Do cancer centers designated by the National Cancer Institute have better surgical outcomes?

Geographic disparities amongst patients with gynecologic malignancies at an urban NCI-designated cancer center

OBJECTIVE

Women with gynecologic malignancies require specialized care. We hypothesize that a geographic disparity exists amongst patients with gynecologic malignancies and that longer distance and time traveled negatively impact completion of adjuvant therapy.

METHODS

Patients with incident gynecologic malignancies at a single, urban NCI-designated cancer center were identified. Distances from the patient's home to the treating facility were calculated in miles and minutes. Demographic variables were evaluated for their impact on treatment outcomes using Chi-squared, ANOVA and Kruskal-Wallis analyses.

RESULTS

One hundred and fifty consecutive patients were identified. The median distance traveled to the hospital was 16.9miles with a median travel time of 28min. The distance and time traveled were significantly different between insurance groups, with the uninsured traveling the furthest for care by distance (p=0.04) and time (p=0.03). Race, tumor site, medical comorbidities and median income at zip code were not associated with travel distance or time to the hospital. The majority of patients (87%) completed recommended initial treatment. Treatment completion was related to distance traveled with those patients living at the distance extremes (<10miles or >50miles) least likely to complete care (p<0.01). The presence of medical comorbidities (p<0.01) but not insurance status was correlated to treatment completion.

CONCLUSIONS

Geographic disparities exist in women with gynecologic malignancies receiving treatment at an NCI-designated cancer center. Approaches to decreasing these disparities may include improved support for cancer patients needing assistance with travel and additional social work and psychosocial support to patients with medical co-morbidities.

Establishing a complex surgical oncology program with low morbidity and mortality at a community hospital

BACKGROUND

We report our experience with a large volume of complex oncologic resections and describe the framework necessary to develop a program with low morbidity and mortality in a community hospital.

METHODS

From August 2010 to May 2014, 224 consecutive patients underwent abdominal oncological resection, at a community hospital by a single surgeon (R.N.B.). Cases included pancreatic, gastric, hepatobiliary, colorectal, hyperthermic intraperitoneal chemotherapy with cytoreduction, splenic, and sarcoma resections. We retrospectively reviewed our prospectively maintained database and evaluated postoperative complications.

RESULTS

There was no 0, 30-, 60-, or 90-day mortality. The complication rate was 44%, including 5% grade I, 28% grade II, 9% grade III, and 1% grade IV complications. The median length of stay was 8 days. Mean follow-up for the entire group was 643 days.

CONCLUSION

Our study demonstrates that complex oncologic resections can be safely performed in the community setting if a well-organized, surgeon-led multidisciplinary team is assembled.

Factors influencing patient pathways for receipt of cancer care at an NCI-designated comprehensive cancer center

Background

Within the field of oncology, increasing access to high quality care has been identified as a priority to reduce cancer disparities. Previous research reveals that the facilities where patients receive their cancer care have implications for cancer outcomes. However, there is little understanding of how patients decide where to seek cancer care. This study examined the factors that shape patients’ pathways to seek their cancer care at a National Cancer Institute-designated comprehensive cancer center (NCI-CCC), and differences in these factors by race, income and education.

Methods

In-depth interviews and survey questionnaires were administered to a random sample of 124 patients at one NCI-CCC in the Northeast US. In-depth interview data was first analyzed qualitatively to identify themes and patterns in patients’ pathways to receive their cancer care at an NCI-CCC. Logistic Regression was used to examine if these pathways varied by patient race, income, and education.

Results

Two themes emerged: following the recommendation of a physician and following advice from social network members. Quantitative data analysis shows that patient pathways to care at an NCI-CCC varied by education and income. Patients with lower income and education most commonly sought their cancer care at an NCI-CCC due to the recommendation of a physician. Patients with higher income and education most commonly cited referral by a specialist physician or the advice of a social network member. There were no statistically significant differences in pathways to care by race.

Conclusions

Our findings show that most patients relied on physician recommendations or advice from a social network member in deciding to seek their cancer care at an NCI-CCC. Due to the role of physicians in shaping patients’ pathways to the NCI-CCC, initiatives that strengthen partnerships between NCI-CCCs and community physicians who serve underserved communities may improve access to NCI-CCCs.

Health care delivery for head-and-neck cancer patients in Alberta: a practice guideline

BACKGROUND

The treatment of head-and-neck cancer is complex and requires the involvement of various health care professionals with a wide range of expertise. We describe the process of developing a practice guideline with recommendations about the organization and delivery of health care services for head-and-neck cancer patients in Alberta.

METHODS

Outcomes of interest included composition of the health care team, qualification requirements for team members, cancer centre and team member volumes, infrastructure needs, and wait times. A search for existing practice guidelines and a systematic review of the literature addressing the organization and delivery of health care services for head-and-neck cancer patients were conducted. The search included the Standards and Guidelines Evidence (sage) directory of cancer guidelines and PubMed.

RESULTS

One practice guideline was identified for adaptation. Three additional practice guidelines provided supplementary evidence to inform guideline recommendations. Members of the Alberta Provincial Head and Neck Tumour Team (consisting of various health professionals from across the province) provided expert feedback on the adapted recommendations through an online and in-person review process. Selected experts in head-and-neck cancer from outside the province participated in an external online review.

SUMMARY

The recommendations outlined in this practice guideline are based on existing guidelines that have been modified to fit the Alberta context. Although specific to Alberta, the recommendations lend credence to similar published guidelines and could be considered for use by groups lacking the resources of appointed guideline panels. The recommendations are meant to be a guide rather than a fixed protocol. The implementation of this practice guideline will depend on many factors, including but not limited to availability of trained personnel, adequate funding of infrastructure, and collaboration with other associations of health care professionals in the province.

Hospital and surgeon volume in relation to long-term survival after oesophagectomy: systematic review and meta-analysis

BACKGROUND

Centralisation of healthcare, especially for advanced cancer surgery, has been a matter of debate. Clear short-term mortality benefits have been described for oesophageal cancer surgery conducted at high-volume hospitals and by high-volume surgeons.

OBJECTIVE

To clarify the association between hospital volume, surgeon volume and hospital type in relation to long-term survival after oesophagectomy for cancer, by a meta-analysis.

