151
|
Gooiker GA, Lemmens VEPP, Besselink MG, Busch OR, Bonsing BA, Molenaar IQ, Tollenaar RAEM, de Hingh IHJT, Wouters MWJM. Impact of centralization of pancreatic cancer surgery on resection rates and survival. Br J Surg 2014; 101:1000-5. [PMID: 24844590 DOI: 10.1002/bjs.9468] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Centralization of pancreatic surgery has been shown to reduce postoperative mortality. It is unknown whether resection rates and survival have also improved. The aim of this study was to analyse the impact of nationwide centralization of pancreatic surgery on resection rates and long-term survival. METHODS All patients diagnosed in the Netherlands between 2000 and 2009 with cancer of the pancreatic head were identified in the Netherlands Cancer Registry. Changes in referral pattern, resection rates and survival after pancreatoduodenectomy were analysed. Multivariable regression analysis was used to assess the impact of hospital volume (20 or more procedures per year) on survival after resection. RESULTS Between 2000 and 2009, 11,160 patients were diagnosed with cancer of the pancreatic head. The resection rate increased from 10.7 per cent in 2000-2004 to 15.3 per cent in 2005-2009 (P < 0.001). No significant difference in survival after resection was observed between the two intervals (P = 0.135), although survival was significantly better in high-volume hospitals (median survival 18 months versus 16 months in low/medium-volume hospitals; P = 0.017). After adjustment for patient and tumour characteristics, high hospital volume remained associated with better overall survival after resection (hazard ratio 0.70, 95 per cent confidence interval 0.58 to 0.84; P < 0.001). CONCLUSION Centralization of pancreatic cancer surgery led to increased resection rates. High-volume centres had significantly better survival rates. Centralization improves patient outcomes and should be encouraged.
Collapse
|
152
|
de Ridder M, Smeele LE, van den Brekel MWM, van Harten MC, Wouters MWJM, Balm AJM. Volume criteria for the treatment of head and neck cancer: Are they evidence based? Head Neck 2014; 36:760-2. [DOI: 10.1002/hed.23555] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 11/22/2013] [Indexed: 11/11/2022] Open
|
153
|
Kolfschoten NE, Marang-van de Mheen PJ, Wouters MWJM, Eddes EH, Tollenaar RAEM, Stijnen T, Kievit J. A combined measure of procedural volume and outcome to assess hospital quality of colorectal cancer surgery, a secondary analysis of clinical audit data. PLoS One 2014; 9:e88737. [PMID: 24558418 PMCID: PMC3928280 DOI: 10.1371/journal.pone.0088737] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 01/02/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To identify, on the basis of past performance, those hospitals that demonstrate good outcomes in sufficient numbers to make it likely that they will provide adequate quality of care in the future, using a combined measure of volume and outcome (CM-V&O). To compare this CM-V&O with measures using outcome-only (O-O) or volume-only (V-O), and verify 2010-quality of care assessment on 2011 data. DESIGN Secondary analysis of clinical audit data. SETTING The Dutch Surgical Colorectal Audit database of 2010 and 2011, the Netherlands. PARTICIPANTS 8911 patients (test population, treated in 2010) and 9212 patients (verification population, treated in 2011) who underwent a resection of primary colorectal cancer in 89 Dutch hospitals. MAIN OUTCOME MEASURES Outcome was measured by Observed/Expected (O/E) postoperative mortality and morbidity. CM-V&O states 2 criteria; 1) outcome is not significantly worse than average, and 2) outcome is significantly better than substandard, with 'substandard care' being defined as an unacceptably high O/E threshold for mortality and/or morbidity (which we set at 2 and 1.5 respectively). RESULTS Average mortality and morbidity in 2010 were 4.1 and 24.3% respectively. 84 (94%) hospitals performed 'not worse than average' for mortality, but only 21 (24%) of those were able to prove they were also 'better than substandard' (O/E<2). For morbidity, 42 hospitals (47%) met the CM-V&O. Morbidity in 2011 was significantly lower in these hospitals (19.8 vs. 22.8% p<0.01). No relationship was found between hospitals' 2010 performance on O-O en V-O, and the quality of their care in 2011. CONCLUSION CM-V&O for morbidity can be used to identify hospitals that provide adequate quality and is associated with better outcomes in the subsequent year.
Collapse
|
154
|
Dassen AE, Dikken JL, Bosscha K, Wouters MWJM, Cats A, van de Velde CJH, Coebergh JW, Lemmens VEPP. Gastric cancer: decreasing incidence but stable survival in the Netherlands. Acta Oncol 2014; 53:138-42. [PMID: 23829603 DOI: 10.3109/0284186x.2013.789139] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastric cardia and non-cardia cancer exhibit differences in biological and epidemiological features across the world. The aims of this study were to analyze trends in incidence, stage distribution, and survival over a 20-year period in the Netherlands, separately for both types of gastric cancer. METHODS Data on all patients with a diagnosis of gastric cancer in the period 1989-2008 were obtained from the nationwide Netherlands Cancer Registry. Time trends in incidence [analyzed as European Standard Rate per 100 000 (ESR)] and relative survival were separately analyzed for cardia and non-cardia gastric cancer. RESULTS A total of 47 295 patients were included. Incidence rates per 100 000 for cardia cancer declined from 5.7 to 4.3 for males and remained stable for females (1.2). For non-cardia cancer, the incidence in males declined from 25 to 14 and in females from 10 to 7. Proportional incidence in stage IV cardia and non-cardia cancer increased in 2004-2008 (cardia 32-42%, non-cardia 33-45%). Five-year survival rates for stage I-III and X (unknown) remained stable (cardia cancer: 20%, non-cardia gastric cancer: 31%). Five-year survival for stage IV disease was 1.9% and 1.0% for cardia and non-cardia gastric cancer. CONCLUSION The incidence of gastric cancer in the Netherlands markedly decreased over the past decades, in particular of non-cardia cancer. Survival remained dismal. Improvement of survival remains a challenge for the multidisciplinary team involved in gastric cancer treatment.
