Hospital-level outcomes associated with laparoscopic colectomy for cancer in the minimally invasive era

National disparities in use of minimally invasive surgery for rectal cancer in older adults

BACKGROUND

Minimally invasive surgery (MIS) is safe and improves outcomes in older persons with rectal cancer but may be underutilized. As older persons are the largest surgical population, investigation of the current use and factors impacting MIS use is warranted. Our goal is to investigate the trends and disparities that affect utilization of MIS in older persons with rectal cancer.

METHODS

The National Cancer Database was reviewed for persons 65 years and older who underwent curative resection for rectal adenocarcinoma from 2010 to 2017. Cases were stratified by surgical approach (open or MIS [laparoscopic or robotic]). Univariate analysis compared patient and provider demographics across approaches. Multivariate analysis investigated variables associated with MIS use. Main outcome measures were trends and factors associated with MIS use in older persons.

RESULTS

Of 31,910 patients analyzed, 51.9% (n = 16,555) were open and 48.1% (n = 15,355) MIS. The MIS cohort was 66.7% (n = 10,236) laparoscopic and 33.3% (n = 5119) robotic. MIS increased from 29% in 2010 (n = 1197; 25% laparoscopic, 4% robotic) to 65% in 2017 (n = 2382; 35% laparoscopic, 30% robotic), likely from annual increases in robotics (OR 1.24/year, p < 0.0001). In the unadjusted analysis, there were significant differences in MIS use by age, race, comorbidity, socioeconomic status, and facility type. In multivariate analysis, patients with advancing age (OR 0.93, p < 0.001), major comorbidity (OR 0.75, p < 0.001), total proctectomy (OR0.78, p < 0.001), and advanced pathologic stage (OR 0.51, p < 0.001) were less likely to undergo MIS.

CONCLUSION

Nationwide, less than half of rectal cancer cases in older persons were performed with MIS, despite steady robotic growth. Patient and facility factors impacted MIS use. Further work on regionalizing rectal cancer care and ensuring equitable MIS access and training could improve utilization.

Laparoscopic surgery for colon cancer

Background

To evaluate a new procedure in daily clinical practice, it might not be sufficient to rely exclusively on the findings of randomized clinical trials (RCTs). This is the first systematic review providing a synthesis of the most important RCTs and relevant retrospective cohort studies on short- and long-term outcomes of laparoscopic surgery in colon cancer patients.

Materials and methods

In a literature search, more than 1800 relevant publications on the topic were identified. Relevant RCTs and representative high-quality retrospective studies were selected based on the widely accepted Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. Finally, 9 RCTs and 14 retrospective cohort studies were included.

Results

Laparoscopic surgery for colon cancer is associated with a slightly longer duration of surgery, but a variety of studies show an association with a lower rate of postoperative complications and a shorter duration of hospital stay. Particularly in older patients with more frequent comorbidities, laparoscopy seems to contribute to decreasing postoperative mortality. Concerning long-term oncologic outcomes, the laparoscopic and open techniques were shown to be at least equivalent.

Conclusion

The findings of the existing relevant RCTs on laparoscopic surgery for colon cancer are mostly confirmed by representative retrospective cohort studies based on real-world data; therefore, its further implementation into clinical practice can be recommended.

Comparison of clinical outcomes between laparoscopic and open surgery for left-sided colon cancer: a nationwide population-based study

The role of laparoscopic surgery for left-sided colon cancer has been supported by the results of randomized controlled trials. However, its benefits and disadvantages in the real world setting should be further assessed with population-based studies.The hospitalization data of patients undergoing open or laparoscopic surgery for left-sided colon cancer were sourced from the Taiwan National Health Insurance Research Database. Patient and hospital characteristics and perioperative outcomes including length of hospital stay, operation time, opioid use, blood transfusion, intensive care unit (ICU) admission, and use of mechanical ventilation were compared. The overall survival was also assessed. Patients undergoing laparoscopic surgery had shorter hospital stay (p < 0.0001) and less demand for opioid analgesia (p = 0.0005). Further logistic regression revealed that patients undergoing open surgery were 1.70, 2.89, and 3.00 times more likely to have blood transfusion, to be admitted to ICU, and to use mechanical ventilation than patients undergoing laparoscopic surgery. Operations performed in medical centers were also associated with less adverse events. The overall survival was comparable between the 2 groups.With adequate hospital quality and volume, laparoscopic surgery for left-sided colon cancer was associated with improved perioperative outcomes. The long-term survival was not compromised.