DESIGN

The systematic literature search included PubMed, Web of Science, Cochrane library, EMBASE and Science Citation Index, for the period 1990-2013. Eligible articles were those which reported survival (time to death) as HRs after oesophagectomy for cancer by hospital volume, surgeon volume or hospital type. Fully adjusted HRs for the longest follow-up were the main outcomes. Results were pooled by a meta-analysis, and reported as HRs and 95% CIs.

RESULTS

Sixteen studies from seven countries met the inclusion criteria. These studies reported hospital volume (N=13), surgeon volume (N=4) or hospital type (N=4). A survival benefit was found for high-volume hospitals (HR=0.82, 95% CI 0.75 to 0.90), and possibly also, for high-volume surgeons (HR=0.87, 95% CI 0.74 to 1.02) compared with their low-volume counterparts. No association with survival remained for hospital volume after adjustment for surgeon volume (HR=1.01, 95% CI 0.97 to 1.06; N=2), while a survival benefit was found in favour of high-volume surgeons after adjustment for hospital volume (HR=0.91, 95% CI 0.85 to 0.98; N=2).

CONCLUSIONS

This meta-analysis demonstrated better long-term survival (even after excluding early deaths) after oesophagectomy with high-volume surgery, and surgeon volume might be more important than hospital volume. These findings support centralisation with fewer surgeons working at large centres.

Outcomes in thoracic surgical management of non-small cell lung cancer

Thoracic surgeons traditionally have measured their outcomes in terms of mortality, complication rates, recurrence patterns, and long-term survival for their cancer patients. These metrics of quality continue to be important today, but increasingly surgeons are under scrutiny for resource utilization, patient experience, and cost effectiveness. Intelligent decisions about resource use require knowledge of utility, disutility, and cost -- information that is still limited and not easily implemented at the time treatment decisions are made. If we accept the proposition that lung cancer care requires a multidisciplinary team making best use of available resources to minimize unwarranted variation, maximize outcomes, and control costs, then three critical needs can be identified: consensus on goals, robust data, and alignment of incentives across disciplines.

Physician social networks and variation in rates of complications after radical prostatectomy

OBJECTIVES

Variation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks-as defined by shared patients-are associated with rates of complications after radical prostatectomy.

METHODS

In five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure-along with specific characteristics of the network subgroups-was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume.

RESULTS

Networks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics-average urologist centrality and patient racial composition-were significantly associated with rates of surgical complications.

CONCLUSIONS

Analysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.

The effect of care setting in the delivery of high-value colon cancer care

BACKGROUND

The effect of care setting on value of colon cancer care is unknown.

METHODS

A Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort study of 6544 patients aged ≥ 66 years with stage IV colon cancer (based on the American Joint Committee on Cancer staging system) who were diagnosed between 1996 and 2005 was performed. All patients were followed through December 31, 2007. Using outpatient and carrier claims, patients were assigned to a treating hospital based on the hospital affiliation of the primary oncologist. Hospitals were classified academic or nonacademic using the SEER-Medicare National Cancer Institute Hospital File.

RESULTS

Of the 6544 patients, 1605 (25%) received care from providers affiliated with academic medical centers. The unadjusted median cancer-specific survival was 16.0 months at academic medical centers versus 13.9 months at nonacademic medical centers (P < .001). After adjustment, treatment at academic hospitals remained significantly associated with a reduced risk of death from cancer (hazard ratio, 0.87; 95% confidence interval [95% CI], 0.82-0.93 [P < .001]). Adjusted mean 12-month Medicare spending was $8571 higher at academic medical centers (95% CI, $2340-$14,802; P = .007). The adjusted median cost was $1559 higher at academic medical centers; this difference was not found to be statistically significant (95% CI, -$5239 to $2122; P = .41). A small percentage of patients who received very expensive care skewed the difference in mean cost; the only statistically significant difference in adjusted costs in quantile regressions was at the 99.9th percentile of costs (P < .001).

CONCLUSIONS

Among Medicare beneficiaries with stage IV colon cancer, treatment by a provider affiliated with an academic medical center was associated with a 2 month improvement in overall survival. Except for patients in the 99.9th percentile of the cost distribution, costs at academic medical centers were not found to be significantly different from those at nonacademic medical centers.

Trends in the use of evidence-based therapy for resectable gastric cancer

BACKGROUND AND OBJECTIVES

Two pivotal randomized controlled trials (RCTs), the Intergroup (INT-0116) and Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trials, demonstrated a survival benefit of multimodality therapy in patients with resectable gastric cancer. The purpose of this study was to determine utilization rates of these treatment regimens in the United States and to identify factors associated with receipt of evidence-based care.

METHODS

We performed a retrospective cohort study of patients with Stage IB-IV (M0) gastric adenocarcinoma who underwent resection from 1991 to 2009 using the linked SEER-Medicare database.

RESULTS

Only 19.1% of patients received post-operative chemoradiation therapy (CRT), and 1.9% received peri-operative chemotherapy; most patients underwent surgery alone (60.9%). Patients with more advanced stage, younger age, and fewer comorbidities were more likely to receive evidence-based care. We found no association between National Cancer Institute (NCI) designation and delivery of multimodality therapy. However, patients who underwent medical oncology consultation were much more likely to receive evidence-based treatment (OR 3.10, 95% CI 2.35-4.09).

CONCLUSIONS

Rates of peri-operative chemotherapy and post-operative CRT in patients with resected gastric cancer remain remarkably low, despite high-quality RCT evidence demonstrating their benefit. Furthermore, NCI designation does not appear to be associated with administration of evidence-based treatment.

Failure to rescue as a source of variation in hospital mortality after hepatic surgery

BACKGROUND

The mechanisms that underlie the association between high surgical volume and improved outcomes remain uncertain. This study examined the impact of complications and failure to rescue patients from these complications on mortality following hepatic resection.

METHODS

The Nationwide Inpatient Sample was used to identify patients who had liver surgery between 2000 and 2010. Hospital volume was stratified into tertiles (low, intermediate and high). Rates of major complications, failure to rescue and mortality following hepatic surgery were compared.