Collapse
|
155
|
Dassen AE, Dikken JL, van de Velde CJH, Wouters MWJM, Bosscha K, Lemmens VEPP. Changes in treatment patterns and their influence on long-term survival in patients with stages I-III gastric cancer in The Netherlands. Int J Cancer 2013; 133:1859-66. [PMID: 23564267 DOI: 10.1002/ijc.28192] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 03/04/2013] [Indexed: 12/23/2022]
Abstract
Studies investigating perioperative chemotherapy and/or radiotherapy changed the treatment of curable gastric cancer in The Netherlands. These changes were evaluated including their influence on survival. Data on patients diagnosed with gastric cancer from 1989 to 2009 were obtained from The Netherlands Cancer Registry. Changes over time in surgery and administration of perioperative chemotherapy, 30-day mortality, 5-year survival and adjusted relative excess risk (RER) of dying were analyzed with multivariable regression for cardia and noncardia cancer. In stages I and II disease, most patients underwent surgery. Since 2005, more patients are treated with (neo)adjuvant chemotherapy. Postoperative mortality ranged from 1% to 7% and 0.4% to 12.2% in cardia and noncardia cancer (<55 to 75+ years). Five-year survival for cardia cancer and noncardia cancer stages I-III and X (unknown stage) was 33% and 50% (2005-2008). The RER of dying was associated with period of diagnosis, age, gender, region, stage, (neo)adjuvant chemotherapy in case of cardia cancer and type of gastric resection in case of noncardia cancer. Administration of (neo)adjuvant chemotherapy has increased. No improvement in long-term survival could yet be seen, though it is still too early to expect an improvement in survival as a result of the use of chemotherapy.
Collapse
|
156
|
Snijders HS, Henneman D, van Leersum NL, ten Berge M, Fiocco M, Karsten TM, Havenga K, Wiggers T, Dekker JW, Tollenaar RAEM, Wouters MWJM. Anastomotic leakage as an outcome measure for quality of colorectal cancer surgery. BMJ Qual Saf 2013; 22:759-67. [PMID: 23687168 DOI: 10.1136/bmjqs-2012-001644] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION When comparing mortality rates between hospitals to explore hospital performance, there is an important role for adjustment for differences in case-mix. Identifying outcome measures that are less influenced by differences in case-mix may be valuable. The main goal of this study was to explore whether hospital differences in anastomotic leakage (AL) and postoperative mortality are due to differences in case-mix or to differences in treatment factors. METHODS Data of the Dutch Surgical Colorectal Audit were used. Case-mix factors and treatment-related factors were identified from the literature and their association with AL and mortality were analysed with logistic regression. Hospital differences in observed AL and mortality rates, and adjusted rates based on the logistic regression models were shown. The reduction in hospital variance after adjustment was analysed with Levene's test for equality of variances. RESULTS 17 of 22 case-mix factors and 4 of 11 treatment factors related to AL derived from the literature were available in the database. Variation in observed AL rates between hospitals was large with a maximum rate of 17%. This variation could not be attributed to differences in case-mix but more to differences in treatment factors. Hospital variation in observed mortality rates was significantly reduced after adjustment for differences in case-mix. CONCLUSIONS Hospital variation in AL is relatively independent of differences in case-mix. In contrast to 'postoperative mortality' the observed AL rates of hospitals evaluated in our study were only slightly affected after adjustment for case-mix factors. Therefore, AL rates may be suitable as an outcome indicator for measurement of surgical quality of care.
Collapse
|
157
|
Henneman D, Snijders HS, Fiocco M, van Leersum NJ, Kolfschoten NE, Wiggers T, Wouters MWJM, Tollenaar RAEM. Hospital variation in failure to rescue after colorectal cancer surgery: results of the Dutch Surgical Colorectal Audit. Ann Surg Oncol 2013; 20:2117-23. [PMID: 23417434 DOI: 10.1245/s10434-013-2896-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Postoperative mortality is frequently used in hospital comparisons as marker for quality of care. Differences in mortality between hospitals may be explained by varying complication rates. A possible modifying factor may be the ability to let patients with a serious complication survive, referred to as failure to rescue (FTR). The purpose of this study was to evaluate how hospital performance on postoperative mortality is related to severe complications or to FTR and to explore the value of FTR in quality improvement programs. METHODS All patients operated for colorectal cancer from 2009 to 2011, registered in the Dutch Surgical Colorectal Audit, were included. Logistic regression models were used to obtain adjusted mortality, complication, and FTR rates. Hospitals were grouped into 5 quintiles according to adjusted mortality. Outcomes were compared between quintiles. RESULTS A total of 24,667 patients were included. Severe complications ranged from 19 % in the lowest to 25 % in the highest mortality quintile (odds ratio 1.5, 95 % confidence interval 1.37-1.67). Risk-adjusted FTR rates showed a marked difference between the quintiles, ranging from 9 % to 26 % (odds ratio 3.0, 95 % confidence interval 2.29-3.98). There was significant variability in FTR rates. Seven hospitals had significantly lower FTR rates than average. CONCLUSIONS High-mortality hospitals had slightly higher rates of severe complications than low-mortality hospitals. However, FTR was three times higher in high-mortality hospitals than in low-mortality hospitals. In quality improvement projects, feedback to hospitals of FTR rates, along with complication rates, may illustrate shortcomings (prevention or management of complications) per hospital, which may be an important step in reducing mortality.
