes are associated with an elevated risk of a complication after surgically induced abortion. Future investigation should compare processes of care between low- and higher-volume physicians to facilitate quality improvement in abortion care.
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Affiliation(s)
- Ning Liu
- Institute of Health Policy Management and Evaluation (Liu, Vigod, Ray), University of Toronto; ICES (Liu, Vigod, Urquia, Ray); Women's College Hospital and Department of Psychiatry (Vigod), University of Toronto; Mount Sinai Hospital (Farrugia); Department of Obstetrics and Gynaecology (Farrugia), University of Toronto; Dalla Lana School of Public Health (Urquia), University of Toronto; Departments of Medicine, and Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont.; Manitoba Centre for Health Policy (Urquia), Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man
| | - Simone N Vigod
- Institute of Health Policy Management and Evaluation (Liu, Vigod, Ray), University of Toronto; ICES (Liu, Vigod, Urquia, Ray); Women's College Hospital and Department of Psychiatry (Vigod), University of Toronto; Mount Sinai Hospital (Farrugia); Department of Obstetrics and Gynaecology (Farrugia), University of Toronto; Dalla Lana School of Public Health (Urquia), University of Toronto; Departments of Medicine, and Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont.; Manitoba Centre for Health Policy (Urquia), Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man
| | - M Michèle Farrugia
- Institute of Health Policy Management and Evaluation (Liu, Vigod, Ray), University of Toronto; ICES (Liu, Vigod, Urquia, Ray); Women's College Hospital and Department of Psychiatry (Vigod), University of Toronto; Mount Sinai Hospital (Farrugia); Department of Obstetrics and Gynaecology (Farrugia), University of Toronto; Dalla Lana School of Public Health (Urquia), University of Toronto; Departments of Medicine, and Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont.; Manitoba Centre for Health Policy (Urquia), Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man
| | - Marcelo L Urquia
- Institute of Health Policy Management and Evaluation (Liu, Vigod, Ray), University of Toronto; ICES (Liu, Vigod, Urquia, Ray); Women's College Hospital and Department of Psychiatry (Vigod), University of Toronto; Mount Sinai Hospital (Farrugia); Department of Obstetrics and Gynaecology (Farrugia), University of Toronto; Dalla Lana School of Public Health (Urquia), University of Toronto; Departments of Medicine, and Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont.; Manitoba Centre for Health Policy (Urquia), Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man
| | - Joel G Ray
- Institute of Health Policy Management and Evaluation (Liu, Vigod, Ray), University of Toronto; ICES (Liu, Vigod, Urquia, Ray); Women's College Hospital and Department of Psychiatry (Vigod), University of Toronto; Mount Sinai Hospital (Farrugia); Department of Obstetrics and Gynaecology (Farrugia), University of Toronto; Dalla Lana School of Public Health (Urquia), University of Toronto; Departments of Medicine, and Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont.; Manitoba Centre for Health Policy (Urquia), Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.
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Yoon S, Jang EJ, Kim GH, Kim DH, Lim TY, Lee H, Ryu HG. Adult lung transplantation case-volume and in-hospital and long-term mortality in Korea. J Cardiothorac Surg 2019; 14:19. [PMID: 30674327 PMCID: PMC6343357 DOI: 10.1186/s13019-019-0849-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/17/2019] [Indexed: 11/17/2022] Open
Abstract
Background The inverse relationship between case-volume and surgical mortality has been reported in complex surgical procedures. The aim of this study was to evaluate the effect of case-volume on mortality after lung transplantation in Korea. Methods The National Health Insurance Service data was used to analyse all adult lung transplantations in Korea between 2007 and 2016. Institutions were categorized into low-volume (< 5 lung transplantations/year) centers or high-volume (≥ 5 lung transplantations/year) centers. Risk-adjusted in-hospital mortality and long-term survival according to case-volume was evaluated. Results A total of 315 adult recipients underwent lung transplantation at 7 centers. The odds ratio for in-hospital mortality in low-volume centers was similar to high-volume centers (OR, 1.496; 95% CI, 0.81–2.76; p = 0.197). Log-rank analysis of Kaplan-Meier curves according to case-volume also did not show a difference in long-term survival between high- and low-volume centers (p = 0.052). Conclusions There was no association between case-volume and in-hospital mortality after lung transplantation in Korea, although there was a tendency towards better long-term survival associated with high-volume centers.