RESULTS

Some 9874 patients were identified. The major complication rate was 19.6 per cent in low-volume, 19.3 per cent in intermediate-volume and 16.6 per cent in high-volume hospitals (P < 0.001). Most common major complications included respiratory insufficiency or failure (8.8 per cent), acute renal failure (4.2 per cent) and gastrointestinal bleeding (3.9 per cent), with each of these complications being less common in high-volume hospitals (P < 0.050). The incidence of major morbidity following hepatectomy remained the same over the past decade, but failure to rescue patients from these complications decreased (P = 0.011). The overall inpatient mortality rate following liver surgery was 3.2 per cent (3.8, 3.6 and 2.3 per cent for low-, intermediate- and high-volume hospitals respectively; P < 0.001). The rate of failure to rescue (death after a complication) was higher at low- and intermediate-volume hospitals (16.8 and 16.1 per cent respectively) compared with high-volume hospitals (11.8 per cent) (P = 0.032). After accounting for patient and hospital characteristics, patients treated at low-volume hospitals who had a complication were 40 per cent more likely to die than patients with a complication in a high-volume hospital (odds ratio 1.40, 95 per cent confidence interval 1.02 to 1.93).

CONCLUSION

The risk of death following hepatic surgery is lower at high-volume hospitals. The reduction in mortality appears to be the result of both lower complication rates and a better ability in high-volume hospitals to rescue patients with major complications.

Impact of the Establishment of a Specialty Hernia Referral Center

Background. Creating a surgical specialty referral center requires a strong interest, expertise, and a market demand in that particular field, as well as some form of promotion. In 2004, we established a tertiary hernia referral center. Our goal in this study was to examine its impact on institutional volume and economics. Materials and methods. The database of all hernia repairs (2004-2011) was reviewed comparing hernia repair type and volume and center financial performance. The ventral hernia repair (VHR) patient subset was further analyzed with particular attention paid to previous repairs, comorbidities, referral patterns, and the concomitant involvement of plastic surgery. Results. From 2004 to 2011, 4927 hernia repairs were performed: 39.3% inguinal, 35.5% ventral or incisional, 16.2% umbilical, 5.8% diaphragmatic, 1.6% femoral, and 1.5% other. Annual billing increased yearly from 7% to 85% and averaged 37% per year. Comparing 2004 with 2011, procedural volume increased 234%, and billing increased 713%. During that period, there was a 2.5-fold increase in open VHRs, and plastic surgeon involvement increased almost 8-fold, ( P = .004). In 2005, 51 VHR patients had a previous repair, 27.0% with mesh, versus 114 previous VHR in 2011, 58.3% with mesh ( P < .0001). For VHR, in-state referrals from 2004 to 2011 increased 340% while out-of-state referrals jumped 580%. In 2011, 21% of all patients had more than 4 comorbidities, significantly increased from 2004 ( P = .02). Conclusion. The establishment of a tertiary, regional referral center for hernia repair has led to a substantial increase in surgical volume, complexity, referral geography, and financial benefit to the institution.

Logic regression for provider effects on kidney cancer treatment delivery

In the delivery of medical and surgical care, often times complex interactions between patient, physician, and hospital factors influence practice patterns. This paper presents a novel application of logic regression in the context of kidney cancer treatment delivery. Using linked data from the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program and Medicare we identified patients diagnosed with kidney cancer from 1995 to 2005. The primary endpoints in the study were use of innovative treatment modalities, namely, partial nephrectomy and laparoscopy. Logic regression allowed us to uncover the interplay between patient, provider, and practice environment variables, which would not be possible using standard regression approaches. We found that surgeons who graduated in or prior to 1980 despite having some academic affiliation, low volume surgeons in a non-NCI hospital, or surgeons in rural environment were significantly less likely to use laparoscopy. Surgeons with major academic affiliation and practising in HMO, hospital, or medical school based setting were significantly more likely to use partial nephrectomy. Results from our study can show efforts towards dismantling the barriers to adoption of innovative treatment modalities, ultimately improving the quality of care provided to patients with kidney cancer.

Value of geriatric frailty and nutritional status assessment in predicting postoperative mortality in gastric cancer surgery

OBJECTIVES

This study seeks to evaluate assessment of geriatric frailty and nutritional status in predicting postoperative mortality in gastric cancer surgery.

METHODS

Preoperatively, patients operated for gastric adenocarcinoma underwent assessment of Groningen Frailty Indicator (GFI) and Short Nutritional Assessment Questionnaire (SNAQ). We studied retrospectively whether these scores were associated with in-hospital mortality.

RESULTS

From 2005 to September 2012 180 patients underwent surgery with an overall mortality of 8.3%. Patients with a GFI ≥ 3 (n = 30, 24%) had a mortality rate of 23.3% versus 5.2% in the lower GFI group (OR 4.0, 95%CI 1.1-14.1, P = 0.03). For patients who underwent surgery with curative intent (n = 125), this was 27.3% for patients with GFI ≥ 3 (n = 22, 18%) versus 5.7% with GFI < 3 (OR 4.6, 95% CI 1.0-20.9, P = 0.05). SNAQ ≥ 1 (n = 98, 61%) was associated with a mortality rate of 13.3% versus 3.2% in patients with SNAQ =0 (OR 5.1, 95% CI 1.1-23.8, P = 0.04). Given odds ratios are corrected in multivariate analyses for age, neoadjuvant chemotherapy, type of surgery, tumor stage and ASA classification.

CONCLUSIONS

This study shows a significant relationship between gastric cancer surgical mortality and geriatric frailty as well as nutritional status using a simple questionnaire. This may have implications in preoperative decision making in selecting patients who optimally benefit from surgery.

What factors influence minority use of National Cancer Institute-designated cancer centers?

BACKGROUND

National Cancer Institute (NCI) cancer centers provide high-quality care and are associated with better outcomes. However, racial and ethnic minority populations tend not to use these settings. The current study sought to understand what factors influence minority use of NCI cancer centers.

METHODS

A data set containing California Cancer Registry (CCR) data linked to patient discharge abstracts identified all patients with colorectal cancer (CRC) who were treated from 1996 through 2006. Multivariable models were generated to predict the use of NCI settings by race. Geographic proximity to an NCI center and patient sociodemographic and clinical characteristics were assessed.

RESULTS

Approximately 5% of all identified patients with CRC (n = 79,231) were treated in NCI settings. The median travel distance for treatment for all patients in all hospitals was ≤ 5 miles. A higher percentage of minorities lived near an NCI cancer center compared with whites. A baseline multivariable model predicting use showed a negative association between Hispanic ethnicity and NCI center use (odds ratio, 0.71; 95% confidence interval, 0.64-0.79). Asian/Pacific Islander patients were more likely to use NCI centers (odds ratio, 1.41; 95% confidence interval, 1.28-1.54). There was no difference in use noted among black patients. Increasing living distance from an NCI cancer center was found to be predictive of lower odds of use for all populations. Medicare and Medicaid insurance statuses were positively associated with NCI center use. Neighborhood-level education was found to be a more powerful predictor of NCI use than poverty or unemployment.