Comparison of complication and conversion rates between robotic-assisted and laparoscopic rectal resection for rectal cancer: which patients and providers could benefit most from robotic-assisted surgery?

AIMS

To compare (1) complication and (2) conversion rates to open surgery (OS) from laparoscopic surgery (LS) and robotic-assisted surgery (RA) for rectal cancer patients who underwent rectal resection. (3) To identify patient, physician, and hospital predictors of conversion.

MATERIALS AND METHODS

A US-based database study was conducted utilizing the 2012-2014 Premier Healthcare Data, including rectal cancer patients ≥18 with rectal resection. ICD-9-CM diagnosis and procedural codes were utilized to identify surgical approaches, conversions to OS, and surgical complications. Propensity score matching on patient, surgeon, and hospital level characteristics was used to create comparable groups of RA\LS patients (n = 533 per group). Predictors of conversion from LS and RA to OS were identified with stepwise logistic regression in the unmatched sample.

RESULTS

Post-match results suggested comparable perioperative complication rates (RA 29% vs LS 29%; p = .7784); whereas conversion rates to OS were 12% for RA vs 29% for LS (p < .0001). Colorectal surgeons (RA 9% vs LS 23%), general surgeons (RA 13% vs LS 35%), and smaller bed-size hospitals (RA 14% vs LS 33%) have reduced conversion rates for RA vs LS (p < .0001). Statistically significant predictors of conversion included LS, non-colorectal surgeon, and smaller bed-size hospitals.

LIMITATIONS

Retrospective observational study limitations apply. Analysis of the hospital administrative database was subject to the data captured in the database and the accuracy of coding. Propensity score matching limitations apply. RA and LS groups were balanced with respect to measured patient, surgeon, and hospital characteristics.

CONCLUSIONS

Compared to LS, RA offers a higher probability of completing a successful minimally invasive surgery for rectal cancer patients undergoing rectal resection without exacerbating complications. Male, obese, or moderately-to-severely ill patients had higher conversion rates. While colorectal surgeons had lower conversion rates from RA than LS, the reduction was magnified for general surgeons and smaller bed-size hospitals.

Surgeon Variation in Complications With Minimally Invasive and Open Colectomy: Results From the Michigan Surgical Quality Collaborative

Importance

Minimally invasive colectomy (MIC) is an increasingly common surgical procedure. Although case series and controlled prospective trials have found the procedure to be safe, it is unclear whether safe adaptation of this approach from open colectomy (OC) is occurring among surgeons.

Objective

To assess rates of complications for MIC compared with OC among surgeons.

Design, Setting, and Participants

We analyzed 5196 patients who underwent MIC or OC from January 1, 2012, through December 31, 2015, by 97 surgeons in the Michigan Surgical Quality Collaborative, with each surgeon performing at least 10 OCs and 10 MICs. Hierarchical regression was used to assess surgeon variation in adjusted rates of complications and the association of these outcomes across approaches.

Main Outcomes and Measures

Primary study outcome measurements included overall 30-day complication rates, variation in complication rates among surgeons, and surgeon rank by complication rate for MIC vs OC.

Results

Of the 5196 patients (mean [SD] age, 62.9 [14.4] years; 2842 [54.7%] female; 4429 [85.2%] white), 3118 (60.0%) underwent MIC and 2078 (40.0%) underwent OC. Overall, 1149 patients (22.1%) experienced complications (702 [33.8%] in the OC group vs 447 [14.3%] in the MIC group; P < .001). For MIC, the rates of complications varied from 8.8% to 25.9% among surgeons. For OC, rates of complications were higher but varied less (1.7-fold) among surgeons, ranging from 25.9% to 43.8%. Among the 97 surgeons ranked, the mean change in ranking between OC and MIC was 25 positions. The top 10 surgeons ranged in rank from 6 of 97 for OC to 89 of 97 for MIC.