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Affiliation(s)
- Susie Yoon
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, 1375 Gyeongdong-ro, Andong-si, Gyeongsangbuk-do, 36729, South Korea
| | - Ga Hee Kim
- Department of Statistics, Kyungpook National University, 80 Daehak-ro, Buk-gu, Daegu, 41566, South Korea
| | - Dal Ho Kim
- Department of Statistics, Kyungpook National University, 80 Daehak-ro, Buk-gu, Daegu, 41566, South Korea
| | - Tae-Yoon Lim
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Hannah Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Ho Geol Ryu
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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Claassen YHM, van Sandick JW, Hartgrink HH, Dikken JL, De Steur WO, van Grieken NCT, Boot H, Cats A, Trip AK, Jansen EPM, Meershoek-Klein Kranenbarg WM, Braak JPBM, Putter H, van Berge Henegouwen MI, Verheij M, van de Velde CJH. Association between hospital volume and quality of gastric cancer surgery in the CRITICS trial. Br J Surg 2019; 105:728-735. [PMID: 29652082 DOI: 10.1002/bjs.10773] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/16/2017] [Accepted: 10/30/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Studies investigating the association between hospital volume and quality of gastric cancer surgery are lacking. In the present study, the effect of hospital volume on quality of gastric cancer surgery was evaluated by analysing data from the CRITICS (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach) trial. METHODS Patients who underwent gastrectomy with curative intent in the Netherlands were selected from the CRITICS trial database. Annual hospital volume of participating centres was derived from the Netherlands Cancer Registry. Hospital volume was categorized into very low (1-10 gastrectomies per year per institution), low (11-20), medium (21-30) and high (31 or more), and linked to the CRITICS database. Quality of surgery was analysed by surgicopathological compliance (removal of at least 15 lymph nodes), surgical compliance (removal of indicated lymph node stations) and the Maruyama Index. Postoperative morbidity and mortality were also compared between hospital categories. RESULTS Between 2007 and 2015, 788 patients were included in the CRITICS study, of whom 494 were analysed. Surgicopathological compliance was higher (86·7 versus 50·4 per cent; P < 0·001), surgical compliance was greater (52·9 versus 19·8 per cent; P < 0·001) and median Maruyama Index was lower (0 versus 6; P = 0·006) in high-volume hospitals compared with very low-volume hospitals. There was no statistically significant difference in postoperative complications or mortality between the hospital volume categories. CONCLUSION Surgery performed in high-volume hospitals was associated with better surgical quality than surgery carried out in lower-volume hospitals.
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Affiliation(s)
- Y H M Claassen
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - H H Hartgrink
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J L Dikken
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - W O De Steur
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - N C T van Grieken
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - H Boot
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A Cats
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A K Trip
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - E P M Jansen
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - J P B M Braak
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - H Putter
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - M Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - C J H van de Velde
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
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Perioperative mortality and morbidity after sublobar versus lobar resection for early-stage non-small-cell lung cancer: post-hoc analysis of an international, randomised, phase 3 trial (CALGB/Alliance 140503). THE LANCET RESPIRATORY MEDICINE 2018; 6:915-924. [PMID: 30442588 DOI: 10.1016/s2213-2600(18)30411-9] [Citation(s) in RCA: 284] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/11/2018] [Accepted: 09/27/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Increased detection of small-sized, peripheral, non-small-cell lung cancer has renewed interest in sublobar resection instead of lobectomy, the traditional standard of care for early-stage lung cancer. We aimed to assess morbidity and mortality associated with lobar and sublobar resection for early-stage lung cancer. METHODS CALGB/Alliance 140503 is a multicentre, international, non-inferiority, phase 3 trial in patients with peripheral non-small-cell lung cancer clinically staged as T1aN0. Patients were recruited from 69 academic and community-based institutions in Australia, Canada, and the USA. Patients were randomly assigned intraoperatively to either lobar or sublobar resection. The random