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Wright FC, Milkovich J, Hunter A, Darling G, Irish J. Refining the thoracic surgical oncology regionalization standards for esophageal surgery in Ontario, Canada: Moving from good to better. J Thorac Cardiovasc Surg 2023; 166:1502-1509. [PMID: 37005118 DOI: 10.1016/j.jtcvs.2023.03.002] [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: 12/14/2022] [Revised: 02/10/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND The consolidation of surgical practices has been suggested to improve patient outcomes for complex surgeries. In 2005, Ontario Health-Cancer Care Ontario released the Thoracic Surgical Oncology Standards to facilitate the regionalization process at thoracic centers in Ontario, Canada. This work describes the quality-improvement process involved in updating the minimum surgical volume and supporting requirement recommendations for thoracic centers to further optimize patient care for esophageal cancer. METHODS We conducted a literature review to identify and synthesize evidence informing the volume-outcome relationship related to esophagectomy. The results of this review and esophageal cancer surgery common indicators (reoperation rate, unplanned visit rate, 30-day and 90-day mortality) from Ontario's Surgical Quality Indicator Report were presented and reviewed by a Thoracic Esophageal Standards Expert Panel and Surgical Oncology Program Leads at Ontario Health-Cancer Care Ontario. Hospital outliers were identified, and a subgroup analysis was conducted to determine the most appropriate minimum surgical volume threshold based on 30- and 90-day mortality rates data from the last 3 fiscal years. RESULTS Based on the finding that a significant decrease in mortality occurred at 12 to 15 esophagectomies per year, the Thoracic Esophageal Standards Expert Panel reached a consensus that thoracic centers should perform a minimum of 15 esophagectomies per year. The panel also recommended that any center performing esophagectomies have at least 3 thoracic surgeons to ensure continuity in clinical care. CONCLUSIONS We have described the process involved in updating the provincial minimum volume threshold and the appropriate support services for esophageal cancer surgery in Ontario.
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Affiliation(s)
- Frances C Wright
- Surgical Oncology Program, Ontario Health-Cancer Care Ontario, Toronto, Ontario, Canada; Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
| | - John Milkovich
- Surgical Oncology Program, Ontario Health-Cancer Care Ontario, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Amber Hunter
- Surgical Oncology Program, Ontario Health-Cancer Care Ontario, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Gail Darling
- Surgical Oncology Program, Ontario Health-Cancer Care Ontario, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery/Surgical Oncology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jonathan Irish
- Surgical Oncology Program, Ontario Health-Cancer Care Ontario, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
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Papneja S, Potter AL, Yang CFJ. Commentary: Refining regionalization standards for esophagectomy: Paving the way to improving esophageal cancer care in Canada and beyond. J Thorac Cardiovasc Surg 2023; 166:1510-1511. [PMID: 37330204 DOI: 10.1016/j.jtcvs.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Shreya Papneja
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alexandra L Potter
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Chi-Fu Jeffrey Yang
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
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Abdul SA, Wright F, Finley C, Gilbert S, Seely AJE, Sundaresan S, Villeneuve PJ, Maziak DE. A 20-Year Update on the Practice of Thoracic Surgery in Canada: A Survey of the Canadian Association of Thoracic Surgeons. J Chest Surg 2023; 56:420-430. [PMID: 37817431 PMCID: PMC10625961 DOI: 10.5090/jcs.23.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/21/2023] [Indexed: 10/12/2023] Open
Abstract
Background This study provides an update to a landmark 2004 report describing demographics, training, and trends in adherence to thoracic surgery practice standards in Canada. Methods An updated questionnaire was administered to all members of the Canadian Association of Thoracic Surgeons via email (n=142, compared to n=68 in 2004). Our report incorporates internal data from Ontario Health and the Canadian Partnership Against Cancer. Results Forty-eight surgeons completed the survey (male, 70.8%; mean±standard deviation age, 50.3±9.3 years). This represents a 33.8% response rate, compared to 64.7% in 2004. Most surgeons (69%) served a patient population of over 1 million per center; 32%-34% reported an on-call ratio of 1:4-1:5 days, and the average weekly hours worked was 56.4±11.9. Greater access to dedicated geographic units per center (73% in 2021 vs. 53% in 2004) has improved thoracic-associated services and house staff, notably endoscopy units (100% vs. 91%), with 73% of respondents having access to both endobronchial and endoscopic ultrasound. Access to thoracic radiology has also improved, particularly regarding positron emission tomography scanners per center (76.9% vs. 13%). Annual case volumes for lung (255 vs. 128), esophageal (41 vs. 19), and mediastinal resections (30 vs. 13), along with hiatal hernia repair (45 vs. 20), have increased substantially despite reports of operating room availability and radiology as rate-limiting steps. Conclusion This survey characterizes compliance with current practice standards, addressing the needs of thoracic surgeons across Canada. Over 85% of respondents were aware of the 2004 compliance paper, and 35% had applied for resources and equipment in response.