CONCLUSIONS

Select minority groups underuse NCI cancer centers for CRC treatment. Sociodemographic factors and proximity to NCI centers are important predictors of use. Interventions to address these factors may improve minority attendance to NCI cancer centers for care.

Disparities in the surgical treatment of colorectal liver metastases

BACKGROUND

Hepatectomy is an accepted standard of care for patients with resectable colorectal liver metastases (CLM). Given that it is unclear whether disparities exist between different patient populations, a population-based analysis was performed to analyze this issue with regards to resection rates and surgical mortality in patients with CLM.

METHODS

Using the Nationwide Inpatient Sample, characteristics and outcomes of adult patients with a diagnosis of colorectal cancer and colorectal metastases that subsequently underwent a liver resection during the years 1993-2007 were identified. Multivariate analysis was used to determine the effects of demographic and clinical covariables on resection rates and in-hospital mortality.

RESULTS

Incident colorectal and liver metastases were identified in 138,565 patients; 3,528 patients (2.6%) underwent subsequent resection. African American and Hispanic race were associated with lower resection rates compared to Caucasian patients (adjusted OR 0.61 (0.52 - 0.71) and 0.81 (0.68 - 0.96) respectively). Medicaid insurance was associated with decreased resection rates compared to private insurance (AOR 0.47 (0.40 - 0.56)). The overall inpatient mortality rate was 3.1%. Multivariate analysis determined that mortality rate was correlated to both insurance status and geographic region.

CONCLUSIONS

The national resection rate is significantly lower than has been reported by most case series. Race and insurance status appear to be correlated to the likelihood of surgical resection. In-hospital mortality is equivalent to the rates reported elsewhere, but is correlated to insurance status and region.

The impact of comorbidity on cancer survival: a review

Background

A number of studies have shown poorer survival among cancer patients with comorbidity. Several mechanisms may underlie this finding. In this review we summarize the current literature on the association between patient comorbidity and cancer prognosis. Prognostic factors examined include tumor biology, diagnosis, treatment, clinical quality, and adherence.

Methods

All English-language articles published during 2002–2012 on the association between comorbidity and survival among patients with colon cancer, breast cancer, and lung cancer were identified from PubMed, MEDLINE and Embase. Titles and abstracts were reviewed to identify eligible studies and their main results were then extracted.

Results

Our search yielded more than 2,500 articles related to comorbidity and cancer, but few investigated the prognostic impact of comorbidity as a primary aim. Most studies found that cancer patients with comorbidity had poorer survival than those without comorbidity, with 5-year mortality hazard ratios ranging from 1.1 to 5.8. Few studies examined the influence of specific chronic conditions. In general, comorbidity does not appear to be associated with more aggressive types of cancer or other differences in tumor biology. Presence of specific severe comorbidities or psychiatric disorders were found to be associated with delayed cancer diagnosis in some studies, while chronic diseases requiring regular medical visits were associated with earlier cancer detection in others. Another finding was that patients with comorbidity do not receive standard cancer treatments such as surgery, chemotherapy, and radiation therapy as often as patients without comorbidity, and their chance of completing a course of cancer treatment is lower. Postoperative complications and mortality are higher in patients with comorbidity. It is unclear from the literature whether the apparent undertreatment reflects appropriate consideration of greater toxicity risk, poorer clinical quality, patient preferences, or poor adherence among patients with comorbidity.

Conclusion

Despite increasing recognition of the importance of comorbid illnesses among cancer patients, major challenges remain. Both treatment effectiveness and compliance appear compromised among cancer patients with comorbidity. Data on clinical quality is limited.

What provider volumes and characteristics are appropriate for gastric cancer resection? Results of an international RAND/UCLA expert panel

BACKGROUND

A relationship between higher volume providers and improved outcomes has been suggested by some studies and has been used to construct guidelines for many diseases. For gastric cancer (GC), however, optimal volume cutoffs are not clear.

METHODS

A multidisciplinary expert panel of 16 physicians from 6 countries scored 120 scenarios regarding provider characteristics for gastric resections for GC. Appropriateness of scenarios was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1 to 3 were considered inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. Agreement was reached when 12 of 16 panelists scored the statement similarly. Appropriate scenarios agreed on were scored subsequently for necessity.

RESULTS

Surgeon and hospital practice volume scenarios were evaluated. The panel felt it was inappropriate for surgeons doing ≤2 GC cases per year to perform a multivisceral resection (MVR), D2 lymphadenectomy (D2-LND), or laparoscopic total gastrectomy, and ≤6 GC cases per year for an MVR involving a pancreatoduodenectomy (MVR-PD), or endoscopic mucosal resections (EMR). It was considered appropriate for surgeons doing ≥11 GC cases per year to perform open gastrectomy or D2-LND, and ≥20 GC cases per year for any MVR, laparoscopic gastrectomy, or EMR. For hospitals, it was considered inappropriate for hospitals managing ≤4 GC cases per year to perform D2-LND or laparoscopic total gastrectomy, and ≤10 GC cases per year, for MVR-PD or EMR. Hospital volumes ≥21 cases per year was considered appropriate for any GC procedure. It was inappropriate for an MVR to be performed in a hospital without interventional radiology services and for a MVR-PD in a hospital with no level I intensive care unit.

CONCLUSION

Appropriate and inappropriate provider volumes for a variety of gastric procedures have been defined by an international expert panel.

A Population-Based Observational Study of First-Course Treatment and Survival for Adolescent and Young Adult Females with Breast Cancer

PURPOSE

Young age at breast cancer diagnosis is associated with poor survival. However, little is known about factors associated with first-course treatment receipt or survival among adolescent and young adult (AYA) females aged 15-39 years.

METHODS

Data regarding 19,906 eligible AYA breast cancers diagnosed in California during 1992-2009 were obtained from the population-based California Cancer Registry. Multivariable logistic regression was used to evaluate clinical and sociodemographic differences in treatment receipt. Multivariable Cox proportional hazards regression was used to examine differences in survival by initial treatment, and by patient and tumor characteristics.