assignment was based on permuted block randomisation without concealment and was stratified according to radiographic tumour size, histology, and smoking status. The primary endpoint of the trial is disease-free survival; here, we report a post-hoc, exploratory, comparative analysis of perioperative mortality and morbidity associated with lobar and sublobar resection. Perioperative mortality was defined as death from any cause within 30 days and 90 days of surgical intervention and was calculated for all randomised patients. Morbidity was graded using Common Terminology Criteria for Adverse Events version 4.0. All analyses were done on an intention-to-treat basis for randomised patients with data available. This trial is registered with ClinicalTrials.gov, number NCT00499330. FINDINGS Between June 15, 2007, and March 13, 2017, 697 patients were randomly allocated to either lobar resection (n=357) or sublobar resection (n=340; 59% wedge resection). Six (0·9%) patients died by 30 days, four (1·1%) after lobar resection and two (0·6%) after sublobar resection; by 90 days, ten (1·4%) patients had died, six (1·7%) after lobar resection and four (1·2%) after sublobar resection (difference at 30 days, 0·5%, 95% CI -1·1 to 2·3; difference at 90 days, 0·5%, 95% CI -1·5 to 2·6). An adverse event of any grade occurred in 193 (54%) of 355 patients after lobar resection and 172 (51%) of 337 patients after sublobar resection. Adverse events of grade 3 or worse occurred in 54 (15%) patients assigned lobar resection and in 48 (14%) patients assigned sublobar resection. No differences between surgical approaches were noted in cardiac or pulmonary complications. Grade 3 haemorrhage (requiring transfusion) occurred in six (2%) patients assigned lobar resection and eight (2%) patients assigned sublobar resection. Prolonged air leak occurred in nine (3%) patients after lobar resection and two (1%) patients after sublobar resection. INTERPRETATION Our post-hoc analysis showed that perioperative mortality and morbidity did not seem to differ between lobar and sublobar resection in physically and functionally fit patients with clinical T1aN0 non-small-cell lung cancer. These data may affect the daily choices made by patients and their doctors in establishing the best treatment approach for stage I lung cancer. FUNDING National Cancer Institute.
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Kennedy GT, Ukert BD, Predina JD, Newton AD, Kucharczuk JC, Polsky D, Singhal S. Implications of Hospital Volume on Costs Following Esophagectomy in the United States. J Gastrointest Surg 2018; 22:1845-1851. [PMID: 30066065 DOI: 10.1007/s11605-018-3849-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/15/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND With increasing focus on health care quality and cost containment, volume-based referral strategies have been proposed to improve value in high-cost procedures, such as esophagectomy. While the effect of hospital volume on outcomes has been demonstrated, our goal was to evaluate the economic consequences of volume-based referral practices for esophagectomy. METHODS The nationwide inpatient sample (NIS) was queried for the years 2004-2013 for all patients undergoing esophagectomy. Patients were stratified by hospital volume quartile and substratified by preoperative risk and age. Clustered multivariable hierarchical logistic regression analysis was used to assess adjusted costs and mortality. RESULTS In total, 9270 patients were clustered based on annual hospital volume quartiles of < 7, 7 to 22, 23 to 87, and > 87 esophagectomies. After stratification by patient variables, high-volume centers performed esophagectomies in high-risk patients at the same cost as low-volume centers without significant difference in resource utilization. Overall, mortality decreased across volume quartiles (lowest 8.9 versus highest 3.6%, p < 0.0001). The greatest volume-mortality differences were observed among patients aged between 70 and 80 years (lowest 12.2 versus highest 6.2%, p = 0.009). Patients with high preoperative risk also derived mortality benefits with increasing hospital volume (lowest 17.5 versus highest 11.8%, p < 0.0001). CONCLUSIONS This study demonstrates that the mortality improvements for high-risk patients undergoing esophagectomy at high-volume centers do not come at increased costs. These results suggest that health systems should consider selectively referring high-risk patients to high-volume centers within their region.
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Affiliation(s)
- Gregory T Kennedy
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Benjamin D Ukert
- The Wharton School and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Andrew D Newton
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - John C Kucharczuk
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA
| | - Daniel Polsky
- The Wharton School and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 6 White Building, Philadelphia, PA, 19104, USA.