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Affiliation(s)
- Sami Aftab Abdul
- Division of Thoracic Surgery, The Ottawa Hospital General Campus, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Frances Wright
- Department of Surgery, Faculty of Medicine, University of Toronto, Canada
- Ontario Health (Cancer Care Ontario), Toronto, ON, Canada
| | - Christian Finley
- Department of Surgery, Faculty of Medicine, McMaster University, Hamilton, ON, Canada
- Canadian Partnership Against Cancer (CPAC), Toronto, ON, Canada
- Canadian Association of Thoracic Surgeons (CATS), Ottawa, ON, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, The Ottawa Hospital General Campus, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Canadian Association of Thoracic Surgeons (CATS), Ottawa, ON, Canada
| | - Andrew J. E. Seely
- Division of Thoracic Surgery, The Ottawa Hospital General Campus, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Canadian Association of Thoracic Surgeons (CATS), Ottawa, ON, Canada
| | - Sudhir Sundaresan
- Division of Thoracic Surgery, The Ottawa Hospital General Campus, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Canadian Association of Thoracic Surgeons (CATS), Ottawa, ON, Canada
| | - Patrick J. Villeneuve
- Division of Thoracic Surgery, The Ottawa Hospital General Campus, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Canadian Association of Thoracic Surgeons (CATS), Ottawa, ON, Canada
| | - Donna Elizabeth Maziak
- Division of Thoracic Surgery, The Ottawa Hospital General Campus, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ontario Health (Cancer Care Ontario), Toronto, ON, Canada
- Canadian Association of Thoracic Surgeons (CATS), Ottawa, ON, Canada
- Telfer School of Management, University of Ottawa, Ottawa, ON, Canada
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Hanna NM, Nguyen P, Chung W, Groome PA. Time to treatment of esophageal cancer in Ontario: A population-level cross-sectional study. JTCVS OPEN 2022; 12:430-449. [PMID: 36590728 PMCID: PMC9801289 DOI: 10.1016/j.xjon.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/07/2022] [Accepted: 07/26/2022] [Indexed: 01/04/2023]
Abstract
Objective Timely cancer treatment improves survival and anxiety for some sites. Patients with esophageal cancer require specific workup before treatment, which can prolong the time from diagnosis to treatment (treatment interval [TI]). The geographical variation of this interval remains uninvestigated in patients with esophageal cancer. Methods This retrospective population-level study conducted in Ontario used linked administrative health care databases. Patients treated for esophageal cancer between 2013 and 2018 were included. The TI was time from diagnosis to treatment. Patients were assigned a geographical Local Health Integration Network on the basis of postal code. Covariates included patient, disease, and diagnosing physician characteristics. Quantile regression modeled TI length at the 50th and 90th percentile and identified associated factors. Results Of 7509 patients, 78% were male and most were aged between 60 and 69 years. The 50th and 90th percentile TI was 36 (interquartile range, 22-55) and 77 days, respectively. The difference between the Local Health Integration Network with the longest and shortest TI at the 50th and 90th percentile was 18 and 25 days, respectively. Older age (P < .0001), greater comorbidity (P = .0005), greater material deprivation (P = .001), rurality (P = .03), histology (P = .02), and treatment group (P < .0001) were associated with a longer median TI. Older age (P = .03), greater comorbidity (P = .003), greater material deprivation (P = .005), rurality (P = .04), and treatment group (P < .0001) were associated with a longer 90th percentile TI. Conclusions Geographic variability of time to treatment exists across Ontario. Investigation of facility-level differences is warranted. Patient and disease factors are associated with longer wait times. These results might inform future health care policy and resource allocation.