Collapse
|
158
|
Kolfschoten NE, Wouters MWJM, Gooiker GA, Eddes EH, Kievit J, Tollenaar RAEM, Marang-van de Mheen PJ. Nonelective colon cancer resections in elderly patients: results from the dutch surgical colorectal audit. Dig Surg 2012; 29:412-9. [PMID: 23235489 DOI: 10.1159/000345614] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 11/05/2012] [Indexed: 12/10/2022]
Abstract
AIMS The aim of the study was to assess which factors contribute to postoperative mortality, especially in elderly patients who undergo emergency colon cancer resections, using a nationwide population-based database. METHODS 6,161 patients (1,172 nonelective) who underwent a colon cancer resection in 2010 in the Netherlands were included. Risk factors for postoperative mortality were investigated using a multivariate logistic regression model for different age groups, elective and nonelective patients separately. RESULTS For both elective and nonelective patients, mortality risk increased with increasing age. For nonelective elderly patients (80+ years), each additional risk factor increased the mortality risk. For a nonelective patient of 80+ years with an American Society of Anesthesiologists score of III+ and a left hemicolectomy or extended resection, postoperative mortality rate was 41% compared with 7% in patients without additional risk factors. CONCLUSIONS For elderly patients with two or more additional risk factors, a nonelective resection should be considered a high-risk procedure with a mortality risk of up to 41%. The results of this study could be used to adequately inform patient and family and should have consequences for composing an operative team.
Collapse
|
159
|
Dikken JL, van Sandick JW, Allum WH, Johansson J, Jensen LS, Putter H, Coupland VH, Wouters MWJM, Lemmens VEP, van de Velde CJH, van der Geest LGM, Larsson HJ, Cats A, Verheij M. Differences in outcomes of oesophageal and gastric cancer surgery across Europe. Br J Surg 2012. [PMID: 23180474 DOI: 10.1002/bjs.8966] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND In several European countries, centralization of oesophagogastric cancer surgery has been realized and clinical audits initiated. The present study was designed to evaluate differences in resection rates, outcomes and annual hospital volumes between these countries, and to analyse the relationship between hospital volume and outcomes. METHODS National data were obtained from cancer registries or clinical audits in the Netherlands, Sweden, Denmark and England. Differences in outcomes were analysed between countries and between hospital volume categories, adjusting for available case-mix factors. RESULTS Between 2004 and 2009, 10 854 oesophagectomies and 9010 gastrectomies were registered. Resection rates in England were 18·2 and 21·6 per cent for oesophageal and gastric cancer respectively, compared with 28·5-29·9 and 41·4-41·9 per cent in the Netherlands and Denmark (P < 0·001). The adjusted 30-day mortality rate after oesophagectomy was lowest in Sweden (1·9 per cent). After gastrectomy, the adjusted 30-day mortality rate was significantly higher in the Netherlands (6·9 per cent) than in Sweden (3·5 per cent; P = 0·017) and Denmark (4·3 per cent; P = 0·029). Increasing hospital volume was associated with a lower 30-day mortality rate after oesophagectomy (odds ratio 0·55 (95 per cent confidence interval 0·42 to 0·72) for at least 41 versus 1-10 procedures per year) and gastrectomy (odds ratio 0·64 (0·41 to 0·99) for at least 21 versus 1-10 procedures per year). CONCLUSION Hospitals performing larger numbers of oesophagogastric cancer resections had a lower 30-day mortality rate. Differences in outcomes between several European countries could not be explained by differences in hospital volumes. To understand these differences in outcomes and resection rates, with reliable case-mix adjustments, a uniform European upper gastrointestinal cancer audit with recording of standardized data is warranted.
Collapse
|
160
|
van Leersum NJ, Janssen-Heijnen MLG, Wouters MWJM, Rutten HJT, Coebergh JW, Tollenaar RAEM, Lemmens VEPP. Increasing prevalence of comorbidity in patients with colorectal cancer in the South of the Netherlands 1995-2010. Int J Cancer 2012; 132:2157-63. [PMID: 23015513 DOI: 10.1002/ijc.27871] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 08/23/2012] [Indexed: 11/11/2022]
Abstract
Comorbidity has large impact on colorectal cancer (CRC) treatment and outcomes and may increase as the population ages. We aimed to evaluate the prevalence and time trends of comorbid diseases in patients with CRC from 1995 to 2010. The Eindhoven Cancer Registry registers comorbidity in all patients with primary CRC in the South of the Netherlands. We analyzed the prevalence of serious comorbid diseases in four time frames from 1995 to 2010. Thereby, we addressed its association with age, gender and socio-economic status (SES). The prevalence of comorbidity was registered in 27,339 patients with primary CRC. During the study period, the prevalence of comorbidity increased from 47% to 62%, multimorbidity increased from 20% to 37%. Hypertension and cardiovascular diseases were most prevalent and increased largely over time (respectively 16-29% and 12-24%). Pulmonary diseases increased in women, but remained stable in men. Average age at diagnosis increased from 68.3 to 69.5 years (p = 0.004). A low SES and male gender were associated with a higher risk of comorbidity (not changing over time). This study indicates that comorbidity among patients with CRC is common, especially in males and patients with a low SES. The prevalence of comorbidity increased from 1995 to 2010, in particular in presumably nutritional diseases. Ageing, increased life expectancy and life style changes may contribute to more comorbid diseases. Also, improved awareness among health care providers on the importance of comorbidity may have resulted in better registration. The increasing burden of comorbidity in patients with CRC emphasizes the need for more focus on individualized medicine.
