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Muslim Z, Stroever S, Poulikidis K, Connery CP, Nitzkorski JR, Bhora FY. Impact of facility type and volume in locally advanced esophageal cancer. Asian Cardiovasc Thorac Ann 2024; 32:19-26. [PMID: 37994000 DOI: 10.1177/02184923231215539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND We hypothesized that academic facilities and high-volume facilities would be independently associated with improved survival and a greater propensity for performing surgery in locally advanced esophageal cancer. METHODS We identified patients diagnosed with stage IB-III esophageal cancer during 2004-2016 from the National Cancer Database. Facility type was categorized as academic or community, and facility volume was based on the number of times a facility's unique identification code appeared in the dataset. Each facility type was dichotomized into high- and low-volume subgroups using the cutoff of 20 esophageal cancers treated/year. We fitted multivariable regression models in order to assess differences in surgery selection and survival between facilities according to type and volume. RESULTS Compared to patients treated at high-volume community hospitals, those at high-volume academic facilities were more likely to undergo surgery (odds ratio: 1.865, p < 0.001) and were associated with lower odds of death (odds ratio: 0.784, p = 0.004). For both academic and community hospitals, patients at high-volume facilities were more likely to undergo surgery compared to those at low-volume facilities, p < 0.05. For patients treated at academic facilities, high-volume facilities were associated with lower odds of death (odds ratio: 0.858, p = 0.02) compared to low-volume facilities, while there was no significant difference in the odds of death between high- and low-volume community hospitals (odds ratio: 1.018, p = 0.87). CONCLUSIONS Both facility type and case volume impact surgery selection and survival in locally advanced esophageal cancer. Compared to community hospitals, academic facilities were more likely to perform surgery and were associated with improved survival.
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Affiliation(s)
- Zaid Muslim
- Division of Thoracic Surgery, Rudy L. Ruggles Biomedical Research Institute, Danbury, CT, USA
| | | | | | - Cliff P Connery
- Division of Thoracic Surgery, Nuvance Health, Poughkeepsie, NY, USA
| | | | - Faiz Y Bhora
- Division of Thoracic Surgery, Rudy L. Ruggles Biomedical Research Institute, Danbury, CT, USA
- Division of Thoracic Surgery, Nuvance Health, Danbury, CT, USA
- Division of Thoracic Surgery, Nuvance Health, Poughkeepsie, NY, USA
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Alvarado CE, Worrell SG, Sarode AL, Bassiri A, Jiang B, Linden PA, Towe CW. Disparities and access to thoracic surgeons among esophagectomy patients in the United States. Dis Esophagus 2023; 36:doad025. [PMID: 37163475 DOI: 10.1093/dote/doad025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/27/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
Esophagectomy is a complex operation with significant morbidity and mortality. Previous studies have shown that sub-specialization is associated with improved esophagectomy outcomes. We hypothesized that disparities would exist among esophagectomy patients regarding access to thoracic surgeons based on demographic, geographic, and hospital factors. The Premier Healthcare Database was used to identify adult inpatients receiving esophagectomy for esophageal and gastric cardia cancer, Barrett's esophagus, and achalasia from 2015 to 2019 using ICD-10 codes. Patients were categorized as receiving their esophagectomy from a thoracic versus non-thoracic provider. Survey methodology was used to correct for sampling error. Backwards selection from bivariable analysis was used in a survey-weighted multivariable logistic regression to determine predictors of esophagectomy provider specialization. During the study period, 960 patients met inclusion criteria representing an estimated population size of 3894 patients. Among them, 1696 (43.5%) were performed by a thoracic surgeon and 2199 (56.5%) were performed by non-thoracic providers. On multivariable analysis, factors associated with decreased likelihood of receiving care from a thoracic provider included Black (OR 0.41, p < 0.001), Other (OR 0.21, p < 0.001), and Unknown race (OR 0.22, p = 0.04), and uninsured patients (OR 0.53, p = 0.03). Urban hospital setting was associated with an increased likelihood of care by a thoracic provider (OR 4.43, p = 0.001). In this nationally representative study, Nonwhite race, rural hospital setting, and lower socioeconomic status were factors associated with decreased likelihood of esophagectomy patients receiving care from a thoracic surgeon. Efforts to address these disparities and provide appropriate access to thoracic surgeons is warranted.