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Key Words
- AC, adenocarcinoma
- ADG, Aggregated Diagnosis Group
- CIHI, Canadian Institute for Health Information
- ED, Emergency Department
- ICES, Institute for Clinical Evaluative Sciences
- IQR, interquartile range
- LHIN, Local Health Integration Network
- NACRS, National Ambulatory Care Reporting System
- OCR, Ontario Cancer Registry
- PCCF, Postal Code Conversion File
- SCC, squamous cell carcinoma
- TI, treatment interval
- epidemiology
- esophageal cancer
- geographical variability
- treatment interval
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Affiliation(s)
- Nader M. Hanna
- Division of General Surgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada,Address for reprints: Nader M. Hanna, MBBS, MSc, Department of Surgery, Kingston General Hospital, 76 Stuart St, Kingston, Ontario K7L 2V7, Canada.
| | - Paul Nguyen
- ICES, Queen's, Queen's University, Kingston, Ontario, Canada
| | - Wiley Chung
- Division of Thoracic Surgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Patti A. Groome
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada,ICES, Queen's, Queen's University, Kingston, Ontario, Canada,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
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Hanna NM, Nguyen P, Chung W, Groome PA. Time to Surgery for Patients with Esophageal Cancer Undergoing Trimodal Therapy in Ontario: A Population-Based Cross-Sectional Study. Curr Oncol 2022; 29:5901-5918. [PMID: 36005204 PMCID: PMC9406364 DOI: 10.3390/curroncol29080466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/14/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
Patients with resectable esophageal cancer are recommended to undergo chemoradiotherapy before esophagectomy. A longer time to surgery (TTS) and/or time to consultation (TTC) may be associated with inferior cancer-related outcomes and heightened anxiety. Thoracic cancer surgery centers (TCSCs) oversee esophageal cancer management, but differences in TTC/TTS between centers have not yet been examined. This Ontario population-level study used linked administrative healthcare databases to investigate patients with esophageal cancer between 2013–2018, who underwent neoadjuvant chemoradiotherapy and then surgery. TTC and TTS were time from diagnosis to the first surgical consultation and then to surgery, respectively. Patients were assigned a TCSC based on the location of the surgery. Patient, disease, and diagnosing physician characteristics were investigated. Quantile regression was used to model TTS/TTC at the 50th and 90th percentiles and identify associated factors. The median TTS and TTC were 130 and 29 days, respectively. The adjusted differences between the TCSCs with the longest and shortest median TTS and TTC were 32 and 18 days, respectively. Increasing age was associated with a 16-day longer median TTS. Increasing material deprivation was associated with a 6-day longer median TTC. Significant geographic variability exists in TTS and TTC. Therefore, the investigation of TCSC characteristics is warranted. Shortening wait times may reduce patient anxiety and improve the control of esophageal cancer.
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Affiliation(s)
- Nader M. Hanna
- Department of Surgery, Division of General Surgery, Queen’s University, 76 Stuart Street, Kingston, ON K7L 2V7, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 2V7, Canada
- Correspondence:
| | - Paul Nguyen
- ICES Queen’s, Queen’s University, Kingston, ON K7L 2V7, Canada
| | - Wiley Chung
- Department of Surgery, Division of Thoracic Surgery, Queen’s University, Kingston, ON K7L 2V7, Canada
| | - Patti A. Groome
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 2V7, Canada
- ICES Queen’s, Queen’s University, Kingston, ON K7L 2V7, Canada
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, ON K7L 2V7, Canada
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Shargall Y, Brunelli A, Murthy S, Schneider L, Minervini F, Bertolaccini L, Agzarian J, Linkins LA, Kestenholz P, Li H, Rocco G, Girard P, Venuta F, Samama M, Scarci M, Anraku M, Falcoz PE, Kirk A, Solli P, Hofstetter W, Okumura M, Douketis J, Litle V. Venous thromboembolism prophylaxis in thoracic surgery patients: an international survey. Eur J Cardiothorac Surg 2021; 57:331-337. [PMID: 31363740 DOI: 10.1093/ejcts/ezz191] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/22/2019] [Accepted: 05/30/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Venous thromboembolic events (VTE) after thoracic surgery (TS) can be prevented with mechanical and chemical prophylaxis. Unlike other surgical specialties, TS lacks evidence-based guidelines. In the process of developing these guidelines, an understanding of the current prophylaxis methods practiced internationally is necessary and is described in this article. METHODS A 26-item survey was distributed to members of the European Society of Thoracic Surgeons (ESTS), American Association of Thoracic Surgery (AATS), Japanese Association for Chest Surgery (JACS) and Chinese Society for Thoracic and Cardiovascular Surgery (CSTCS) electronically or in person. Participants were asked to report their current prophylaxis selection, timing of initiation and duration of prophylaxis, perceived risk factors and the presence and adherence to institutional VTE guidelines for patients undergoing TS for malignancies. RESULTS In total, 1613 surgeons anonymously completed the survey with an overall 36% response rate. Respondents were senior surgeons working in large academic hospitals (≥70%, respectively). More than 83.5% of ESTS, AATS and JACS respondents report formal TS thromboprophylaxis protocols in their institutions, but 53% of CSTCS members report not having such a protocol. The regions varied in the approaches utilized for VTE prophylaxis, the timing of initiation perioperatively and the use and type of extended prophylaxis. Respondents reported that multiple risk factors and sources of information impact their VTE prophylaxis decision-making processes, and these factors vastly diverge regionally. CONCLUSIONS There is little agreement internationally on the optimal approach to thromboprophylaxis in the TS population, and guidelines will be helpful and vastly welcomed.
