Quality Management and Key Performance Indicators in Oncologic Esophageal Surgery

Metastatic bone disease: new quality performance indicator development

OBJECTIVES

Patients with metastatic bone disease (MBD) should receive the same standard of care regardless of which centre they are treated in. The aim was to develop and test a set of quality performance indicators (QPIs) to evaluate care for patients with MBD referred to orthopaedics.

METHODS

QPIs were adapted from the literature and ranked on feasibility and necessity during a modified RAND/Delphi consensus process. They were then validated and field tested in a retrospective cohort of 108 patients using indicator-specific targets set during consensus.

RESULTS

2568 articles including six guidelines were reviewed. 43 quality objectives were extracted and 40 proceeded to expert consensus. After two rounds, 18 QPIs for MBD care were generated, with the following generating the highest consensus: 'Patients with high fracture risk should receive urgent assessment' (combined mean 6.7/7, 95% CI 6.5 to 6.8) and 'preoperative workup should include full blood tests including group and save' (combined mean 6.7/7, 95% CI 6.5 to 6.9). In the pilot test, targets were met for 5/18 QPIs (mean 52%, standard deviation 22%). The median deviation from projected target was -14% (interquartile range -11% to -31%, range -74% to 11%). The highest scoring QPI was 'adults with fractures should have surgery within 7 days' (target 80%:actual 92%).

CONCLUSIONS

The published evidence and guidelines were adapted into a set of validated QPIs for MBD care which can be used to evaluate variation in care between centres. These QPIs should be correlated with outcome scores to determine whether they can act as predictors of outcome after surgery.

Impact of the interval between neoadjuvant concurrent chemoradiotherapy and esophagectomy in the modern era: a population-based propensity-score-matched retrospective cohort study in Asia

Background

Neoadjuvant concurrent chemoradiotherapy (nCCRT) is one of the standard-of-care options for locally advanced esophageal squamous cell carcinoma (LA-ESqCC). The optimal interval between nCCRT and esophagectomy is unknown.

Methods

We constructed a propensity-score-matched [1:1 for long (8–12 weeks) vs short (4–7 weeks) intervals] cohort of LA-ESqCC patients who were diagnosed from 2011 to 2015 and treated with nCCRT via the Taiwan Cancer Registry and related databases. We compared the hazard ratios (HRs) of death using a robust variance estimator. We also evaluated alternative covariables, outcomes, and interval definitions.

Results

Our study population included 80 patients for each group; groups were balanced with respect to the observed covariables. There was no significant difference for the HR of death [1.22; 95% confidence interval 0.78–1.91, P = 0.39] when the long interval group was compared to the short interval group. There were also no significant differences when alternative covariables, outcomes, or interval definitions were evaluated.

Conclusions

In this population-based study in modern Asia, we found that for LA-ESqCC patients treated with nCCRT and esophagectomy, overall survival was similar for either long or short intervals between nCCRT and esophagectomy. Randomized controlled trials are needed to verify this finding.

Hospital Volume, In-Hospital Mortality, and Failure to Rescue in Esophageal Surgery

BACKGROUND

In Germany, complex esophageal surgery is often performed in hospitals with low case numbers. For these procedures, an association exists between hospital case numbers and treatment outcomes, possibly because of differences in complication management. This aspect of the association between volume and outcome in esophageal surgery has not yet been studied in Germany.

METHODS

On the basis of nationwide hospital discharge data (DRG statistics) from the years 2010 to 2015, the association between volume and outcome was analyzed in relation to in-hospital mortality, the frequency of complications, and the mortality of patients who had complications.

RESULTS

22 700 cases of complex esophageal surgery were identified. The probability of dying after esophageal surgery was much lower in hospitals with very high case numbers (median, 62 per year) than in those with very low case numbers (median, two per year), with an odds ratio (OR) of 0.50 (95% confidence interval, [0.42; 0.60]). At least one complication was documented for more than half of all patients; no association was found between the frequency of complications and the hospital case volume. The in-hospital mortality among patients who had complications was 12.3% [11.1; 13.7] in hospitals with very high case numbers and 20.0% [18.5; 21.6] in hospitals with very low case numbers. Of the 4032 procedures performed in 2015, 83% were for cancer of the esophagus.

CONCLUSION

These findings indicate that the quality of care for patients undergoing esophageal surgery in Germany could be improved if more patients were treated in hospitals with high case numbers. The observed association between case numbers and outcomes is tightly linked to failure to rescue.

Neoadjuvant vs definitive concurrent chemoradiotherapy in locally advanced esophageal squamous cell carcinoma patients

Background

The optimal treatment for locally advanced esophageal squamous cell carcinoma remains unclear. We compared the clinical outcomes of neoadjuvant concurrent chemoradiotherapy (CCRT) followed by esophagectomy [the surgery group] and CCRT without surgery [the CCRT group] in patients with squamous cell carcinoma from an Asian population.

