[Economic aspects of oncological esophageal surgery : Centralization is essential]

Disparities in major surgery for esophagogastric cancer among hospitals by case volume

Background

The purpose of this study was to characterize disparities among centers performing major surgery for esophageal or gastric cancer stratified by case volume.

Methods

The National Cancer Data Base (NCDB) was queried for cases of esophagectomy or total gastrectomy. Centers were compared based on number of cases during 2004-2013: low volume [1-99], middle [100-200], and high [>200].

Results

For esophagectomy, 17,547 patients were included; 73.5% were treated in low volume centers, 14.6% in middle, and 11.9% in high. For gastrectomy, 20,059 patients were included, with 87.5%, 8.3%, and 4.3%, respectively. Patients treated at low volume centers were more likely to be of racial/ethnic minorities, uninsured, and have lower socioeconomic status. Overall survival (OS) was superior for patients treated at high volume centers. On multivariable analysis for either procedure, a higher number of disparate factors was identified in the low and middle volume centers compared to the high volume centers, which were associated with poorer OS.

Conclusions

This study identified higher numbers of disparate patient factors associated with low/middle volume centers compared to high volume centers, which were associated with worse OS, and further makes the case for performance of esophagectomy and total gastrectomy at high volume centers.

Dimensions of Quality and Their Increasing Relevance for Visceral Medicine in Germany

BACKGROUND

'Quality in medicine' is a term used in a broad sense. In this work the definition and dimensions of quality in medicine and the implementation of a measurement and reporting system in Germany are discussed. Existing applications are described and possible future effects are pointed out.

METHODS

The ongoing process of implementing a quality reporting system into the German healthcare system is studied by publicly available legal texts, published reactions of stakeholders and publications of G-BA and IQTIG. Definitions of quality, dimensions of quality and quality measurement in medicine are studied by using textbooks as well as the world wide web and PubMed search.

RESULTS

Donabedian's 'dimensions of quality' are fundamental in dealing with quality in medicine. Existing measurement and reporting systems have immanent strengths and weaknesses, as the definition of quality is affected by one's point of view. The legislator will have to decide which 'dimension of quality' is mandatory and how to measure it.

CONCLUSION

Quality has become a control instrument with unforeseeable consequences. A clear definition of the used quality concept is as essential as the use of feasible measurement and reporting systems. The use of routine data could be an interesting option.