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Affiliation(s)
- Yaron Shargall
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Laura Schneider
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Kantonsspital Luzern, Lucerne, Switzerland
| | | | - John Agzarian
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Lori-Ann Linkins
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Peter Kestenholz
- Department of Thoracic Surgery, Kantonsspital Luzern, Lucerne, Switzerland
| | - Hui Li
- Department of Thoracic Surgery, Capital Medical University, Beijing, China
| | - Gaetano Rocco
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Girard
- Thoracic Department, Institut Mutualiste Montsouris, Paris, France
| | - Federico Venuta
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc Samama
- Department of Anaesthesia and Intensive Care Medicine, Cochin and Hôtel-Dieu University Hospitals, Paris, France
| | - Marco Scarci
- Department of Thoracic Surgery, San Gerardo Hospital, Monza, Italy
| | - Masaki Anraku
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | | | - Alan Kirk
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | | | - Wayne Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Meinoshin Okumura
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Virginia Litle
- Department of Surgery, Boston University School of Medicine, Boston, MA, USA
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Ely S, Jiang SF, Dominguez DA, Patel AR, Ashiku SK, Velotta JB. Effect of thoracic surgery regionalization on long-term survival after lung cancer resection. J Thorac Cardiovasc Surg 2021; 163:769-777. [PMID: 33934900 DOI: 10.1016/j.jtcvs.2021.03.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Existing evidence demonstrates some benefit of regionalization on early postoperative outcomes following lung cancer resection, but data regarding the persistence of this effect in long-term mortality are lacking. We investigated whether previously reported improvements in short-term outcomes translated to long-term survival benefit. METHODS We retrospectively reviewed patients undergoing major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) for cancer within our integrated health care system before (2011-2013; n = 782) and after (2015-2017; n = 845) thoracic surgery regionalization. Overall survival was compared by Kaplan-Meier analysis, and 1- and 3-year mortality was compared by the by χ2 or Fisher exact test. Multivariable Cox regression models evaluated the effect of regionalization on mortality adjusted for relevant factors. RESULTS Kaplan-Meier curves showed that overall survival was better among patients undergoing surgery postregionalization (log-rank test, P < .0001). Both 1- and 3-year mortality were decreased after regionalization: to 5.7% from 11.1% (P < .0001) for 1 year and to 17.0% from 25.5% (P = .0002) for 3 years. The multivariable adjusted Cox regression analysis revealed that only regionalization (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.42-0.76), age (HR, 1.03; 95% CI, 1.02-1.04), cancer stage (HR, 1.72, 1.83, and 2.56 for stages II, III, and IV, respectively), and Charlson comorbidity index (HR, 1.80 for 1-2; 2.05 for ≥3) were independent predictors of mortality. CONCLUSIONS We found that overall mortality as well as 1- and 3-year mortality for lung cancer resection were lower after thoracic surgery regionalization. The association between regionalization and reduced mortality was significant even after adjusting for other related factors in a multivariable Cox analysis. Notably, surgeon volume, facility volume, surgeon specialty, neoadjuvant treatment, and video-assisted thoracoscopic surgery approach did not significantly affect mortality in the adjusted model.
