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Saraswathula A, Austin JM, Fakhry C, Vosler PS, Mandal R, Koch WM, Tan M, Eisele DW, Frick KD, Gourin CG. Surgeon Volume and Laryngectomy Outcomes. Laryngoscope 2023; 133:834-840. [PMID: 35634691 PMCID: PMC9708934 DOI: 10.1002/lary.30229] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/11/2022] [Accepted: 05/12/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the relationship between surgeon volume and operative morbidity and mortality for laryngectomy. DATA SOURCES The Nationwide Inpatient Sample was used to identify 45,156 patients who underwent laryngectomy procedures for laryngeal or hypopharyngeal cancer between 2001 and 2011. Hospital and surgeon laryngectomy volume were modeled as categorical variables. METHODS Relationships between hospital and surgeon volume and mortality, surgical complications, and acute medical complications were examined using multivariable regression. RESULTS Higher-volume surgeons were more likely to operate at large, teaching, nonprofit hospitals and were more likely to treat patients who were white, had private insurance, hypopharyngeal cancer, low comorbidity, admitted electively, and to perform partial laryngectomy, concurrent neck dissection, and flap reconstruction. Surgeons treating more than 5 cases per year were associated with lower odds of medical and surgical complications, with a greater reduction in the odds of complications with increasing surgical volume. Surgeons in the top volume quintile (>9 cases/year) were associated with a decreased odds of in-hospital mortality (OR = 0.09 [0.01-0.74]), postoperative surgical complications (OR = 0.58 [0.45-0.74]), and acute medical complications (OR = 0.49 [0.37-0.64]). Surgeon volume accounted for 95% of the effect of hospital volume on mortality and 16%-47% of the effect of hospital volume on postoperative morbidity. CONCLUSION There is a strong volume-outcome relationship for laryngectomy, with reduced mortality and morbidity associated with higher surgeon and higher hospital volumes. Observed associations between hospital volume and operative morbidity and mortality are mediated by surgeon volume, suggesting that surgeon volume is an important component of the favorable outcomes of high-volume hospital care. Laryngoscope, 133:834-840, 2023.
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Affiliation(s)
- Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J. Matthew Austin
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Carole Fakhry
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter S. Vosler
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rajarsi Mandal
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wayne M. Koch
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marietta Tan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David W. Eisele
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin D. Frick
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins Carey Business School, Baltimore, MD
| | - Christine G. Gourin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
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Saraswathula A, Austin JM, Fakhry C, Eisele DW, Kachalia A, Gourin CG. Volume-Based Versus Mortality-Based Standards for Surgical Quality: Both Risk Adjustment and Volume Matter. J Clin Oncol 2022; 40:2996-2997. [PMID: 35671418 DOI: 10.1200/jco.22.00407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - J Matthew Austin
- Anirudh Saraswathula, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; J. Matthew Austin, PhD, MS, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD; Carole Fakhry, MD, MPH, David W. Eisele, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Allen Kachalia, MD, JD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Christine G. Gourin, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
| | - Carole Fakhry
- Anirudh Saraswathula, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; J. Matthew Austin, PhD, MS, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD; Carole Fakhry, MD, MPH, David W. Eisele, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Allen Kachalia, MD, JD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Christine G. Gourin, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
| | - David W Eisele
- Anirudh Saraswathula, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; J. Matthew Austin, PhD, MS, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD; Carole Fakhry, MD, MPH, David W. Eisele, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Allen Kachalia, MD, JD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Christine G. Gourin, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
| | - Allen Kachalia
- Anirudh Saraswathula, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; J. Matthew Austin, PhD, MS, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD; Carole Fakhry, MD, MPH, David W. Eisele, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Allen Kachalia, MD, JD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Christine G. Gourin, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
| | - Christine G Gourin