Collapse
|
161
|
Kolfschoten NE, Kievit J, Gooiker GA, van Leersum NJ, Snijders HS, Eddes EH, Tollenaar RAEM, Wouters MWJM, Marang-van de Mheen PJ. Focusing on desired outcomes of care after colon cancer resections; hospital variations in 'textbook outcome'. Eur J Surg Oncol 2012; 39:156-63. [PMID: 23102705 DOI: 10.1016/j.ejso.2012.10.007] [Citation(s) in RCA: 182] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 08/29/2012] [Accepted: 10/05/2012] [Indexed: 01/13/2023] Open
Abstract
AIMS We propose a summarizing measure for outcome indicators, representing the proportion of patients for whom all desired short-term outcomes of care (a 'textbook outcome') is realized. The aim of this study was to investigate hospital variation in the proportion of patients with a 'textbook outcome' after colon cancer resections in the Netherlands. METHODS Patients who underwent a colon cancer resection in 2010 in the Netherlands were included in the Dutch Surgical Colorectal Audit. A textbook outcome was defined as hospital survival, radical resection, no reintervention, no ostomy, no adverse outcome and a hospital stay < 14 days. We calculated the number of hospitals with a significantly higher (positive outlier) or lower (negative outlier) Observed/Expected (O/E) textbook outcome than average. As quality measures may be more discriminative in a low-risk population, analyses were repeated for low-risk patients only. RESULTS A total of 5582 patients, treated in 82 hospitals were included. Average textbook outcome was 49% (range 26-71%). Eight hospitals were identified as negative outliers. In these hospitals a 'textbook outcome' was realized in 35% vs. 52% in average hospitals (p < 0.01). In a sub-analysis for low-risk patients, only one additional negative outlier was identified. CONCLUSIONS The textbook outcome, representing the proportion of patients with a perfect hospitalization, gives a simple comprehensive summary of hospital performance, while preventing indicator driven practice. Therewith the 'textbook outcome' is meaningful for patients, providers, insurance companies and healthcare inspectorate.
Collapse
|
162
|
Dikken JL, Stiekema J, van de Velde CJH, Verheij M, Cats A, Wouters MWJM, van Sandick JW. Quality of care indicators for the surgical treatment of gastric cancer: a systematic review. Ann Surg Oncol 2012; 20:381-98. [PMID: 23054104 DOI: 10.1245/s10434-012-2574-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Quality assurance is increasingly acknowledged as a crucial factor for the (surgical) treatment of gastric cancer. The purpose of the current study was to define a minimum set of evidence-based quality of care indicators for the surgical treatment of locally advanced gastric cancer. METHODS A systematic review of the literature published between January 1990 and May 2011 was performed, using search terms on gastric cancer, treatment, and quality of care. Studies were selected based on predefined selection criteria. Potential quality of care indicators were assessed based on their level of evidence and were grouped into structure, process, and outcome indicators. RESULTS A total of 173 articles were included in the current study. For structural measures, evidence was found for the inverse relationship between hospital volume and postoperative mortality as well as overall survival. Regarding process measures, the most common indicators concerned surgical technique, perioperative care, and multimodality treatment. The only outcome indicator with supporting evidence was a microscopically radical resection. CONCLUSIONS Although specific literature on quality of care indicators for the surgical treatment of locally advanced gastric cancer is limited, several quality of care indicators could be identified. These indicators can be used in clinical audits and other quality assurance programs.
Collapse
|
163
|
Snijders HS, Wouters MWJM, van Leersum NJ, Kolfschoten NE, Henneman D, de Vries AC, Tollenaar RAEM, Bonsing BA. Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality. Eur J Surg Oncol 2012; 38:1013-9. [PMID: 22954525 DOI: 10.1016/j.ejso.2012.07.111] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 06/25/2012] [Accepted: 07/19/2012] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Availability of anastomotic leakage rates and mortality rates following anastomotic leakage is essential when informing patients with rectal cancer preoperatively. We performed a meta-analysis of studies describing anastomotic leakage and the subsequent postoperative mortality in relation to the overall postoperative mortality after low anterior resection for rectal cancer. METHODS A systematic search was performed of the published literature. Data on the definition and incidence rate of AL, postoperative mortality caused by AL, and overall postoperative mortality were extracted. Data were pooled and a meta-analysis was performed. RESULTS Twenty-two studies with 10,343 patients in total were analyzed. Meta-analysis of the data showed an average AL rate of 9%, postoperative mortality caused by leakage of 0.7% and overall postoperative mortality of 2%. The studies showed variation in incidence, definition and measurement of all outcomes. CONCLUSION We found a considerable overall AL rate and a large contribution of AL to the overall postoperative mortality. The variability of definitions and measurement of AL, postoperative mortality caused by leakage and overall postoperative mortality may hinder providing reliable risk information. Large-scale audit programs may provide accurate and valid risk information which can be used for preoperative decision making.