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Affiliation(s)
- Sora Ely
- Department of Surgery, UCSF East Bay, Highland Hospital, Oakland, Calif; Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif.
| | - Sheng-Fang Jiang
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| | - Dana A Dominguez
- Department of Surgery, UCSF East Bay, Highland Hospital, Oakland, Calif; Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif
| | - Ashish R Patel
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif
| | - Simon K Ashiku
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif
| | - Jeffrey B Velotta
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif
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Nason GJ, Wood LA, Huddart RA, Albers P, Rendon RA, Einhorn LH, Nichols CR, Kollmannsberger C, Anson-Cartwright L, Sweet J, Warde P, Jewett MA, Chung P, Bedard PL, Hansen AR, Hamilton RJ. A Canadian approach to the regionalization of testis cancer: A review. Can Urol Assoc J 2020; 14:346-351. [PMID: 32432537 PMCID: PMC7716843 DOI: 10.5489/cuaj.6268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
At the Canadian Testis Cancer Workshop, the rationale and feasibility of regionalization of testis cancer care were discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents and fellows, and nurses, as well as patients and patient advocacy groups.This review summarizes the discussion and recommendations of one of the central topics of the workshop - the centralization of testis cancer in Canada. It was acknowledged that non-guideline-concordant care in testis cancer occurs frequently, in the range of 18-30%. The National Health Service in the U.K. stipulates various testis cancer care modalities be delivered through supra-regional network. All cases are reviewed at a multidisciplinary team meeting and aspects of care can be delivered locally through the network. In Germany, no such network exists, but an insurance-supported online second opinion network was developed that currently achieves expert case review in over 30% of cases. There are clear benefits to regionalization in terms of survival, treatment morbidity, and cost. There was agreement at the workshop that a structured pathway for diagnosis and treatment of testis cancer patients is required.Regionalization may be challenging in Canada because of geography; independent administration of healthcare by each province; physicians fearing loss of autonomy and revenue; patient unwillingness to travel long distances from home; and the inability of the larger centers to handle the ensuing increase in volume. We feel the first step is to identify the key performance indicators and quality metrics to track the quality of care received. After identifying these metrics, implementation of a "networks of excellence" model, similar to that seen in sarcoma care in Ontario, could be effective, coupled with increased use of health technology, such as virtual clinics and telemedicine.
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Affiliation(s)
- Gregory J. Nason
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Lori A. Wood
- Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Robert A. Huddart
- The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Peter Albers
- Department of Urology, Heinrich-Heine University, Medical Faculty, Düsseldorf, Germany
| | | | - Lawrence H. Einhorn
- Department of Oncology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Craig R. Nichols
- Testicular Cancer Multidisciplinary Clinic, Virginia Mason Medical Center, Seattle, WA, United States
| | - Christian Kollmannsberger
- British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, BC, Canada
| | - Lynn Anson-Cartwright
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Joan Sweet
- Department of Pathology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Padraig Warde
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
| | - Michael A.S. Jewett
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Peter Chung
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
| | - Philippe L. Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Aaron R. Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Robert J. Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Raphael MJ, Siemens R, Peng Y, Vera-Badillo FE, Booth CM. Volume of systemic cancer therapy delivery and outcomes of patients with solid tumors: A systematic review and methodologic evaluation of the literature. J Cancer Policy 2020. [DOI: 10.1016/j.jcpo.2020.100215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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10
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Trends in survival based on treatment modality for esophageal cancer: a population-based study. Eur J Gastroenterol Hepatol 2019; 31:1192-1199. [PMID: 31464787 DOI: 10.1097/meg.0000000000001498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The primary objective was to examine the trends in treatment modalities and the respective survival rates for esophageal cancer in the province of Ontario, Canada. METHODS This is a population-based study of all esophageal cancer cases diagnosed in Ontario between 2007 and 2015, including squamous cell carcinoma and adenocarcinoma, with known disease stage. Other characteristics include sex, age, date of diagnosis, and treatment modalities. Treatment modalities were classified as no-treatment, radiation only or chemotherapy only, chemoradiation, and surgical resection. RESULTS In total, 2572 patients were identified with esophageal cancer from 2007 to 2015, of which 2014 (78.3%) were male. The mean age at diagnosis was 66.6 (SD = 11.7) years. Survival rate increased over time in patients who underwent chemoradiation or surgical resection but remained unchanged for the radiation-only or chemotherapy-only group and decreased for the no-treatment group. Survival considerably improved (15-20%) for patients with stages I-III disease. CONCLUSIONS The positive trends in the survival rate for esophageal patients could be due to adoption of multimodal therapy. Despite a lower proportion of advanced disease among patients over 80, they received less curative treatments compared with other age groups. Further studies are required to identify strategies to maximize survival for patients with stage IV disease, and patients 80 years and older.