RESULTS

Black and Hispanic AYAs diagnosed with in situ or stages I-III breast cancer were more likely than White AYAs to receive breast-conserving surgery (BCS) without radiation; Asian and Hispanic AYAs were more likely than Whites to receive mastectomy. Women in lower socioeconomic status (SES) neighborhoods were more likely to omit radiation after BCS, more likely to receive mastectomy, and less likely to receive chemotherapy, compared to those in higher SES neighborhoods. Among patients with invasive disease, survival improved an average of 5% per year during 1992-2009. AYAs who received BCS with radiation experienced better survival than other surgery/radiation options. Black AYAs had poorer survival than Whites. AYAs who resided in higher SES neighborhoods had better survival.

CONCLUSIONS

Treatment receipt among AYAs with breast cancer varied by race/ethnicity and neighborhood SES. Poor survival for Black AYAs and AYAs living in low SES neighborhoods in models adjusted for treatment receipt suggests that factors other than treatment may also be important to disease outcome.

Hospital volume, proportion resected and mortality from oesophageal and gastric cancer: a population-based study in England, 2004-2008

OBJECTIVE

This study assessed the associations between hospital volume, resection rate and survival of oesophageal and gastric cancer patients in England.

DESIGN

62,811 patients diagnosed with oesophageal or gastric cancer between 2004 and 2008 were identified from a national population-based cancer registration and Hospital Episode Statistics-linked dataset. Cox regression analyses were used to assess all-cause mortality according to hospital volume and resection rate, adjusting for case-mix variables (sex, age, socioeconomic deprivation, comorbidity and type of cancer). HRs and 95% CIs, according to hospital volume, were evaluated for three predefined periods following surgery: <30, 30-365, and >365 days. Analysis of mortality in relation to resection rate was performed among all patients and among the 13 189 (21%) resected patients.

RESULTS

Increasing hospital volume was associated with lower mortality (p trend=0.0001; HR 0.87, 95% CI 0.79 to 0.95 for hospitals resecting 80+ and compared with <20 patients a year). In relative terms, the association between increasing hospital volume and lower mortality was particularly strong in the first 30 days following surgery (p trend<0.0001; HR 0.52, (0.39 to 0.70)), but a clinically relevant association remained beyond 1 year (p trend=0.0011; HR 0.82, (0.72 to 0.95)). Increasing resection rates were associated with lower mortality among all patients (p trend<0.0001; HR 0.86, (0.84 to 0.89) for the highest, compared with the lowest resection quintile).

CONCLUSIONS

With evidence of lower short-term and longer-term mortality for patients resected in high-volume hospitals, this study supports further centralisation of oesophageal and gastric cancer surgical services in England.

Current perspectives in bladder cancer management

More than 350,000 new cases of bladder cancer are diagnosed worldwide each year; the vast majority (> 90%) of these are transitional cell carcinomas (TCC). The most important risk factors for the development of bladder cancer are smoking and occupational exposure to toxic chemicals. Painless visible haematuria is the most common presenting symptom of bladder cancer; significant haematuria requires referral to a specialist urology service. Cystoscopy and urine cytology are currently the recommended tools for diagnosis of bladder cancer. Excluding muscle invasion is an important diagnostic step, as outcomes for patients with muscle invasive TCC are less favourable. For non-muscle invasive bladder cancer, transurethral resection followed by intravesical chemotherapy (typically Mitomycin C or epirubicin) or immunotherapy [bacillus Calmette-Guérin (BCG)] is the current standard of care. For patients failing BCG therapy, cystectomy is recommended; for patients unsuitable for surgery, the choice of treatment options is currently limited. However, novel interventions, such as chemohyperthermia and electromotive drug administration, enhance the effects of conventional chemotherapeutic agents and are being evaluated in Phase III trials. Radical cystectomy (with pelvic lymphadenectomy and urinary diversion) or radical radiotherapy are the current established treatments for muscle invasive TCC. Neoadjuvant chemotherapy is recommended before definitive treatment of muscle invasive TCC; cisplatin-containing combination chemotherapy is the recommended regimen. Palliative chemotherapy is the first-choice treatment in metastatic TCC.

Current treatment options for the management of esophageal cancer

In recent years, esophageal cancer characteristics and management options have evolved significantly. There has been a sharp increase in the frequency of esophageal adenocarcinoma and a decline in the frequency of squamous cell carcinoma. A more comprehensive understanding of prognostic factors influencing outcome has also been developed. This has led to more management options for esophageal cancer at all stages than ever before. A multidisciplinary, team approach to management in a high volume center is the preferred approach. Each patient should be individually assessed based on type of cancer, local or regional involvement, and his or her own functional status to determine an appropriate treatment regimen. This review will discuss management of esophageal cancer relative to disease progression and patient functional status.

The role of National Cancer Institute-designated cancer center status: observed variation in surgical care depends on the level of evidence

OBJECTIVE

We sought to evaluate differences in guideline concordance between National Cancer Institute (NCI)-designated and other centers and determine whether the level of available evidence influences the degree of variation in concordance.

BACKGROUND

The National Cancer Institute recognizes centers of excellence in the advancement of cancer care. These NCI-designated cancer centers have been shown to have better outcomes for cancer surgery; however, little work has compared surgical process measures.

METHODS

A retrospective cohort study was conducted using Surveillance, Epidemiology and End Results registry linked to Medicare claims data. Fee-for-service Medicare patients with a definitive surgical resection for breast, colon, gastric, rectal, or thyroid cancers diagnosed between 2000 and 2005 were identified. Claims data from 1999 to 2006 were used. Our main outcome measure was guideline concordance at NCI-designated centers compared to other institutions, stratified by level of evidence as graded by National Comprehensive Cancer Network guideline panels.

RESULTS

All centers achieved at least 90%, and often 95%, concordance with guidelines based on level 1 evidence. Concordance rates for guidelines with lower-level evidence ranged from 30% to 97% and were higher at NCI-designated centers. The adjusted concordance ratios for category 1 guidelines were between 1.02 and 1.08, whereas concordance ratios for guidelines with lower-level evidence ranged from 0.97 to 2.19, primarily favoring NCI-designated centers.

CONCLUSIONS

When strong evidence supports a guideline, there is little variation in practice between NCI-designated centers and other hospitals, suggesting that all are providing appropriate care. Variation in care may exist, however, for guidelines that are based on expert consensus rather than strong evidence. This suggests that future efforts to generate needed evidence on the optimal approach to care may also reduce institutional variation.

Influence of hospital type on outcomes after oesophageal and gastric cancer surgery

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.