Collapse
|
164
|
Dikken JL, Wouters MWJM, Lemmens VEP, Putter H, van der Geest LGM, Verheij M, Cats A, van Sandick JW, van de Velde CJH. Influence of hospital type on outcomes after oesophageal and gastric cancer surgery. Br J Surg 2012; 99:954-63. [PMID: 22569956 DOI: 10.1002/bjs.8787] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND Outcomes after oesophagectomy and gastrectomy vary considerably between hospitals. Possible explanations include differences in case mix, hospital volume and hospital type. The present study examined the distribution of oesophagectomies and gastrectomies between hospital types in the Netherlands, and the relationship between hospital type and outcome. METHODS Data were obtained from the nationwide Netherlands Cancer Registry. Hospitals were categorized as university hospitals (UH), non-university teaching hospitals (NUTH) and non-university non-teaching hospitals (NUNTH). Hospital type-outcome relationships were analysed by Cox regression, adjusting for case mix, hospital volume, year of diagnosis and use of multimodal therapies. RESULTS Between 1989 and 2009, 10 025 oesophagectomies and 14 221 gastrectomies for cancer were performed in the Netherlands. The percentage of oesophagectomies and gastrectomies performed in UH increased from 17·6 and 6·4 per cent respectively in 1989 to 44·1 and 12·9 per cent in 2009. After oesophagectomy, the 3-month mortality rate was 2·5 per cent in UH, 4·4 per cent in NUTH and 4·1 per cent in NUNTH (P = 0·006 for UH versus NUTH). After gastrectomy, the 3-month mortality rate was 4·9 per cent in UH, 8·9 per cent in NUTH and 8·7 per cent in NUNTH (P < 0·001 for UH versus NUTH). Three-year survival was also higher in UH than in NUTH and NUNTH. CONCLUSION Oesophagogastric resections performed in UH were associated with better outcomes but, owing to variation in outcomes within hospital types, centres of excellence cannot be designated solely on hospital type. Detailed information on case mix and outcomes is needed to identify centres of excellence.
Collapse
|
165
|
Kolfschoten NE, Gooiker GA, Bastiaannet E, van Leersum NJ, van de Velde CJH, Eddes EH, Marang-van de Mheen PJ, Kievit J, van der Harst E, Wiggers T, Wouters MWJM, Tollenaar RAEM. Combining process indicators to evaluate quality of care for surgical patients with colorectal cancer: are scores consistent with short-term outcome? BMJ Qual Saf 2012; 21:481-9. [DOI: 10.1136/bmjqs-2011-000439] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
166
|
Dikken JL, Dassen AE, Lemmens VEP, Putter H, Krijnen P, van der Geest L, Bosscha K, Verheij M, van de Velde CJH, Wouters MWJM. Effect of hospital volume on postoperative mortality and survival after oesophageal and gastric cancer surgery in the Netherlands between 1989 and 2009. Eur J Cancer 2012; 48:1004-13. [PMID: 22456179 DOI: 10.1016/j.ejca.2012.02.064] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 01/02/2012] [Accepted: 02/19/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND High hospital volume is associated with better outcomes after oesophagectomy and gastrectomy. In the Netherlands, a minimal volume standard of 10 oesophagectomies per year was introduced in 2006. For gastrectomy, no minimal volume standard was set. Aims of this study were to describe changes in hospital volumes, mortality and survival and to explore if high hospital volume is associated with better outcomes after oesophagectomy and gastrectomy in the Netherlands. METHODS From 1989 to 2009, 24,246 patients underwent oesophagectomy (N = 10,025) or gastrectomy (N = 14,221) in the Netherlands. Annual hospital volumes were defined as very low (1-5), low (6-10), medium (11-20), and high (≥ 21). Volume-outcome analyses were performed using Cox regression, adjusting for year of diagnosis, case-mix and the use of multi-modality treatment. RESULTS From 1989 to 2009, the percentage of patients treated in high-volume hospitals increased for oesophagectomy (from 7% to 64%), but decreased for gastrectomy (from 8% to 5%). Six-month mortality (from 15% to 7%) and 3-year survival (from 41% to 52%) improved after oesophagectomy, and to a lesser extent after gastrectomy (6-month mortality: 15%-10%, three-year survival: 55-58%). High hospital volume was associated with lower 6-month mortality (hazard ratio (HR) 0.48, P<0.001) and longer 3-year survival (HR 0.77, P<0.001) after oesophagectomy, but not after gastrectomy. CONCLUSIONS Oesophagectomy was effectively centralised in the Netherlands, improving mortality and survival. Gastrectomies were mainly performed in low volumes, and outcomes after gastrectomy improved to a lesser extent, indicating an urgent need for improvement in quality of surgery and perioperative care for gastric cancer in the Netherlands.