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12
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Kidane B, Jacob B, Gupta V, Peel J, Saskin R, Waddell TK, Darling GE. Medium and long-term emergency department utilization after oesophagectomy: a population-based analysis. Eur J Cardiothorac Surg 2019; 54:683-688. [PMID: 29648637 DOI: 10.1093/ejcts/ezy155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 03/14/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Oesophagectomy is a complex operation with the potential for prolonged recovery. The aim of this study was to evaluate healthcare resource utilization, specifically emergency department (ED) visits within 1 year of oesophagectomy, and to identify risk factors for ED visits and frequent ED use (FEDU). METHODS A retrospective cohort study of consecutive oesophagectomies for cancer in all Ontario hospitals was conducted using linked health data (2000-2012) including the ability to identify ED visits at non-index hospitals. Ontario has a single-payer healthcare system with a population of 13.8-million people. Multivariable regression was used to identify independent factors associated with ED visits and FEDU (≥3 ED visits) within 1 year after oesophagectomy. RESULTS There were 3344 oesophagectomies with in-hospital mortality of 5.8% (n = 193). Of those discharged, 16.4% (n = 549), 36.0% (n = 1203) and 55.8% (n = 1866) had ED visits within 30 days, 90 days and 1 year, respectively. Higher comorbidity [adjusted odds ratio (aOR) = 1.08, 95% confidence interval (CI): 1.05-1.11, P < 0.0001], rurality (aOR = 1.40, 95% CI: 1.10-1.78, P = 0.006) and receipt of chemotherapy and/or radiation therapy (aOR = 2.55, 95% CI: 2.12-3.08, P < 0.0001) were independent risk factors for ED visits within 1 year of oesophagectomy. Thoracoscopic-assisted surgery was independently associated with decreased ED visits (aOR = 0.67, 95% CI: 0.45-0.99, P = 0.049). Eight hundred and thirteen (24.3%) patients had FEDU. Higher comorbidity (aOR = 1.11, 95% CI: 1.08-1.14, P < 0.0001), rurality (aOR = 1.66, 95% CI: 1.31-2.10, P < 0.0001) and receipt of chemotherapy and/or radiation therapy (aOR = 2.38, 95% CI: 1.93-2.93, P < 0.0001) were independent risk factors for FEDU. One health region had more ED visits (P = 0.04) and more FEDU (P = 0.001) when compared with the other regions. There were higher ED visits and FEDU in the later years of the study period (both P < 0.0001). CONCLUSIONS ED visits are common after oesophagectomy with almost 25% of patients having ≥3 visits and >50% having ≥1 visit within 1 year of oesophagectomy. We have identified demographic, surgical and regional risk factors for the potential targeted quality improvement.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, MB, Canada.,Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - Binu Jacob
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Vaibhav Gupta
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - John Peel
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada.,Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada.,Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
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Chang AC. Centralizing Esophagectomy to Improve Outcomes and Enhance Clinical Research: Invited Expert Review. Ann Thorac Surg 2018; 106:916-923. [DOI: 10.1016/j.athoracsur.2018.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/01/2018] [Indexed: 12/19/2022]
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Morche J, Renner D, Pietsch B, Kaiser L, Brönneke J, Gruber S, Matthias K. International comparison of minimum volume standards for hospitals. Health Policy 2018; 122:1165-1176. [PMID: 30193981 DOI: 10.1016/j.healthpol.2018.08.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 08/17/2018] [Accepted: 08/24/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Minimum volume standards have been implemented in various countries for quality or safety policies. We present minimum volume standards in an international comparison, focusing on regulatory approaches, selected sets of procedures and thresholds as well as predetermined consequences of non-compliance. MATERIALS AND METHODS We combined a comprehensive literature search in electronic databases in March 2016 with a hand-search of governmental and related organisations' webpages. We also contacted international experts to verify the information we found in the literature and to obtain additional data. RESULTS Minimum volume standards have been introduced in different countries predominantly for highly specialized surgical procedures. The same evidence has led to different definitions and ways of implementation of minimum volume standards in Germany, Canada (Ontario), the Netherlands, Switzerland, and Austria. The regulatory approaches to minimum volume standards and the predetermined consequences of non-compliance differ across the countries. CONCLUSION The sets of procedures for which minimum volume standards and corresponding thresholds have been introduced vary across countries, possibly due to different regulatory approaches. In addition, key attributes of the health care system might affect the development and implementation of minimum volume standards. Therefore, it is not feasible to formulate uniform recommendations that are applicable to all countries. Our results provide a comprehensive overview of international minimum volume standards and can be used to inform policy decisions.