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van Putten M, Nelen SD, Lemmens VEPP, Stoot JHMB, Hartgrink HH, Gisbertz SS, Spillenaar Bilgen EJ, Heisterkamp J, Verhoeven RHA, Nieuwenhuijzen GAP. Overall survival before and after centralization of gastric cancer surgery in the Netherlands. Br J Surg 2018; 105:1807-1815. [PMID: 30132789 DOI: 10.1002/bjs.10931] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/06/2018] [Accepted: 06/12/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Centralization of surgery has been shown to improve outcomes for oesophageal and pancreatic cancer, and has been implemented for gastric cancer since 2012 in the Netherlands. This study evaluated the impact of centralizing gastric cancer surgery on outcomes for all patients with gastric cancer. METHODS Patients diagnosed with non-cardia gastric adenocarcinoma in the intervals 2009-2011 and 2013-2015 were selected from the Netherlands Cancer Registry. Clinicopathological data, treatment characteristics and mortality were assessed for the periods before (2009-2011) and after (2013-2015) centralization. Cox regression analyses were used to assess differences in overall survival between these intervals. RESULTS A total of 7204 patients were included. Resection rates increased slightly from 37·6 per cent before to 39·6 per cent after centralization (P = 0·023). Before centralization, 50·1 per cent of surgically treated patients underwent gastrectomy in hospitals that performed fewer than ten procedures annually, compared with 9·2 per cent after centralization. Patients who had gastrectomy in the second interval were younger and more often underwent total gastrectomy (29·3 per cent before versus 41·2 per cent after centralization). Thirty-day postoperative mortality rates dropped from 6·5 to 4·1 per cent (P = 0·004), and 90-day mortality rates decreased from 10·6 to 7·2 per cent (P = 0·002). Two-year overall survival rates increased from 55·4 to 58·5 per cent among patients who had gastrectomy (P = 0·031) and from 27·1 to 29·6 per cent for all patients (P = 0·003). Improvements remained after adjustment for case mix; however, adjustment for hospital volume attenuated this association for surgically treated patients. CONCLUSION Centralization of gastric cancer surgery was associated with reduced postoperative mortality and improved survival.
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Affiliation(s)
- M van Putten
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, The Netherlands
| | - S D Nelen
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - V E P P Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, The Netherlands.,Department of Public Health, Erasmus MC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - J H M B Stoot
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - H H Hartgrink
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - J Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - R H A Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, The Netherlands
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40
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Abstract
How best to improve the surgical quality remains unknown. Historically, most efforts were either top down national policy efforts or local hospital/practice level efforts. This article reviews the limitations of these methods and how collaborative quality improvement a mix of local, regional, and national efforts is the most effective means of achieving sustainable, meaningful improvement in surgical care.
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Affiliation(s)
- Amir A Ghaferi
- Department of Surgery, University of Michigan, 2800 Plymouth Road, NCRC, Building 16, Room 140E, Ann Arbor, MI 48109, USA.