- Anirudh Saraswathula, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; J. Matthew Austin, PhD, MS, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD; Carole Fakhry, MD, MPH, David W. Eisele, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Allen Kachalia, MD, JD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Christine G. Gourin, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
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Levy DA, Li H, Sterba KR, Hughes-Halbert C, Warren GW, Nussenbaum B, Alberg AJ, Day TA, Graboyes EM. Development and Validation of Nomograms for Predicting Delayed Postoperative Radiotherapy Initiation in Head and Neck Squamous Cell Carcinoma. JAMA Otolaryngol Head Neck Surg 2020; 146:455-464. [PMID: 32239201 PMCID: PMC7118672 DOI: 10.1001/jamaoto.2020.0222] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The standard of care for initiation of postoperative radiotherapy (PORT) in head and neck squamous cell carcinoma (HNSCC) is within 6 weeks of surgical treatment. Delays in guideline-adherent PORT initiation are common, associated with mortality, and a measure of quality care, but patient-specific tools to estimate the risk of these delays are lacking. Objective To develop and validate 2 nomograms (that use presurgical and postsurgical data) for predicting delayed PORT initiation. Design, Setting, and Participants This cohort study obtained patient data from January 1, 2004, to December 31, 2015, from the National Cancer Database. Adults aged 18 years or older with a newly diagnosed HNSCC who underwent surgical treatment and PORT at a Commission on Cancer-accredited facility were included. Data analysis was conducted from June 2, 2019, to January 29, 2020. Exposures Surgical treatment and PORT. Main Outcomes and Measures The primary outcome measure was PORT initiation more than 6 weeks after the surgical intervention. Multivariable logistic regression models were created in a random selection of 80% of the sample (derivation cohort) and were internally validated with bootstrapping, assessed for discrimination by calibration plots and the concordance (C) index, and externally validated in the remaining 20% of the sample (validation cohort). Results The study included 60 766 adults with HNSCC who were grouped into derivation and validation cohorts. The derivation cohort comprised 48 625 patients (mean [SD] age, 59.59 [11.3] years; 36 825 men [75.7%]) selected randomly from the full sample, whereas 12 151 patients (mean [SD] age, 59.63 [11.2] years; 9266 men [76.3%]) composed the validation cohort. The rate of PORT delay was 55.8% (n=27140) in the derivation cohort and 56.7% (n=6900) in the validation cohort. Both nomograms created to predict the risk of PORT initiation delay used variables, including race/ethnicity, insurance type, tumor site, and facility type. The nomogram based on presurgical variables included clinical stage and severity of comorbidity, whereas the nomogram with postsurgical variables included US region, length of stay, and care fragmentation between surgical and radiotherapy facilities. For the presurgical nomogram, the concordance indices were 0.670 (95% CI, 0.664-0.676) in the derivation cohort and 0.674 (95% CI, 0.662-0.685) in the validation cohort. For the nomogram with postsurgical variables, the concordance indices were 0.691 (95% CI, 0.686-0.696) in the derivation cohort and 0.694 (95% CI, 0.685-0.704) in the validation cohort. Conclusions and Relevance This study found that a nomogram developed with presurgical data to generate personalized estimates of PORT initiation delay may improve pretreatment counseling and the delivery of interventions to patients at high risk for such a delay. A nomogram including postsurgical data can drive institutional quality improvement initiatives and enhance risk-adjusted comparisons of delay rates across facilities.
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Affiliation(s)
- Dylan A Levy
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Hong Li
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
- Hollings Cancer Center, Medical University of South Carolina, Charleston
| | - Katherine R Sterba
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
- Hollings Cancer Center, Medical University of South Carolina, Charleston
| | - Chanita Hughes-Halbert
- Hollings Cancer Center, Medical University of South Carolina, Charleston
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Graham W Warren
- Hollings Cancer Center, Medical University of South Carolina, Charleston
- Department of Radiation Oncology, Medical University of South Carolina, Charleston
- Department of Cell and Molecular Pharmacology, Medical University of South Carolina, Charleston
| | - Brian Nussenbaum
- American Board of Otolaryngology-Head & Neck Surgery, Houston, Texas
| | - Anthony J Alberg
- Arnold School of Public Health, Department of Epidemiology and Biostatistics, University of South Carolina, Columbia
| | - Terry A Day
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Evan M Graboyes
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
- Hollings Cancer Center, Medical University of South Carolina, Charleston
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