Collapse
|
167
|
Dikken JL, Lemmens VE, Wouters MWJM, Wijnhoven BP, Siersema PD, Nieuwenhuijzen GA, van Sandick JW, Cats A, Verheij M, Coebergh JW, van de Velde CJH. Increased incidence and survival for oesophageal cancer but not for gastric cardia cancer in the Netherlands. Eur J Cancer 2012; 48:1624-32. [PMID: 22317953 DOI: 10.1016/j.ejca.2012.01.009] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 11/28/2011] [Accepted: 01/07/2012] [Indexed: 12/15/2022]
Abstract
INTRODUCTION A worldwide increasing incidence is seen for oesophageal adenocarcinoma, but not for oesophageal squamous cell carcinoma (SCC) and gastric cardia adenocarcinoma. Purposes of the current study were to evaluate the changing incidence rates of oesophageal and gastric cardia cancer, and to assess survival trends. PATIENTS AND METHODS Patients diagnosed with oesophageal adenocarcinoma (N=12,195) or SCC (N=9046), or gastric cardia adenocarcinoma (N=9900) between 1989 and 2008 in the Netherlands were included. Changes in European Standard Population (ESP) and relative survival over time were evaluated. RESULTS Incidence rates for oesophageal adenocarcinoma increased in males (+7.5%, P<0.001) and females (+5.2%, P<0.001), while the incidence for oesophageal SCC remained stable in males (-0.2%, P=0.6) and slightly increased in females (+1.7%, P=0.001). The incidence for gastric cardia cancer decreased in males (-1.2%, P<0.006), and remained stable in females (-0.2%, P=0.7). Five-year survival for both M0 and M1 oesophageal carcinoma doubled over the last 20 years. No significant changes in survival were found for M0 and M1 gastric cardia carcinoma. DISCUSSION In the Netherlands, a rising incidence is seen for oesophageal adenocarcinoma, but not for gastric cardia adenocarcinoma. This finding most likely reflects true changes in disease burden, rather than being the result of changes in diagnosis or classification. The increased survival for oesophageal carcinoma can be attributed to centralisation of surgery, and an increased use of multimodality therapy, factors hardly acknowledged for gastric cancer.
Collapse
|
168
|
Wouters MWJM, Gooiker GA, van Sandick JW, Tollenaar RAEM. The volume-outcome relation in the surgical treatment of esophageal cancer: a systematic review and meta-analysis. Cancer 2011; 118:1754-63. [PMID: 22009562 DOI: 10.1002/cncr.26383] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 04/06/2011] [Accepted: 04/26/2011] [Indexed: 01/16/2023]
Abstract
This study was undertaken to conduct a systematic review and meta-analysis of the literature on the relation between procedural volume and outcome of esophagectomies. A systematic search was carried out to identify articles investigating effects of hospital or surgeon volume on short-term and long-term outcomes published between 1995 and 2010. Articles were scrutinized for methodological quality, and after inclusion of only high-quality studies, a meta-analysis assuming a random effects model was done to estimate the effect of higher volume on patient outcome. Heterogeneity in study results was evaluated with an I(2) -test and risk of publication bias with an Egger regression intercept. Forty-three studies were found. Sixteen studies met the strict inclusion criteria for the meta-analysis on hospital volume and postoperative mortality and 4 studies on hospital volume and survival. The pooled estimated effect size was significant for high-volume providers in the analysis of postoperative mortality (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.89-2.80) and in the survival analysis (OR, 1.17; 95% CI, 1.05-1.30). The meta-analysis of surgical volume and outcome showed no significant results. Studies in which the results were adjusted not only for patient characteristics but also for tumor characteristics and urgency of the operation showed a stronger correlation between hospital volume and mortality. Also, studies performed on data from the United States showed higher effect sizes. The evidence for hospital volume as an important determinant of outcome in esophageal cancer surgery is strong. Concentration of procedures in high-volume hospitals with a dedicated setting for the treatment of esophageal cancer might lead to an overall improvement in patient outcome.
Collapse
|
169
|
Gooiker GA, van Gijn W, Wouters MWJM, Post PN, van de Velde CJH, Tollenaar RAEM. Systematic review and meta-analysis of the volume-outcome relationship in pancreatic surgery. Br J Surg 2011; 98:485-94. [PMID: 21500187 DOI: 10.1002/bjs.7413] [Citation(s) in RCA: 252] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND Many studies have shown lower mortality and higher survival rates after pancreatic surgery with high-volume providers, suggesting that centralization of pancreatic surgery can improve outcomes. The methodological quality of these studies is open to question. This study involves a systematic review of the volume-outcome relationship for pancreatic surgery with a meta-analysis of studies considered to be of good quality. METHODS A systematic search of electronic databases up to February 2010 was performed to identify all primary studies examining the effects of hospital or surgeon volume on postoperative mortality and survival after pancreatic surgery. All articles were critically appraised with regard to methodological quality and risk of bias. After strict inclusion, meta-analysis assuming a random-effects model was done to estimate the effect of higher surgeon or hospital volume on patient outcome. RESULTS Fourteen studies were included in the meta-analysis. The results showed a significant association between hospital volume and postoperative mortality (odds ratio 0.32, 95 per cent confidence interval 0.16 to 0.64), and between hospital volume and survival (hazard ratio 0.79, 0.70 to 0.89).The effect of surgeon volume on postoperative mortality was not significant (odds ratio 0.46, 0.17 to 1.26). Significant heterogeneity was seen in the analysis of hospital volume and mortality. Sensitivity analysis showed no correlation with the extent of risk adjustment or study country; after removing one outlier study, the result was homogeneous. The data did not suggest publication bias. CONCLUSION There was a consistent association between high hospital volume and lower postoperative mortality rates with improved long-term survival.