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Schwarz RE. Clinical trends and effects on quality metrics for surgical gastroesophageal cancer care. Transl Gastroenterol Hepatol 2018; 3:43. [PMID: 30148228 DOI: 10.21037/tgh.2018.06.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/27/2018] [Indexed: 12/11/2022] Open
Abstract
Background Surgical therapy of mid-stage gastric cancer (GC) and other neoplastic conditions requiring gastric resection remains at the center of curative outcomes, while epidemiologic changes and multimodality treatment options have evolved rapidly. Putative quality metrics for gastrectomy such as R0 rate, total lymph node (LN) count or postoperative morbidity may depend partly on changing disease and treatment patterns, and deserve evaluation under various practice conditions. Methods Data within a U.S.-based single surgical oncologist's practice over 15 years were prospectively recorded and retrospectively analyzed for clinicopathologic factors, operative treatment aspects and outcomes. Trends and spectrum changes over three time intervals were analyzed with contingency analysis and continuous data comparative statistics. Results Of 179 patients undergoing gastric resection, 119 were male and 60 female, with a median age of 63 years (range, 24-98 years). Resections included 56 total, 56 subtotal/distal, 30 proximal and 37 segmental gastrectomies. Diagnoses included 96 GCs, 31 gastroesophageal (GE) junction (GEJ) cancers, 21 GI stromal tumors (GISTs), and 31 other conditions. Significant trends from first towards last time interval were observed for resection type (16% to 32% proximal, 9% to 30% segmental, P=0.0003), curative intent (76% to 98%, P=0.002), diagnosis (5% to 42% GEJ cancer, P<0.0001) and preoperative therapy use (0% to 58%, P<0.0001), among others. Intraoperative aspects showed significantly reduced blood loss (median: 500 to 150 mL) and transfusion requirements (39% to 4%), and an increased use of minimally invasive techniques over time (all at P<0.001). Among patients undergoing curative intent GC resection with LN dissection, total LN counts remained steady (mean: 26), while the number of involved LNs decreased (9.0 to 3.7, P=0.0003) and the R0 resection rate increased from 74% to 85% (P=0.05). The number of specimens with >15 LNs examined increased from 69.0% to 92.5% (P=0.022). At the same time, spleen preservation rate (91% overall) and major morbidity (16%) remained unchanged throughout. Postoperative length of stay decreased from a median of 12 to 8 days (P<0.0001). Conclusions This experience represents some variable practice patterns within a clinicopathologic spectrum of GE diseases. Postoperative or oncologic quality metrics have been sustained or did improve, which would support their utility for various practice settings; they compare favorably to other published U.S. experiences during the same time period.
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Affiliation(s)
- Roderich E Schwarz
- Department of Surgery, Indiana University School of Medicine, South Bend, IN, USA.,Goshen Center for Cancer Care, Goshen, IN, USA
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42
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Sun S, Borisenko O, Spelman T, Ahmed AR. Patient Characteristics, Procedural and Safety Outcomes of Bariatric Surgery in England: a Retrospective Cohort Study-2006-2012. Obes Surg 2018; 28:1098-1108. [PMID: 29076010 PMCID: PMC5880868 DOI: 10.1007/s11695-017-2978-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The objective of the study is to analyze procedural and safety outcomes associated with bariatric surgery and describe the characteristics of patients undertaking bariatric procedures in England between April 2006 and March 2012. METHODS This is a retrospective cohort study of all adult patients in England diagnosed with obesity and undergoing bariatric surgery as a primary procedure in NHS-funded sites between April 2006 and March 2012 using data sourced from the Hospital Episode Statistics dataset. Length of stay (LOS), 30-day readmission, and post-surgery complication were analyzed as primary outcomes. Socio-demographic background, provider type, procedure volume, and comorbidities were all analyzed as potential explanatory variables. RESULTS Gastric bypass (GBP, 12,628) was the most utilized procedure, followed by gastric banding (GB, 6872) and sleeve gastrectomy (SG, 3251). The most prevalent comorbidity was type 2 diabetes (23%). Inpatient mortality was low (≤ 0.15%) for all procedure types. LOS and the risks of both post-operative complication and 30-day readmission were significantly lower for GB, relative to those for GBP and SG. Ethnicity, geographical area, surgery type, and volume were all associated with LOS, risk of readmission, and complication. Provider type and deprivation were further associated with LOS while age correlated with readmission only. An increasing comorbidity burden was associated with an increased risk of both readmission and complication. CONCLUSIONS Gastric bypass was the most frequently reported procedure in England across the observation period. While utilization across all procedure types increased between 2007 and 2010, overall uptake of bariatric surgery in England represents only a small proportion of the eligible population. Readmission and complication rates were lower for gastric banding relative to those for either gastric bypass or sleeve gastrectomy. The observed inpatient mortality rate was low across all procedure types.
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Affiliation(s)
- Sun Sun
- Synergus AB, Kevinge Strand 20, 182 57, Stockholm, Sweden.