Quality assessment in oncology

The movement to improve healthcare quality has led to a need for carefully designed quality indicators that accurately reflect the quality of care. Many different measures have been proposed and continue to be developed by governmental agencies and accrediting bodies. However, given the inherent differences in the delivery of care among medical specialties, the same indicators will not be valid across all of them. Specifically, oncology is a field in which it can be difficult to develop quality indicators, because the effectiveness of an oncologic intervention is often not immediately apparent, and the multidisciplinary nature of the field necessarily involves many different specialties. Existing and emerging comparative effectiveness data are helping to guide evidence-based practice, and the increasing availability of these data provides the opportunity to identify key structure and process measures that predict for quality outcomes. The increasing emphasis on quality and efficiency will continue to compel the medical profession to identify appropriate quality measures to facilitate quality improvement efforts and to guide accreditation, credentialing, and reimbursement. Given the wide-reaching implications of quality metrics, it is essential that they be developed and implemented with scientific rigor. The aims of the present report were to review the current state of quality assessment in oncology, identify existing indicators with the best evidence to support their implementation, and propose a framework for identifying and refining measures most indicative of true quality in oncologic care.

Association of hospital spending intensity with mortality and readmission rates in Ontario hospitals

CONTEXT

The extent to which better spending produces higher-quality care and better patient outcomes in a universal health care system with selective access to medical technology is unknown.

OBJECTIVE

To assess whether acute care patients admitted to higher-spending hospitals have lower mortality and readmissions.

DESIGN, SETTING, AND PATIENTS

The study population comprised adults (>18 years) in Ontario, Canada, with a first admission for acute myocardial infarction (AMI) (n = 179,139), congestive heart failure (CHF) (n = 92,377), hip fracture (n = 90,046), or colon cancer (n = 26,195) during 1998-2008, with follow-up to 1 year. The exposure measure was the index hospital's end-of-life expenditure index for hospital, physician, and emergency department services.

MAIN OUTCOME MEASURES

The primary outcomes were 30-day and 1-year mortality and readmissions and major cardiac events (readmissions for AMI, angina, CHF, or death) for AMI and CHF.

RESULTS

Patients' baseline health status was similar across hospital expenditure groups. Patients admitted to hospitals in the highest- vs lowest-spending intensity terciles had lower rates of all adverse outcomes. In the highest- vs lowest-spending hospitals, respectively, the age- and sex-adjusted 30-day mortality rate was 12.7% vs 12.8% for AMI, 10.2% vs 12.4% for CHF, 7.7% vs 9.7% for hip fracture, and 3.3% vs 3.9% for CHF; fully adjusted relative 30-day mortality rates were 0.93 (95% CI, 0.89-0.98) for AMI, 0.81 (95% CI, 0.76-0.86) for CHF, 0.74 (95% CI, 0.68-0.80) for hip fracture, and 0.78 (95% CI, 0.66-0.91) for colon cancer. Results for 1-year mortality, readmissions, and major cardiac events were similar. Higher-spending hospitals had higher nursing staff ratios, and their patients received more inpatient medical specialist visits, interventional (AMI cohort) and medical (AMI and CHF cohorts) cardiac therapies, preoperative specialty care (colon cancer cohort), and postdischarge collaborative care with a cardiologist and primary care physician (AMI and CHF cohorts).

CONCLUSION

Among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates.

Structural/organizational characteristics of health services partly explain racial variation in timeliness of radiation therapy among elderly breast cancer patients

Observed racial/ethnic disparities in the process and outcomes of breast cancer care may be explained, in part, by structural/organizational characteristics of health care systems. We examined the role of surgical facility characteristics and distance to care in explaining racial/ethnic variation in timing of initiation of guideline-recommended radiation therapy (RT) after breast conserving surgery (BCS). We used Surveillance Epidemiology and End Results-Medicare data to identify women ages 65 and older diagnosed with stages I-III breast cancer and treated with BCS in 1994-2002. We used stepwise multivariate logistic regression to examine the interactive effects of race/ethnicity and facility profit status, teaching status, size, and institutional affiliations, and distance to nearest RT on timing of RT initiation, controlling for known covariates. Among 38,574 eligible women who received BCS, 39% received RT within 2 months, 52% received RT within 6 months, and 57% received RT within 12 months post-diagnosis, with significant variation by race/ethnicity. In multivariate models, women attending smaller surgical facilities and those with on-site radiation had higher odds of RT at each time interval, and women attending governmental facilities had lower odds of RT at each time interval (P < 0.05). Increasing distance between patients' residence and nearest RT provider was associated with lower overall odds of RT, particularly among Hispanic women (P < 0.05). In fully adjusted models including race-by-distance interaction terms, racial/ethnic disparities disappeared in RT initiation within 6 and 12 months. Racial/ethnic disparities in timing of RT for breast cancer can be partially explained by structural/organizational health system characteristics. Identifying modifiable system-level factors associated with quality cancer care may help us target policy interventions that can reduce disparities in outcomes.

Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies

OBJECTIVE

The objective of this study is to provide a comprehensive update of the outcome of the ileo-pouch anal anastomosis (IPAA).

DATA SOURCES

An extensive search in PubMed, EMBASE, and The Cochrane Library was conducted.

STUDY SELECTION AND DATA EXTRACTION

All studies published after 2000 reporting on complications or functional outcome after a primary open IPAA procedure for UC or FAP were selected. Study characteristics, functional outcome, and complications were extracted.

DATA SYNTHESIS

A review with similar methodology conducted 10 years earlier was used to evaluate developments in outcome over time. Pooled estimates were compared using a random-effects logistic meta-analyzing technique. Analyses focusing on the effect of time of study conductance, centralization, and variation in surgical techniques were performed.

RESULTS

Fifty-three studies including 14,966 patients were included. Pooled rates of pouch failure and pelvic sepsis were 4.3% (95% CI, 3.5-6.3) and 7.5% (95% CI 6.1-9.1), respectively. Compared to studies published before 2000, a reduction of 2.5% was observed in the pouch failure rate (p = 0.0038). Analysis on the effect of the time of study conductance confirmed a decline in pouch failure. Functional outcome remained stable over time, with a 24-h defecation frequency of 5.9 (95% CI, 5.0-6.9). Technical surgery aspects did not have an important effect on outcome.

CONCLUSION

This review provides up to date outcome estimates of the IPAA procedure that can be useful as reference values for practice and research. It is also shows a reduction in pouch failure over time.