Collapse
|
170
|
van Geel AN, Wouters MWJM, Lans TE, Schmitz PIM, Verhoef C. Chest wall resection for adult soft tissue sarcomas and chondrosarcomas: analysis of prognostic factors. World J Surg 2011; 35:63-9. [PMID: 20857106 PMCID: PMC3006644 DOI: 10.1007/s00268-010-0804-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Wide resection with tumor-free margins is necessary in soft-tissue sarcomas to minimize local recurrence and to contribute to long-term survival. Information about treatment outcome and prognostic factors of adult sarcoma requiring chest wall resection (CWR) is limited. Methods Sixty consecutive patients were retrospectively studied for overall survival (OS), local recurrence-free survival (LRFS), and disease-free survival (DFS). Twenty-one prognostic factors regarding survival were analyzed by univariate analysis using the Kaplan-Meier method and the log-rank test. Results With a median survival of 2.5 years, the OS was 46% (33%) at 5 (10) years. The LRFS was 64% at 5 and 10 years, and the DFS was 30% and 25% at 5 and 10 years. At the end of the study period, 26 patients (43%) were alive, of which 20 patients (33%) had no evidence of disease and 40 patients (67%) had no chest wall recurrence. In the group of 9 patients with a radiation-induced soft-tissue sarcoma, the median survival was 8 months. Favorable outcome in univariate analysis in OS and LRFS applied for the low-grade sarcoma, bone invasion, and sternal resection. For OS only, age below 60 years and no radiotherapy were significant factors contributing to an improved survival. CWR was considered radical (R0) at the pathological examination in 43 patients. There were 52 patients with an uneventful recovery. There was one postoperative death. Conclusions CWR for soft-tissue sarcoma is a safe surgical procedure with low morbidity and a mortality rate of less than 1%. With proper patient selection acceptable survival can be reached in a large group of patients. Care must be given to patients with radiation-induced soft-tissue sarcoma who have a significantly worse prognosis.
Collapse
|
171
|
Gooiker GA, van der Geest LGM, Wouters MWJM, Vonk M, Karsten TM, Tollenaar RAEM, Bonsing BA. Quality improvement of pancreatic surgery by centralization in the western part of the Netherlands. Ann Surg Oncol 2011; 18:1821-9. [PMID: 21544657 PMCID: PMC3115061 DOI: 10.1245/s10434-010-1511-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Indexed: 02/06/2023]
Abstract
Background Centralization of pancreatic surgery in high-volume hospitals is under debate in many countries. In the western part of the Netherlands, the professional network of surgical oncologists agreed to centralize all pancreatic surgery from 2006 in two high-volume hospitals. Our aim is to evaluate whether centralization of pancreatic surgery has improved clinical outcomes and has changed referral patterns. Materials and Methods Data of the Comprehensive Cancer Centre West (CCCW) of all 249 patients who had a resection for suspected pancreatic cancer between 1996 and 2008 in the western part of the Netherlands were analyzed. Multivariable modeling was used to evaluate survival for 3 time periods; 1996–2000, 2001–2005 (introduction of quality standards), and 2006–2008 (after centralization). In addition, the differences in referral pattern were analyzed. Results From 2006, all pancreatic surgery was centralized in 2 hospitals. The 2-year survival rate increased after centralization from 39% to 55% (P = .09) for all patients who had a pancreatic resection for pancreatic cancer. After adjustment for age, tumor location, stage, histology, and adjuvant treatment, the latter period was significantly associated with improved survival (hazard ratio [HR] 0.50; 95% confidence interval [95% CI] 0.34–0.73). Conclusions Centralization of pancreatic surgery was successful and has resulted in improved clinical outcomes in the western part of the Netherlands, demonstrating the effectiveness of centralization.
Collapse
|
172
|
van Leersum NJ, Kolfschoten NE, Klinkenbijl JHG, Tollenaar RAEM, Wouters MWJM. ['Clinical auditing', a novel tool for quality assessment in surgical oncology]. NEDERLANDS TIJDSCHRIFT VOOR GENEESKUNDE 2011; 155:A4136. [PMID: 22085580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To determine whether systematic audit and feedback of information about the process and outcomes improve the quality of surgical care. DESIGN Systematic literature review. METHOD Embase, PubMed, and Web of Science databases were searched for publications on 'quality assessment' and 'surgery'. The references of the publications found were examined as well. Publications were included in the review if the effect of auditing on the quality of surgical care had been investigated. RESULTS In the databases 2415 publications were found. After selection, 28 publications describing the effect of auditing, whether or not combined with a quality improvement project, on guideline adherence or indications of outcomes of care were included. In 21 studies, a statistically significant positive effect of auditing was reported. In 5 studies a positive effect was found, but this was either not significant or statistical significance was not determined. In 2 studies no effect was observed. 5 studies compared the combination of auditing with a quality improvement project with auditing alone; 4 of these reported an additional effect of the quality improvement project. CONCLUSION Audit and feedback of quality information seem to have a positive effect on the quality of surgical care. The use of quality information from audits for the purpose of a quality improvement project can enhance the positive effect of the audit.
Collapse
|
173
|
van Steenbergen LN, van de Poll-Franse LV, Wouters MWJM, Jansen-Landheer MLEA, Coebergh JWW, Struikmans H, Tjan-Heijnen VCG, van de Velde CJH. Variation in management of early breast cancer in the Netherlands, 2003-2006. Eur J Surg Oncol 2010; 36 Suppl 1:S36-43. [PMID: 20620013 DOI: 10.1016/j.ejso.2010.06.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 06/08/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To describe variation in staging and primary treatment by hospital characteristics including type and volume and region in patients with early breast cancer (BC) in the Netherlands, 2003-2006 after completion of national guidelines in 2002. METHODS All patients newly diagnosed with invasive BC in 2003-2006 and recorded in the Netherlands Cancer Registry were included (n = 51 354). Multivariable logistic regression analyses examined the influence of patient and hospital characteristics, also by region, on type of breast surgery, axillary lymph node dissection (ALND), sentinel node procedure (SNP), and adjuvant irradiation and/or systemic treatment. RESULTS Patients <40 years more often underwent breast conserving surgery (BCS) in general hospitals (OR 1.4 (95%CI 1.1-1.5)) than in teaching and academic hospitals, whereas patients of 40-69 years less often received BCS in an academic hospital (OR 0.9 (95%CI 0.8-1.0)) than in teaching hospitals. Patients with pT1-2N0 cancer more often underwent primary ALND in a general hospital than in a larger teaching or academic hospital. Type of hospital did not seem to affect utilization of adjuvant systemic therapy, but patient age and tumour size and grade did. Over time, patients more often received SNP, BCS, and adjuvant systemic therapy, primary ALND being on the decline, but with substantial regional variation between geographic regions. CONCLUSION With detailed evidence-based national guidelines since 2002 the considerable regional and hospital variation in staging procedures and primary treatment among newly diagnosed patients with early breast cancer in the Netherlands decreased markedly, suggesting the presence of late adaptors rather than specific hospital characteristics.