- Health Outcomes and Economic Evaluation Research Group, Center for Healthcare Ethics, Department of Learning, Information, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
- Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
| | - Oleg Borisenko
- Synergus AB, Kevinge Strand 20, 182 57, Stockholm, Sweden
| | - Tim Spelman
- Synergus AB, Kevinge Strand 20, 182 57, Stockholm, Sweden
- Centre for Population Health, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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43
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Cheraghlou S, Kuo P, Mehra S, Yarbrough WG, Judson BL. Salvage Surgery after Radiation Failure in T1/T2 Larynx Cancer: Outcomes following Total versus Conservation Surgery. Otolaryngol Head Neck Surg 2018; 158:497-504. [DOI: 10.1177/0194599817742596] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective After radiation failure for early T-stage larynx cancer, national guidelines recommend salvage surgery. Total laryngectomy and conservation laryngeal surgery with an open or endoscopic approach are both used. Beyond single-institution studies, there is a lack of evidence concerning the outcomes of these procedures. We aim to study whether treatment with conservation laryngeal surgery is associated with poorer outcomes than treatment with total laryngectomy as salvage surgery after radiation failure for T1/T2 larynx cancers. Study Design A retrospective study was conducted of adult squamous cell larynx cancer cases in the National Cancer Database diagnosed from 2004 to 2012. Setting Commission on Cancer cancer programs in the United States. Methods Demographic, facility, tumor, and survival variables were included in the analyses. Multivariate survival regressions as well as univariate Kaplan-Meier analyses were conducted. Results Slightly more than 7% of patients receiving radiotherapy for T1/T2 larynx cancers later received salvage surgery. Salvage with partial laryngectomy was not associated with diminished survival as compared with total laryngectomy. However, positive surgical margins were associated with worse outcomes (hazard ratio, 1.782; P = .001), and a larger percentage of patients receiving partial laryngectomy had positive margins than those receiving total laryngectomy. Facility characteristics were not associated with differences in salvage surgery type or outcomes. Conclusion In recognition of the inherent selection bias, patients who experienced recurrences after radiation for T1/T2 larynx cancer and underwent conservation salvage laryngeal surgery demonstrated clinical outcomes similar to those of patients undergoing salvage total laryngectomy. Increased rates of positive surgical margins were observed among patients undergoing salvage conservation surgery.
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Affiliation(s)
- Shayan Cheraghlou
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Phoebe Kuo
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Saral Mehra
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center, New Haven, Connecticut, USA
| | - Wendell G. Yarbrough
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Benjamin L. Judson
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center, New Haven, Connecticut, USA
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44
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Chazapis M, Gilhooly D, Smith A, Myles P, Haller G, Grocott M, Moonesinghe S. Perioperative structure and process quality and safety indicators: a systematic review. Br J Anaesth 2018; 120:51-66. [DOI: 10.1016/j.bja.2017.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 12/12/2022] Open
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45
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Henneman D, Dikken JL, Putter H, Lemmens VEPP, Van der Geest LGM, van Hillegersberg R, Verheij M, van de Velde CJH, Wouters MWJM. In Reply: Centralization of Upper Gastrointestinal Cancer Care Should Be Dictated by Quality of Care. Ann Surg Oncol 2017; 24:621-622. [PMID: 29134375 DOI: 10.1245/s10434-017-6222-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Daniel Henneman
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Johan L Dikken
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Surgery, Medical Center Haaglanden, Medisch Centrum Haaglanden, The Hague, The Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | - Marcel Verheij
- Department of Radiotherapy, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Michel W J M Wouters
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Surgery, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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46
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Zacharia BE, Youngerman BE, Bruce SS, Hershman DL, Neugut AI, Bruce JN, Wright JD. Quality of Postoperative Venous Thromboembolism Prophylaxis in Neuro-oncologic Surgery. Neurosurgery 2017; 80:73-81. [PMID: 27258769 DOI: 10.1227/neu.0000000000001270] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 02/28/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Given the vagaries of published guidelines and the lack of high-quality evidence on the method, timing, and dose of venous thromboembolism (VTE) prophylaxis in neurological surgery, little is known about practice patterns regarding VTE prophylaxis in the United States. OBJECTIVE To estimate the use of VTE prophylaxis in patients who underwent surgery for a cerebral neoplasm and to identify patient, physician, and hospital characteristics associated with prophylaxis. METHODS Using the Premier Perspective database, we classified patients undergoing surgery for intracranial neoplasm between 2006 and 2012 on the basis of the type of VTE prophylaxis they received (mechanical, pharmacological, or combination). Generalized estimating equations were used to analyze the effects of pretreatment patient and system variables, including hospital and surgeon volume, on prophylaxis while controlling for hospital clustering. RESULTS A total of 43 327 patients were identified. Venous thromboembolism prophylaxis was given to 70.2% of patients. Overall, 16 957 (39.2%) had only mechanical prophylaxis, 5628 (13%) received only pharmacological prophylaxis, and 7826 (18.1%) received combination prophylaxis. Patients with high-volume providers (odds ratio, 2.22; 95% confidence interval, 1.33-3.69) were more likely to receive prophylaxis. CONCLUSION Nearly one-third of patients who underwent surgery for an intracranial tumor did not receive any VTE prophylaxis. We noted that the rate of overall VTE prophylaxis did not significantly change over the course of the 7 years analyzed despite an increasing focus on complication prevention. High-volume surgeons were more likely to provide VTE prophylaxis.