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Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Anuja L Sarode
- UH-RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Morse RT, Mouw TJ, Moreno M, Erwin JT, Cao Y, DiPasco P, Al-Kasspooles M, Hoover A. Neoadjuvant Radiotherapy Facility Type Affects Anastomotic Complications After Esophagectomy. J Gastrointest Surg 2023; 27:1313-1320. [PMID: 36973500 DOI: 10.1007/s11605-023-05660-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/28/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Esophagectomy is a complex oncologic surgery that results in lower perioperative morbidity and mortality when performed in high-volume hospitals by experienced surgeons; however, limited data exists evaluating the importance of neoadjuvant radiotherapy delivery at high- versus low-volume centers. We sought to compare postoperative toxicity among patients treated with preoperative radiotherapy delivered at an academic medical center (AMC) versus community medical centers (CMC). METHODS Consecutive patients undergoing esophagectomy for locally advanced esophageal or gastroesophageal junction (GEJ) cancer at an academic medical center between 2008 and 2018 were reviewed. Associations between patient factors and treatment-related toxicities were calculated in univariate (UVA) and multivariable analyses (MVA). RESULTS One hundred forty-seven consecutive patients were identified: 89 CMC and 58 AMC. Median follow-up was 30 months (0.33-124 months). Most patients were male (86%) with adenocarcinoma (90%) located in the distal esophagus or GEJ (95%). Median radiation dose was 50.4 Gy between groups. Radiotherapy at CMCs resulted in higher rates of re-operation after esophagectomy (18% vs 7%, p = 0.055) and increased rates of anastomotic leak (38% vs 17%, p < 0.01). On MVA, radiation at a CMC remained predictive of anastomotic leak (OR 6.13, p < 0.01). CONCLUSION Esophageal cancer patients receiving preoperative radiotherapy had higher rates of anastomotic leaks when radiotherapy was completed at a community medical center versus academic medical center. Explanations for these differences are uncertain but further exploratory analyses regarding dosimetry and radiation field size are warranted.
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Affiliation(s)
- Ryan T Morse
- Department of Radiation Oncology, University of North Carolina Chapel Hill, 101 Manning Drive, Chapel Hill, NC, 27514, USA.
| | - Tyler J Mouw
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Matthew Moreno
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, USA
| | - Jace T Erwin
- University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Ying Cao
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, USA
| | - Peter DiPasco
- Department of Surgery, University of Kansas Medical Center, Kansas City, USA
| | - Mazin Al-Kasspooles
- Department of Surgery, University of Kansas Medical Center, Kansas City, USA
| | - Andrew Hoover
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, USA
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Roman KM, Torabi SJ, Bitner BF, Goshtasbi K, Haidar YM, Tjoa T, Kuan EC. The Impact of Facility Type and Volume on Outcomes in Head and Neck Mucosal Melanoma. Otolaryngol Head Neck Surg 2023; 168:1079-1088. [PMID: 36939581 DOI: 10.1002/ohn.173] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/11/2022] [Accepted: 09/15/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate differences in treatment outcomes for head and neck mucosal melanoma (HNMM) patients seen at academic versus nonacademic centers and high versus low volume facilities. STUDY DESIGN Retrospective cohort study. SETTING National Cancer Database. METHODS Differences in treatment course and overall survival (OS) by facility type and volume were assessed for 2772 HNMM cases reported by the 2004 to 2017 National Cancer Database. A subgroup analysis was performed with a smaller cohort containing staging data. The analysis employed Kaplan-Meier and Cox proportional hazards models. RESULTS A higher proportion of patients treated at academic centers within the HNMM cohort waited longer for surgery after diagnosis (p < .001), had negative surgical margins (p < .001), and were readmitted to the hospital within 30 days of surgery (p = .001); these relationships remained significant when controlling for cancer stage. Kaplan-Meier analysis demonstrated higher 5-year OS for patients treated at academic versus nonacademic facilities within the main cohort (32.5% ± 1.3% vs 27.3% ± 1.5%; p = .006) and within the stage-controlled subgroup (34.8% ± 2.1% vs 27.2% ± 2.6%; p = .003). Treatment at high volume versus low volume facilities was associated with improved 5-year OS for main cohort patients (33.5% ± 1.7% vs 28.8% ± 1.2%; p = .016) but not for subgroup patients (35.3% ± 2.7% vs 30.1% ± 2.1%; p = .100). Upon multivariate analysis controlling for demographic and oncologic factors, there was no significant difference in OS by facility type (main cohort: odds ratio [OR] = 1.07, 95% confidence interval [CI] = 1.01-1.21; subgroup: OR = 1.13, 95% CI = 0.97-1.32). CONCLUSION Neither facility type nor surgical volume predicts overall survival in HNMM.