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Affiliation(s)
- Johannes Morche
- Federal Joint Committee, Medical Consultancy Department, Wegelystraße 8, D-10623, Berlin, Germany.
| | - Daniela Renner
- Federal Joint Committee, Medical Consultancy Department, Germany
| | - Barbara Pietsch
- Federal Joint Committee, Medical Consultancy Department, Germany
| | - Laura Kaiser
- Federal Joint Committee, Medical Consultancy Department, Germany
| | - Jan Brönneke
- Federal Joint Committee Quality, Assurance and Cross-sectoral Healthcare Department, Germany
| | - Sabine Gruber
- Federal Joint Committee, Medical Consultancy Department, Germany
| | - Katja Matthias
- Federal Joint Committee, Medical Consultancy Department, Germany
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Sullivan T, Irish J. Building the Ontario Surgical Oncology Program. Healthc Manage Forum 2017; 31:22-25. [PMID: 29231070 DOI: 10.1177/0840470417729171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
From the 1940s onward the establishment of an increasing number of cancer centres in Ontario concentrated predominantly on radiation and systemic therapy. Increasing attention to the organization of cancer surgery services in Ontario over the last 3 decades through measures led by Cancer Care Ontario has resulted in building a progressive provincial and regional surgical oncology network. These networks are rooted in leadership mobilization and have used quality data and best evidence to promote the elaboration of communities of practice to achieve better outcomes. This article briefly chronicles this journey and points to areas of progress.
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Affiliation(s)
- Terrence Sullivan
- 1 Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Irish
- 1 Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
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Bendzsak AM, Baxter NN, Darling GE, Austin PC, Urbach DR. Regionalization and Outcomes of Lung Cancer Surgery in Ontario, Canada. J Clin Oncol 2017; 35:2772-2780. [DOI: 10.1200/jco.2016.69.8076] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Purpose Regionalization of complex surgery to high-volume hospitals has been advocated based on cross-sectional volume-outcome studies. In April 2007, the agency overseeing cancer care in Ontario, Canada, implemented a policy to regionalize lung cancer surgery at 14 designated hospitals, enforced by economic incentives and penalties. We studied the effects of implementation of this policy. Methods Using administrative health data, we used interrupted time series models to analyze the immediate and delayed effects of implementation of the policy on the distribution of lung cancer surgery among hospitals, surgical outcomes, and health services use. Results From 2004 to 2012, 16,641 patients underwent surgery for lung cancer. The proportion of operations performed in designated hospitals increased from 71% to 89% after the policy was implemented. Although operative mortality decreased from 4.1% to 2.9% (adjusted odds ratio, 0.68; 95% CI, 0.58 to 0.81; P < .001), the reduction was due to a preexisting declining trend in mortality. In contrast, in the years after implementation of the policy, length of hospital stay decreased more than expected from the baseline trend by 7% per year (95% CI, 5% to 9%; P < .001), and the distance traveled by all patients to the hospital for surgery increased by 4% per year (95% CI, 0% to 8%; P = .03), neither of which were explained by preexisting trends. Analyses limited to patients ≥ 70 years of age demonstrated a reduction in operative mortality (odds ratio, 0.80 per year after regionalization; 95% CI, 0.67 to 0.95; P = .01). Conclusion A policy to regionalize lung cancer surgery in Ontario led to increased centralization of surgery services but was not independently associated with improvements in operative mortality. Improvements in length of stay and in operative mortality among elderly patients suggest areas where regionalization may be beneficial.