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Affiliation(s)
- Brad E Zacharia
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Brett E Youngerman
- Department of Neurological Surgery, Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - Samuel S Bruce
- Department of Neurological Surgery, Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | | | | | - Jeffrey N Bruce
- Department of Neurological Surgery, Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
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Mukai Y, Kurokawa Y, Takiguchi S, Mori M, Doki Y. Are treatment outcomes in gastric cancer associated with either hospital volume or surgeon volume? Ann Gastroenterol Surg 2017; 1:186-192. [PMID: 29863147 PMCID: PMC5881359 DOI: 10.1002/ags3.12031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 07/06/2017] [Indexed: 11/23/2022] Open
Abstract
Surgical resection is the only curative treatment for gastric cancer. Postoperative outcomes may be affected by the average or total number of surgeries carried out at an institution (hospital volume) or by a surgeon (surgeon volume). Among seven large‐scale studies that each enrolled over 10 000 patients who underwent gastrectomy, six showed that higher hospital volume contributed to a lower mortality rate after gastrectomy. Surgeon volume was also reported by three of four studies that each included over 1000 patients to be a significant factor contributing to heterogeneity in mortality rates after gastrectomy. In contrast, most studies showed no relationship between hospital volume and postoperative morbidity. A significant long‐term relationship was demonstrated in four of nine studies that each included more than 1000 patients, but the other five studies showed negative results. A recent correlative study of randomized phase III trials for gastric cancer surgeries showed a significant relationship between hospital volume and postoperative morbidity in one trial but not in another trial. There was no correlation between overall survival and either hospital or surgeon volume. In addition, another correlative study of a phase III trial of randomized chemotherapy for unresectable or recurrent gastric cancer found that there was no correlation between hospital volume and overall survival, although there was a large degree of heterogeneity in median overall survival among participating institutions.
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Affiliation(s)
- Yosuke Mukai
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Yukinori Kurokawa
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Shuji Takiguchi
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery Osaka University Graduate School of Medicine Osaka Japan
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48
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Traveling to a High-volume Center is Associated With Improved Survival for Patients With Esophageal Cancer. Ann Surg 2017; 265:743-749. [PMID: 28266965 DOI: 10.1097/sla.0000000000001702] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND An association between volume and outcomes has been observed for esophagectomy, though little is known about why or how patients choose low- or high-volume centers. The purpose of this study was to evaluate how travel burden and hospital volume influence treatment and outcomes of patients with locally advanced esophageal cancer. METHODS Predictors of receiving esophagectomy for patients with T1-3N1M0 mid or distal esophageal cancer in the National Cancer Data Base from 2006 to 2011 were identified using multivariable logistic regression. Survival was compared using propensity score-matched groups: patients in the bottom quartile of travel distance who underwent treatment at low-volume facilities (Local) and patients in the top quartile of travel distance who underwent treatment at high-volume facilities (Travel). RESULTS Of 4979 patients who met inclusion criteria, we identified 867 Local patients who traveled 2.7 [interquartile range (IQR): 1.6-4 miles] miles to centers that treated 2.6 (IQR: 1.9-3.3) esophageal cancers per year, and 317 Travel patients who traveled 107.1 (IQR: 65-247) miles to centers treating 31.9 (IQR: 30.9-38.5) cases. Travel patients were more likely to undergo esophagectomy (67.8% vs 42.9%, P < 0.001) and had significantly better 5-year survival (39.8% vs 20.6%, P < 0.001) than Local patients. CONCLUSIONS Patients who travel longer distances to high-volume centers have significantly different treatment and better outcomes than patients who stay close to home at low-volume centers. Strategies that support patient travel for treatment at high-volume centers may improve esophageal cancer outcomes.