Conclusions and Relevance

Surgeon-level variation in complications was nearly twice as great for MIC than for OC among surgeons enrolled in a statewide quality collaborative. Moreover, surgeon rankings for OC outcomes differed substantially from outcomes for those same surgeons performing MIC. This finding implies a need for improved training in adoption of MIC techniques among some surgeons.

Provider Experience and the Comparative Safety of Laparoscopic and Open Colectomy

OBJECTIVE

To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy.

DATA SOURCES

National Medicare data (2008-2010) for beneficiaries undergoing laparoscopic or open colectomy.

STUDY DESIGN

Using instrumental variable methods to address selection bias, we evaluated outcomes of laparoscopic and open colectomy. Our instrument was the regional use of laparoscopy in the year prior to a patient's operation. We then evaluated outcomes stratified by surgeons' annual volume of laparoscopic colectomy.

PRINCIPAL FINDINGS

Laparoscopic colectomy was associated with lower mortality (OR: 0.75, 95 percent CI: 0.70-0.78) and fewer complications than open surgery (OR: 0.82, 95 percent CI: 0.79-0.85). Increasing surgeon volume was associated with better outcomes for both procedures, but the relationship was stronger for laparoscopy. The comparative safety depended on surgeon volume. High-volume surgeons had 40 percent lower mortality (OR: 0.60, 95 percent CI: 0.55-0.65) and 30 percent fewer complications (OR: 0.70, 95 percent CI: 0.67-0.74) with laparoscopy. Conversely, low-volume surgeons had 7 percent higher mortality (OR: 1.07, 95 percent CI: 1.02-1.13) and 18 percent more complications (OR: 1.18, 95 percent CI: 1.12-1.24) with laparoscopy.

CONCLUSIONS

This population-based study demonstrates that the comparative safety of laparoscopic and open colectomy is influenced by surgeon volume. Laparoscopic colectomy is only safer for patients whose surgeons have sufficient experience.

National estimated costs of never events following radical prostatectomy

OBJECTIVE

To examine the Centers for Medicare and Medicaid Services, which since 2008 has identified and not reimbursed 10 common postoperative complications deemed "never events" or hospital-acquired conditions (HACs). Prostate cancer, the most frequent cancer among U.S. men, is most often treated with radical prostatectomy (RP). Therefore, its complications in total may represent significant costs to hospitals and providers if not reimbursed. We evaluated the potential effect of these unreimbursed HACs following RP on clinical outcomes and costs.

METHODS AND MATERIALS

Using the Nationwide Inpatient Sample, we selected a weighed, national, estimated sample of 451,707 men with prostate cancer who underwent RP between 2002 and 2009. Baseline sociodemographic and hospital characteristics are described. We calculated estimated frequencies and costs of HACs and the predictors of in-hospital mortality, prolonged length of stay, and increased total hospital costs.

RESULTS

Overall, HACs were infrequent at 0.08%, with pressure ulcer development (0.02%) and foreign object retained at surgery (0.02%) being the most common. HAC occurrence was not affected by hospital teaching status or surgical volume, but larger hospital size was related to more HACs. Those experiencing an HAC were much more likely to have a prolonged length of stay (odds ratio = 6.68, 95% CI: 5.34-8.36) and increased hospital costs (odds ratio = 5.03, 95% CI: 4.05-6.24). HACs after RP cost an estimated nearly $1 million annually in the United States.

CONCLUSION

In a robust sample of patients who underwent RP in the United States, HACs were very uncommon and contributed approximately $1 million in additional expenditures. As the U.S. government continues to expand quality improvement programs and develop incentives to avoid complications, efforts to monitor unnecessary complications should continue as well.