Collapse
|
174
|
Elferink MAG, Krijnen P, Wouters MWJM, Lemmens VEPP, Jansen-Landheer MLEA, van de Velde CJH, Langendijk JA, Marijnen CAM, Siesling S, Tollenaar RAEM. Variation in treatment and outcome of patients with rectal cancer by region, hospital type and volume in the Netherlands. Eur J Surg Oncol 2010; 36 Suppl 1:S74-82. [PMID: 20598844 DOI: 10.1016/j.ejso.2010.06.028] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 06/10/2010] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Aim of this study was to describe treatment patterns and outcome according to region and hospital type and volume among patients with rectal cancer in the Netherlands. METHODS All patients with rectal carcinoma diagnosed in the period 2001-2006 were selected from the Netherlands Cancer Registry. Logistic regression analyses were performed to examine the influence of relevant factors on the odds of receiving preoperative radiotherapy and on the odds of postoperative mortality. Relative survival analysis was used to estimate relative excess risk of dying according to hospital type and volume. RESULTS In total, 16 039 patients were selected. Patients diagnosed in a teaching or university hospital had a lower odds (OR 0.85; 95% CI 0.73-0.99 and OR 0.70; 95% CI 0.52-0.92) and patients diagnosed in a hospital performing >50 resections per year had a higher odds (OR 1.95; 95% CI 1.09-1.76) of receiving preoperative radiotherapy. A large variation between individual hospitals in rates of preoperative radiotherapy and between Comprehensive Cancer Centre-regions in the administration of preoperative chemoradiation was revealed. Postoperative mortality was not correlated to hospital type or volume. Patients with T1-M0 tumours diagnosed in a hospital with >50 resections per year had a better survival compared to patients diagnosed in a hospital with <25 resections per year (RER 0.11; 95% CI 0.02-0.78). CONCLUSION This study demonstrated variation in treatment and outcome of patients with rectal cancer in the Netherlands, with differences related to hospital volume and hospitals teaching or academic status. However, variation in treatment patterns between individual hospitals proved to be much larger than could be explained by the investigated characteristics. Future studies should focus on the reasons behind these differences, which could lead to a higher proportion of patients receiving optimal treatment for their stage of the disease.
Collapse
|
175
|
Wouters MWJM, Siesling S, Jansen-Landheer ML, Elferink MAG, Belderbos J, Coebergh JW, Schramel FMNH. Variation in treatment and outcome in patients with non-small cell lung cancer by region, hospital type and volume in the Netherlands. Eur J Surg Oncol 2010; 36 Suppl 1:S83-92. [PMID: 20598845 DOI: 10.1016/j.ejso.2010.06.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Accepted: 06/08/2010] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Care processes for patients with NSCLC can vary by provider, which may lead to unwanted variation in outcomes. Therefore, in modern health care an increased focus on guideline development and implementation is seen. It is expected that more guideline adherence leads to a higher number of patients receiving optimal treatment for their cancer which could improve overall survival. OBJECTIVE The aim of this study was to evaluate variations in treatment patterns and outcomes of patients with NSCLC treated in different (types of) hospitals and regions in the Netherlands. Especially, variation in the percentage of patients receiving the optimal treatment for the stage of their disease, according to the Dutch national guideline of 2004, was analyzed. METHODS All patients with a histological confirmed primary NSCLC diagnosed in the period 2001-2006 in all Dutch hospitals (N = 97) were selected from the population-based Netherlands Cancer Registry. Hospitals were divided in groups based on their region (N = 9), annual volume of NSCLC patients, teaching status and presence of radiotherapy facilities. Stage-specific differences in optimal treatment rates between (groups of) hospitals and regions were evaluated. RESULTS In the study period 43 544 patients were diagnosed with NSCLC. The resection rates for stage I/II NSCLC patients increased during the study period, but resection rates varied by region and were higher in teaching hospitals for thoracic surgeons (OR 1.5; 95%CI 1.2-1.9, p = 0.001) and in hospitals with a diagnostic volume of more than 50/year (OR 1.3; 95%CI 1.1-1.5, p = 0.001). Also the use of chemoradiation in stage III patients increased, though marked differences between hospitals in the use of chemoradiation for stage III patients were revealed. Differences in optimal treatment rates between hospitals led to differences in survival. CONCLUSION Treatment patterns and outcome of NSCLC patients in the Netherlands varied by region and the hospital their cancer was diagnosed in. Though resection rates were higher in hospitals training thoracic surgeons, variation between individual hospitals was much more distinct. Hospital characteristics like a high diagnostic volume, teaching status or availability of radiotherapy facilities proved no guarantee for optimal treatment rates.
Collapse
|