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Ho V, Short MN, Aloia TA. Can postoperative process of care utilization or complication rates explain the volume-cost relationship for cancer surgery? Surgery 2017; 162:418-428. [PMID: 28438333 DOI: 10.1016/j.surg.2017.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Past studies identify an association between provider volume and outcomes, but less is known about the volume-cost relationship for cancer surgery. We analyze the volume-cost relationship for 6 cancer operations and explore whether it is influenced by the occurrence of complications and/or utilization of processes of care. METHODS Medicare hospital and inpatient claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Regressions were first estimated to quantify the association of provider volume with costs, excluding measures of complications and processes of care as explanatory variables. Next, these variables were added to the regressions to test whether they weakened any previously observed volume-cost relationship. RESULTS Higher hospital volume is associated with lower patient costs for esophagectomy but not for other operations. Higher surgeon volume reduces costs for most procedures, but this result weakens when processes of care are added to the regressions. Processes of care that are frequently implemented in response to adverse events are associated with 14% to 34% higher costs. Utilization of these processes is more prevalent among low-volume versus high-volume surgeons. CONCLUSION Processes of care implemented when complications occur explain much of the surgeon volume-cost relationship. Given that surgeon volume is readily observed, better outcomes and lower costs may be achieved by referring patients to high-volume surgeons. Increasing patient access to surgeons with lower rates of complications may be the most effective strategy for avoiding costly processes of care, controlling expenditure growth.
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Affiliation(s)
- Vivian Ho
- Baker Institute for Public Policy, Rice University, Houston, TX; Department of Economics, Rice University, Houston, TX.
| | - Marah N Short
- Baker Institute for Public Policy, Rice University, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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50
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Mathur AK, Chakrabarti AK, Mellinger JL, Volk ML, Day R, Singer AL, Hewitt WR, Reddy KS, Moss AA. Hospital resource intensity and cirrhosis mortality in United States. World J Gastroenterol 2017; 23:1857-1865. [PMID: 28348492 PMCID: PMC5352927 DOI: 10.3748/wjg.v23.i10.1857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/04/2017] [Accepted: 02/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine whether hospital characteristics predict cirrhosis mortality and how much variation in mortality is attributable to hospital differences.
METHODS We used data from the 2005-2011 Nationwide Inpatient Sample and the American Hospital Association Annual survey to identify hospitalizations for decompensated cirrhosis and corresponding facility characteristics. We created hospital-specific risk and reliability-adjusted odds ratios for cirrhosis mortality, and evaluated patient and facility differences based on hospital performance quintiles. We used hierarchical regression models to determine the effect of these factors on mortality.
RESULTS Seventy-two thousand seven hundred and thirty-three cirrhosis admissions were evaluated in 805 hospitals. Hospital mean cirrhosis annual case volume was 90.4 (range 25-828). Overall hospital cirrhosis mortality rate was 8.00%. Hospital-adjusted odds ratios (aOR) for mortality ranged from 0.48 to 1.89. Patient characteristics varied significantly by hospital aOR for mortality. Length of stay averaged 6.0 ± 1.6 days, and varied significantly by hospital performance (P < 0.001). Facility level predictors of risk-adjusted mortality were higher Medicaid case-mix (OR = 1.00, P = 0.029) and LPN staffing (OR = 1.02, P = 0.015). Higher cirrhosis volume (OR = 0.99, P = 0.025) and liver transplant program status (OR = 0.83, P = 0.026) were significantly associated with survival. After adjusting for patient differences, era, and clustering effects, 15.3% of variation between hospitals was attributable to differences in facility characteristics.
CONCLUSION Hospital characteristics account for a significant proportion of variation in cirrhosis mortality. These findings have several implications for patients, providers, and health care delivery in liver disease care and inpatient health care design.
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