Hernia incidence following single-site vs standard laparoscopic colorectal surgery

AIM

Compared with standard laparoscopic (SDL) approaches, less is known about the incidence of hernias after single-site laparoscopic (SSL) colorectal surgery. This study hypothesized that SSL colorectal surgery was associated with an increased risk of hernia development.

METHOD

Institutional retrospective chart review (September 2008-June 2013) identified 276 evaluable patients who underwent laparoscopic colorectal procedures. The following data were collected: demographic data, risk factors for the development of a hernia, operative details and postoperative course including the development of a hernia. Patients were stratified by laparoscopic technique to compare the characteristics of those undergoing SDL and SSL. Patients were subsequently stratified by the presence or absence of a hernia to identify associated factors.

RESULTS

One hundred and nineteen patients (43.1%) underwent SDL and 157 patients (56.9%) underwent SSL surgery. The development of an incisional hernia was observed in 7.6% (9/119) of SDL patients compared with 17.0% (18/106) of SSL patients (P = 0.03) over a median 18-month follow-up. Similar proportions of patients developed parastomal hernias in both groups [SDL 16.7% (10/60) vs SSL 15.9% (13/80)]. Hernias were diagnosed at a median of 8.1 (SDL) and 6.5 (SSL) months following the index operation and were less likely to be incarcerated in the SSL group [SDL 38.9% (7/18) vs SSL 6.5% (2/31), P = 0.01].

CONCLUSION

SSL colorectal surgery is associated with an increase in the incidence of incisional hernias but not parastomal hernias. Site of specimen extraction in SSL may contribute to the development of an incisional hernia.

Incidence of minimally invasive colorectal cancer surgery at National Comprehensive Cancer Network centers

BACKGROUND

Laparoscopic colectomy has been shown to have equivalent oncologic outcomes to open colectomy for the management of colon cancer, but its adoption nationally has been slow. This study investigates the prevalence and factors associated with laparoscopic colorectal resection at National Comprehensive Cancer Network (NCCN) centers.

METHODS

Data on patients undergoing surgery for colon and rectal cancer at NCCN centers from 2005 to 2010 were obtained from chart review of medical records for the NCCN Outcomes Project and included information on socioeconomic status, insurance coverage, comorbidity, and physician-reported Eastern Cooperative Oncology Group (ECOG) performance status. Associations between receipt of minimally invasive surgery and patient and clinical variables were analyzed with univariate and multivariable logistic regression. All statistical tests were two-sided.

RESULTS

A total of 4032 patients, diagnosed between September 2005 and December 2010, underwent elective colon or rectal resection for cancer at NCCN centers. Median age of colon cancer patients was 62.6 years, and 49% were men. The percent of colon cancer patients treated with minimally invasive surgery (MIS) increased from 35% in 2006 to 51% in 2010 across all centers but varied statistically significantly between centers. On multivariable analysis, factors associated with minimally invasive surgery for colon cancer patients who had surgery at an NCCN institution were older age (P = .02), male sex (P = .006), fewer comorbidities (P ≤ .001), lower final T-stage (P < .001), median household income greater than or equal to $80000 (P < .001), ECOG performance status = 0 (P = .02), and NCCN institution (P ≤ .001).

CONCLUSIONS

The use of MIS increased at NCCN centers. However, there was statistically significant variation in adoption of MIS technique among centers.

A variation in the value of colectomy for cancer across hospitals: mortality, readmissions, and costs

INTRODUCTION

Although hospital variation in costs and outcomes has been described for patients undergoing operation, the relationship between them is unknown. The purpose of this study was to evaluate this relationship among patients undergoing colon resection for cancer and identify characteristics of "high-quality, low-cost" hospitals.

METHODS

We identified adult patients who underwent colon resection for cancer in California, Florida, and New York from 2009 to 2010. We estimated hospital-level, risk-standardized 30-day hospital costs, in-hospital mortality rates, and 30-day readmission rates by using hierarchical generalized linear models. Costs were compared between hospitals identified as low, average, and high performers.