Methods

Eligible patients diagnosed from 2008 to 2015 were identified through the Taiwan Cancer Registry. To balance observable potential confounders, we constructed a 1:1 propensity score-matched cohort [surgery vs CCRT]. We compared the hazard ratios between the surgery and CCRT groups for death using a robust variance estimator. We also evaluated the outcomes of patients for freedom from local regional recurrence (FFLRR) and esophageal cancer-specific survival (ECSS). Extensive supplementary analyses were performed to examine the robustness of our findings.

Results

Our study population included 298 patients balanced with respect to the observed covariables. The hazard ratio of death was 0.56 [95% confidence interval 0.42~0.75] when surgery was compared to CCRT. The results remained significant in the FFLRR and ECSS outcomes. In the supplementary analyses, our results also remained significant when additional covariables were taken into consideration or when the definition of the index date was changed.

Conclusions

When compared to definitive CCRT, neoadjuvant CCRT followed by esophagectomy was associated with improved overall survival for locally advanced esophageal squamous cell carcinoma. However, given the nonrandomized nature of the study and the sensitivity to potentially unmeasured confounders, our results should be interpreted cautiously.

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

The incidence of esophageal carcinoma has increased in recent years in Germany. The aim of this article is a discussion of the economic aspects of oncological esophageal surgery within the German diagnosis-related groups (DRG) system focusing on the association between minimum caseload requirements and outcome quality as well as costs. The margins for the DRG classification G03A are low and quickly exhausted if complications determine the postoperative course. A current study using nationwide German hospital discharge data proved a significant difference in hospital mortality between clinics with and without achieving the minimum caseload requirements for esophagectomy. Data from the USA clearly showed that besides patient-relevant parameters, the caseload of a surgeon is relevant for the cost of treatment. Such cost-related analyses do not exist in Germany at present. Scientific validation of reliable minimum caseload numbers for oncological esophagectomy is desirable in the future.

Is There a Rationale for Structural Quality Assurance in Esophageal Surgery?

BACKGROUND

Advances regarding perioperative mortality rates and oncological outcomes after esophagectomy have been reported extensively by specialized high-volume centers in Europe and the USA over the last decade. However, recent database analyses reveal that the perioperative mortality of esophagectomy remains high in these countries, indicating a discrepancy between surgical quality in baseline hospitals and specialized centers.

METHODS

This article provides an overview over the existing literature on the correlation between structural quality, procedural volume, and surgical outcome in e- sophageal surgery.

RESULTS

Structural, procedural and outcome measures can be used to assess the quality of surgical treatment and perioperative management. Surgical procedures on the esophagus for both benign and malignant diseases are rare and typically associated with high perioperative morbidity and mortality. Usually, direct outcome measures do not provide enough statistical power to actually identify differences in surgical quality between hospitals, making structural quality measures the only feasible parameter to compare the quality of e- sophageal surgery among different centers. Several analyses from different countries have shown a strong correlation between hospital volume and postoperative mortality. Data from countries in which esophageal surgery has been centralized indicate beneficial effects of a centralized health care system on postoperative mortality after esophagectomy. Additionally, only high-volume centers generally provide optimal preoperative and postoperative management and comprehensive access to modern multimodal treatment. In Germany, esophageal surgery is still decentralized, but hospitals performing complex esophageal procedures have to fulfill minimum caseload requirements of 10 cases per year. In practice, these requirements are not met by the majority of hospitals and a detrimental effect on the achieved surgical outcomes can be noted.

CONCLUSION

Therefore, we conclude that structural quality assurance is crucial to further reduce postoperative morbidity after esophageal surgery and to improve long-term results.

[Oncologic esophageal resection and reconstruction : Open, hybrid, minimally invasive or robotic?]

Minimally invasive resections are increasingly employed in oncologic surgery for esophageal carcinoma. The new German S3 guideline states that esophagectomy, as well as reconstruction of the esophagus, can be performed minimally invasively or in combination with open techniques (hybrid). However, the current value of different techniques - ranging from complete minimally invasive esophagectomy over hybrid to robotic surgery - remains unregarded.This review provides a critical comparison of these techniques based on current evidence. Minimally invasive procedures of oncologic esophageal resection are safe in experienced hands and show numerous advantages with regard to postoperative reconvalescence. Laparoscopic gastrolysis with intra-abdominal lymphadenectomy and muscle sparing as well as anterolateral mini-thoracotomy (also via VATS as single-port technique) as a hybrid method also result in a relevant reduction of postoperative mortality and offer the possibility of extended mediastinal lymphadenectomy, which requires a high level of expertise when performed thoracoscopically. At present, robotic esophagectomy is applied in only a few clinics in Germany. A lack of evidence based on studies for esophageal surgery, as well as high acquisition and operating costs of the robotic system, have to be taken into account.