Minimally invasive esophagectomy in the community hospital setting

We report our initial experience with minimally-invasive esophagectomy in 32 patients at Carolinas Medical Center, a community academic medical center. Indications for surgery were adenocarcinoma in 27, squamous cell carcinoma in 3, and benign stricture in 2. Transthoracic Ivor-Lewis esophagectomy with laparoscopy and thoracoscopy was performed in 28, a 3-stage esophagectomy in 3, and transhaital esophagectomy in 1. There was no operative mortality and median hospital stay was 10.5 days for patients treated with minimally invasive esophagectomy. This compares with an operative mortality of 8.9% and median hospital stay of 17 days for open esophagectomy in our institution.

Low-volume centre vs high-volume: the role of a quality assurance programme in colon cancer surgery

AIM

The study aimed to determine whether hospitals within a quality assurance programme have outcomes of colon cancer surgery related to volume.

METHOD

Data were used from an observational study to determine whether outcomes of colon cancer surgery are related to hospital volume. Hospitals were divided into three groups (low, medium and high) based on annual caseload. Cancer staging, resected lymph nodes, perioperative complications and follow up were monitored. Between 2000 and 2004, 345 hospitals entered 31,261 patients into the study: 202 hospitals (group I) were classified as low volume (<30 operations; 7760 patients; 24.8%), 111 (group II) as medium volume (30-60; 14,008 patients; 44.8%) and 32 (groups III) as high volume (>60; 9493 patients; 30.4%).

RESULTS

High-volume centres treated more patients in UICC stages 0, I and IV, whereas low-volume centres treated more in stages II and III (P<0.001). There was no significant difference for intra-operative complications and anastomotic leakage. The difference in 30-day mortality between the low and high-volume groups was 0.8% (P=0.023).Local recurrence at 5 years was highest in the medium group. Overall survival was highest in the high-volume group; however, the difference was only significant between the medium and high-volume groups. For the low and high-volume groups, there was no significant difference in the 5-year overall survival rates.

CONCLUSION

A definitive statement on outcome differences between low-volume and high-volume centres participating in a quality assurance programme cannot be made because of the heterogeneity of results and levels of significance. Studies on volume-outcome effects should be regarded critically.

Predictors of timing of adjuvant chemotherapy in older women with hormone receptor-negative, stages II-III breast cancer

Adherence to consensus guidelines for cancer care may vary widely across health care settings and contribute to differences in cancer outcomes. For some women with breast cancer, omission of adjuvant chemotherapy or delays in its initiation may contribute to differences in cancer recurrence and mortality. We studied adjuvant chemotherapy use among women with stage II or stage III, hormone receptor-negative breast cancer to understand health system and socio-demographic correlates of underuse and delayed adjuvant chemotherapy. We used Surveillance Epidemiology and End Results (SEER)-Medicare linked data to examine the patterns of care for 6,678 women aged 65 and older diagnosed with stage II or stage III hormone receptor-negative breast cancer in 1994-2002, with claims data through 2007. Age-stratified logistic regression was employed to examine the potential role of socio-demographic and structural/organizational health services characteristics in explaining differences in adjuvant chemotherapy initiation. Overall utilization of guideline-recommended adjuvant chemotherapy peaked at 43% in this population. Increasing age, higher co-morbidity burden, and low-income status were associated with lower odds of chemotherapy initiation within 4 months, whereas having positive lymph nodes, more advanced disease, and being married were associated with higher odds (P < 0.05). Health system-related structural/organizational characteristics and race/ethnicity offered little explanatory insight. Timely initiation of guideline-recommended adjuvant chemotherapy was low, with significant variation by age, income, and co-morbidity status. Based on these findings, future studies should seek to explore the more nuanced reasons why older women do not receive chemotherapy and why delays in care occur.

Systematic review and meta-analysis of the volume-outcome relationship in pancreatic surgery

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.

Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality

OBJECTIVE

To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitals

BACKGROUND

High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible. We examined low-volume hospitals and sought to identify characteristics of those with better outcomes.

METHODS

Using national data from Medicare and the American Hospital Association, we studied 4498 elderly patients who underwent an esophagectomy from 2004 to 2007. We divided hospitals into terciles based on esophagectomy volume and examined characteristics of patients and hospitals (size, nurse ratios, and presence of advanced medical, surgical, and radiological services). Our primary outcome was mortality. We identified 5 potentially beneficial systems characteristics in our data set and used multivariable logistic regression to determine whether these characteristics were associated with lower mortality rates at low-volume hospitals.

RESULTS

Of the 874 hospitals that performed esophagectomies, 83% (723) were low-volume hospitals whereas only 3% (25) were high-volume. Low-volume hospitals performed a median of 1 esophagectomy during the 4-year study period and cared for patients that were older, more likely to be minority, and more likely to have multiple comorbidities compared with high-volume centers. Low-volume hospitals that had at least 3 of 5 characteristics (high nurse ratios, lung transplantation services, complex medical oncology services, bariatric surgery services, and positron emission tomography scanners) had markedly lower mortality rates compared with low-volume hospitals with none of these characteristics (12.5% vs. 5.0%; P value = 0.042).

CONCLUSIONS

Low-volume hospitals with certain systems characteristics seem to achieve better esophagectomy outcomes. A more comprehensive study of the beneficial characteristics of low-volume hospitals is warranted because high-volume hospitals are difficult to access for many patients.

Impact of surgeon and hospital volume on short-term outcomes and cost of oropharyngeal cancer surgical care

OBJECTIVE

To evaluate the impact of surgeon and hospital case volume and other related variables on short-term outcomes after surgery for oropharyngeal cancer.

METHODS

The Maryland Health Service Cost Review Commission database was queried for oropharyngeal cancer surgical case volumes from 1990 to 2009. Multivariable regression models were used to identify significant associations between surgeon and hospital case volume, as well as independent variables predictive of in-hospital death, postoperative wound complications, length of hospitalization, and hospital-related cost of care.