RESULTS

The final sample included 14,790 patients discharged from 389 hospitals. After adjusting for case mix, variation was noted in risk-standardized costs (median = $26,169, inter-quartile range [IQR] = $6,559), in-hospital mortality (median = 1.8%, IQR = 2.3%), and 30-day readmission (12.2%, IQR = 0.7%) rates. Minimal correlation was noted between a hospital's costs and outcomes, with similar costs noted across hospital performance groups (low = $25,994 vs average = $26,998 vs high = $25,794, P = .19). High-quality, low-cost hospitals treated a greater percentage of Medicare beneficiaries, approached fewer cases laparoscopically, and trended toward greater volume.

CONCLUSION

Hospital costs are not correlated with outcomes in this population. More work is needed to identify means of providing high-quality care at lesser costs.

Laparoscopic colectomy is associated with a lower incidence of postoperative complications than open colectomy: a propensity score-matched cohort analysis

AIM

Elective laparoscopic colectomy (LC) has been shown to provide short-term results comparable with open colectomy (OC), but there is potential selection bias whereby LC patients may be healthier and therefore more likely to have a superior outcome. The aim of this study was to compare the incidence of postoperative complications between matched laparoscopic and open colectomy cohorts, while controlling for differences in comorbidity.

METHOD

A retrospective cohort study (2005-2010) using National Surgical Quality Improvement Program data was performed, identifying laparoscopic and open partial colectomy patients through common procedural terminology codes. Patient having rectal resection were excluded. The cohorts were matched 1:1 on a propensity score to control for observable selection bias due to patient characteristics, comparing overall complication rates, length of hospital stay (LOS), the incidence of superficial (S-SSI) surgical site infection, urinary tract infection (UTI) and deep-venous thrombosis (DVT).

RESULTS

We analysed 37 249 patients. After propensity score matching the LC group had a significantly lower overall incidence of postoperative complications (29.1 vs 21.2%; P < 0.0001), S-SSI (9.0 vs 5.9%; P = 0.003) and DVT (1.2 vs 0.3%; P = 0.001). The LC group had a shorter LOS (8.7 vs 6.4 days; P < 0.0001), while mortality was comparable between the two groups (4.0 vs 4.1%; P = 0.578).

CONCLUSION

LC is associated with a lower incidence of S-SSI and DVT than OC. Previously suggested advantages for laparoscopy, such as shorter length of stay and overall rate of complications, were observed even after controlling for differences in comorbidity.

Uptake and patient outcomes of laparoscopic colon and rectal cancer surgery in a publicly funded system and following financial incentives

PURPOSE

To assess patterns of uptake and outcomes of laparoscopic colon and rectal cancer surgery in Ontario, and the potential influence of surgical fee incentives instituted on October 1, 2005.

METHODS

We used Ontario administrative databases from fiscal years 2002 to 2009. Study outcomes were uptake rates of laparoscopic surgery, hospital length of stay, 30-day operative mortality, cancer-specific survival, and overall survival. The main descriptor for multivariable regression models was a 5% increase in rate of laparoscopic colon cancer surgery in the previous year.

RESULTS

The annual rate of laparoscopic colon and rectal cancer surgery, respectively, rose from 8.7 to 38.9% and from 4.8 to 19.6%. The greatest increase in rate of laparoscopic colon surgery occurred shortly after October 1, 2005. For each 5% increase in rate of laparoscopic surgery, the odds of 30-day mortality was 1.0 [95% confidence interval (CI) 0.96-1.01, p = 0.264], the hazard of cancer-specific survival was 1.0 (95% CI 0.97-1.00, p = 0.139), the hazard of overall survival was 1.0 (95% CI 0.98-1.00, p = 0.051), and length of hospital stay was lower (estimate = -0.10, 95% CI -0.14 to -0.06, p < 0.001).

CONCLUSIONS

In Ontario by the year 2009, 39% of colon and 20% of rectal cancer surgery was provided laparoscopically. Increased rates were associated with a minimal decrease in hospital length of stay and no changes in 30-day mortality, cancer-specific survival, or overall survival. Financial incentives were likely responsible for the marked increase in laparoscopic colon cancer surgery observed after October 1, 2005.