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Affiliation(s)
- Kelsey M Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Benjamin F Bitner
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Tjoson Tjoa
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California, USA
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Ladekarl M, Rasmussen LS, Kirkegård J, Chen I, Pfeiffer P, Weber B, Skuladottir H, Østerlind K, Larsen JS, Mortensen FV, Engberg H, Møller H, Fristrup CW. Disparity in use of modern combination chemotherapy associated with facility type influences survival of 2655 patients with advanced pancreatic cancer. Acta Oncol 2022; 61:277-285. [PMID: 34879787 DOI: 10.1080/0284186x.2021.2012252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM Academic and high volume hospitals have better outcome for pancreatic cancer (PC) surgery, but there are no reports on oncological treatment. We aimed to determine the influence of facility types on overall survival (OS) after treatment with chemotherapy for inoperable PC. MATERIAL AND METHODS 2,657 patients were treated in Denmark from 2012 to 2018 and registered in the Danish Pancreatic Cancer Database. Facilities were classified as either secondary oncological units or comprehensive, tertiary referral cancer centers. RESULTS The average yearly number of patients seen at the four tertiary facilities was 71, and 31 at the four secondary facilities. Patients at secondary facilities were older, more frequently had severe comorbidity and lived in non-urban municipalities. As compared to combination chemotherapy, monotherapy with gemcitabine was used more often (59%) in secondary facilities than in tertiary (34%). The unadjusted median OS was 7.7 months at tertiary and 6.1 months at secondary facilities. The adjusted hazard ratio (HR) of 1.16 (confidence interval 1.07-1.27) demonstrated an excess risk of death for patients treated at secondary facilities, which disappeared when taking type of chemotherapy used into account. Hence, more use of combination chemotherapy was associated with the observed improved OS of patients treated at tertiary facilities. Declining HR's per year of first treatment indicated improved outcomes with time, however the difference among facility types remained significant. DISCUSSION Equal access to modern combination chemotherapy at all facilities on a national level is essential to ensure equality in treatment results.
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Affiliation(s)
- Morten Ladekarl
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Louise Skau Rasmussen
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Jakob Kirkegård
- Department of Gastrointestinal Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Inna Chen
- Department of Oncology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Britta Weber
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Kell Østerlind
- Department of Oncology, North Zealand Hospital, Hillerød, Denmark
| | - Jim Stenfatt Larsen
- Department of Oncology, Zealand University Hospital, Naestved and Roskilde, Denmark
| | | | - Henriette Engberg
- The Danish Clinical Quality Program and Clinical Registries (RKKP), Aalborg, Denmark
| | - Henrik Møller
- The Danish Clinical Quality Program and Clinical Registries (RKKP), Aalborg, Denmark
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Claus Wilki Fristrup
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Danish Pancreatic Cancer Database (DPCD), Denmark
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Coffey MR, Bachman KC, Worrell SG, Argote-Greene LM, Linden PA, Towe CW. Concurrent diagnosis of anxiety increases postoperative length of stay among patients receiving esophagectomy for esophageal cancer. Psychooncology 2021; 30:1514-1524. [PMID: 33870580 DOI: 10.1002/pon.5707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Psychiatric comorbidities disproportionately affect patients with cancer. While identified risk factors for prolonged length of stay (LOS) after esophagectomy are primarily medical comorbidities, the impact of psychiatric comorbidities on perioperative outcomes is unclear. We hypothesized that psychiatric comorbidities would prolong LOS in patients with esophageal cancer. METHODS The 2016 National Inpatient Sample (NIS) was used to identify patients with esophageal cancer receiving esophagectomy. Concurrent psychiatric illness was categorized using Clinical Classifications Software Refined for ICD-10, creating 34 psychiatric diagnosis groups (PDGs). Only PDGs with >1% prevalence in the cohort were included in the analysis. The outcome of interest was hospital LOS. Bivariable testing was performed to determine the association of PDGs and demographic factors on LOS using rank sum test. Multivariable regression analysis was performed using backward selection from bivariable testing (α ≤ 0.05). RESULTS We identified 1,730 patients who underwent esophagectomy for esophageal cancer in the 2016 NIS. The median LOS was 8 days (IQR 5-12). In bivariable testing, a concurrent diagnosis of anxiety was the only PDG associated with LOS (9 days (IQR 6-14) with anxiety diagnosis versus 8 days (IQR 5-12) with no anxiety diagnosis, p = 0.022). Multivariable modeling showed an independent association between anxiety diagnosis and increased LOS (OR 4.82 (1.25-25.23), p = 0.022). Anxiety was not associated with increased hospital cost or in-hospital mortality. CONCLUSIONS This analysis demonstrates an independent effect of anxiety prolonging postoperative LOS after esophagectomy in the United States. These findings may influence perioperative care, patient expectations, and resource allocation.
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Affiliation(s)
- Max R Coffey
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katelynn C Bachman
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Stephanie G Worrell
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Luis M Argote-Greene
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Philip A Linden
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Christopher W Towe
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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