RESULTS

Overall, 1,534 oropharyngeal cancer surgeries were performed during the study period. Complete financial data was available for 1,482 oropharyngeal cancer surgeries, performed by 233 surgeons at 36 hospitals. The only independently significant factors associated with the risk of in-hospital death were an APR-DRG mortality risk score of 4 (odds ratio [OR] = 14.0, P < .001) and total glossectomy (OR = 5.6, P = .020). Wound fistula or dehiscence was associated with an increased mortality risk score (OR = 5.9, P < .001), total glossectomy (OR = 6.9, P < .001), mandibulectomy (OR = 3.4, P < .001), and flap reconstruction (OR = 2.1, P = .038). Increased mortality risk score, total glossectomy, pharyngectomy, mandibulectomy, flap reconstruction, neck dissection, and Black race were associated with an increased length of stay and hospital-related costs. After controlling for all other variables, a statistically significant negative correlation was observed between surgery at a high-volume hospital and length of hospitalization and hospital-related costs.

CONCLUSIONS

After controlling for other factors, high-volume hospital care is associated with a shorter length of hospitalization and lower hospital-related cost of care for oropharyngeal cancer surgery.

Outcomes after pediatric ureteral reimplantation: a population based analysis

PURPOSE

Pediatric urology literature is often biased toward single, high volume institutions. We determined the impact of patient, surgeon and hospital characteristics on immediate outcomes for children undergoing ureteral reimplantation.

MATERIALS AND METHODS

We queried the University Health-System Consortium Clinical Data Base to identify a pediatric population who underwent ureteroneocystostomy between 2004 and 2009. We measured the association of the outcome variables length of stay, number of days in the intensive care unit and complication rates on the independent variables of age, gender, race, insurance status, year of surgery, and surgeon and hospital characteristics. The data were analyzed using multiple logistic, Poisson and Poisson hurdle model regression analyses incorporating random effects for surgeon and hospital.

RESULTS

We identified 5,668 subjects who underwent ureteroneocystostomy. Compared with patients treated by high volume providers, those treated by low volume surgeons (less than 13 cases per year) had a longer length of stay (47%), higher odds of intensive care unit admission (OR 8.1), longer intensive care unit stays (103%) and higher rate of surgical related complications (162%). Other independent variables of male gender, nonwhite race and prior comorbidities were independently associated with longer length of stay, higher intensive care unit admissions and higher risk of complications.

CONCLUSIONS

Surgeon volume, not hospital volume, is an important and consistent predictor of length of stay, intensive care unit admissions, intensive care unit days and complication rate after ureteroneocystostomy. These findings posit that the short length of stay, low intensive care unit admission rate and low complication rate reported in the literature may not be generalizable, but rather limited to higher volume surgeons.

The development of anti-cancer programs in Canada for the geriatric population: an integrated nursing and medical approach

Cancer control in Canada refers to the development of comprehensive programs utilising modern techniques, tools and approaches that actively prevent, cure or manage cancer. The scope of such programs is quite vast. They range from prevention, early detection and screening, comprehensive treatment both curative and palliative to comprehensive palliative care. Cancer is a disease associated with the aging population, and as the population ages the incidence of cancer would be expected to rise as well. This in itself poses a great challenge. In addition, the aging population demographics with the projected rise in the numbers of senior citizens, especially the over 80 group in the next decade, poses its own creative challenges to health planners. In Canada, health care is centrally administered, and controlled by the provincial governments of Canada, under the Canada Health Act. The challenge of developing comprehensive programs for the geriatric population requires changes in the care models and care pathways. The patient-centred models that have been adapted require a multidisciplinary approach to the clientele and their families that integrates cancer therapy and geriatric care and realities. This requires changes in the nursing and medical approach, as well as education in the subtleties of the two intersecting medical realities.

Impact of surgeon and hospital volume on short-term outcomes and cost of laryngeal cancer surgical care

OBJECTIVE

To evaluate the impact of surgeon and hospital case volume and other related variables on short-term outcomes after surgery for laryngeal cancer.

METHODS

The Maryland Health Service Cost Review Commission database was queried for laryngeal cancer surgical case volumes from 1990 to 2009. Multivariate logistic regression analyses and multiple linear regression models were used to evaluate for significant associations between surgeon and hospital case volume, as well as other independent variables and the risk of in-hospital death, postoperative wound complications, length of hospital stay, and hospital-related cost of care.

RESULTS

Overall, 1,981 laryngeal cancer surgeries were performed with complete financial data available for 1,885 laryngeal cancer surgeries, performed by 284 surgeons at 37 hospitals. The only independently significant factor associated with the risk of in-hospital death was an APR-DRG mortality risk score of 4 (odds ratio [OR] = 10.7, P < .001). Postoperative wound fistula or dehiscence was associated with an increased mortality risk score (OR = 3.1, P < .001), total laryngectomy (OR = 12.4, P = .013), and flap reconstruction (OR = 3.8, P = .001). Increased mortality risk score, partial or total laryngectomy, flap reconstruction, and Black race were associated with an increased length of stay and hospital-related costs. After controlling for all other variables, a statistically significant negative correlation was observed between surgery at a high-volume hospital and both length of hospital stay (geometric mean = -1.5 days, P = .003). and hospital-related costs (geometric mean = -$6,061, P = .003).

CONCLUSIONS

After controlling for other factors, high-volume hospital care is associated with a shorter length of hospitalization and lower hospital-related cost of care for laryngeal cancer surgery.

Influence of place of residence in access to specialized cancer care for African Americans

CONTEXT

Disparities in cancer care for rural residents and for African Americans have been documented, but the interaction of these factors is not well understood.

PURPOSE

The authors examined the simultaneous influence of race and place of residence on access to and utilization of specialized cancer care in the United States.

METHODS

Access to specialized cancer care was measured using: (1) travel time to National Cancer Institute (NCI) Cancer Centers, academic medical centers, and any oncologist for the entire continental US population, and (2) per capita availability of oncologists for the entire United States. Utilization was measured as attendance at NCI Cancer Centers, specialized hospitals, and other hospitals in the Surveillance, Epidemiology, and End Results (SEER) program Medicare population from 1998-2004.

FINDINGS

In urban settings, travel times were shorter for African Americans compared with Caucasians for all three cancer care settings, but they were longer for rural African Americans traveling to NCI Cancer Centers. Per capita oncologist availability was not significantly different by race or place of residence. Urban African American patients were almost 70% more likely to attend an NCI Cancer Center than urban Caucasian patients (OR = 1.66; 95% CI 1.51-1.83), whereas rural African American patients were 58% less likely to attend an NCI Cancer Center than rural Caucasian patients (OR = 0.42; 95% CI 0.26-0.66).

CONCLUSIONS

Urban African Americans have similar or better access to specialized cancer care than urban Caucasians, but rural African Americans have relatively poor access and lower utilization compared with all other groups.