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Affiliation(s)
- Anna M. Bendzsak
- Anna M. Bendzsak, Peter C. Austin, and David R. Urbach, University of Toronto; Nancy N. Baxter, St Michael’s Hospital; Gail E. Darling, University Health Network, Toronto, Ontario, Canada
| | - Nancy N. Baxter
- Anna M. Bendzsak, Peter C. Austin, and David R. Urbach, University of Toronto; Nancy N. Baxter, St Michael’s Hospital; Gail E. Darling, University Health Network, Toronto, Ontario, Canada
| | - Gail E. Darling
- Anna M. Bendzsak, Peter C. Austin, and David R. Urbach, University of Toronto; Nancy N. Baxter, St Michael’s Hospital; Gail E. Darling, University Health Network, Toronto, Ontario, Canada
| | - Peter C. Austin
- Anna M. Bendzsak, Peter C. Austin, and David R. Urbach, University of Toronto; Nancy N. Baxter, St Michael’s Hospital; Gail E. Darling, University Health Network, Toronto, Ontario, Canada
| | - David R. Urbach
- Anna M. Bendzsak, Peter C. Austin, and David R. Urbach, University of Toronto; Nancy N. Baxter, St Michael’s Hospital; Gail E. Darling, University Health Network, Toronto, Ontario, Canada
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Surgery and Surgical Consult Rates for Early Stage Lung Cancer in Ontario: A Population-Based Study. Ann Thorac Surg 2016; 103:906-910. [PMID: 27939011 DOI: 10.1016/j.athoracsur.2016.09.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 09/05/2016] [Accepted: 09/07/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgery offers the best chance for survival for early (stage I and II) non-small cell lung cancer (NSCLC), but worldwide resection rates range from 49% to 77%. We investigated factors that may play a role in resection rates. METHODS Using administrative data, new diagnoses of NSCLC from 2010 through 2012 were captured. The rate of surgical consultation and resection overall and by age group were determined, as well as rates of pulmonary function testing and radiation therapy. RESULTS Of 4,309 persons diagnosed with stage I or II NSCLC between 2010 and 2012, 3,487 (80.9%) received surgical consultations, but only 58.9% (2,539) received surgery. Rates of consultation and surgery decreased with increasing patient age: only 60.3% of patients older than 80 received consultations and 29.9% had resections. Of the 1,770 patients who did not receive surgery, 948 (53.6%) received a surgical consultation, and in this group, 688 (72.5%) were treated with radiation. Of the 822 patients who did not see a surgeon, only 476 (57.9%) were treated with radiation. Pulmonary function testing was performed in 799 (84.3%) of patients who had surgical consults but in only 569 (69.2%) of those who did not see a surgeon. CONCLUSIONS Resection rates for early lung cancer appear low, which may be partly due to low rates of surgical consultation. Interestingly, patients who are seen by surgeons but who do not receive surgery are more likely to receive radiation than patients who are not referred for surgery. Further research is required to identify factors influencing resection rates.
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Schneider L, Farrokhyar F, Schieman C, Shargall Y, D'Souza J, Camposilvan I, Hanna WC, Finley CJ. Pneumonectomy: The Burden of Death After Discharge and Predictors of Surgical Mortality. Ann Thorac Surg 2014; 98:1976-81; discussion 1981-2. [DOI: 10.1016/j.athoracsur.2014.06.068] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 06/06/2014] [Accepted: 06/24/2014] [Indexed: 11/26/2022]
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Design of a Consensus-Derived Synoptic Operative Report for Lung Cancer Surgery. Ann Thorac Surg 2014; 97:1163-8. [DOI: 10.1016/j.athoracsur.2013.12.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 10/22/2013] [Accepted: 12/18/2013] [Indexed: 11/20/2022]
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Grondin SC, Schieman C, Kelly E, Darling G, Maziak D, Mackay MP, Gelfand G. A look at the thoracic surgery workforce in Canada: how demographics and scope of practice may impact future workforce needs. Can J Surg 2013; 56:E75-81. [PMID: 23883508 DOI: 10.1503/cjs.008412] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The purpose of this study is to describe the demographics, training and practice characteristics of physicians performing thoracic surgery across Canada to better assess workforce needs. METHODS We developed a questionnaire using a modified Delphi process to generate questionnaire items. The questionnaire was administered to all Canadian thoracic surgeons via email (n = 102) or mail (n = 35). RESULTS In all, 97 surgeons completed the survey (71% response rate). The mean age of respondents was 47.7 (standard deviation 9.1) years; 10.3% were older than 60. Ninety respondents (88.7%) were men, 95 (81.1%) practised in English and 93 (76%) were born in Canada. Most (90.4%) had a medical school affiliation, with an equal proportion practising in community or university teaching hospitals. Only 18% of respondents reported working fewer than 60 hours per week, and 34% were on call more than 1 in 3. Three-quarters of work hours were devoted to clinical care, with the remaining time split among research, administration and teaching. Malignant lung disease accounted for 61.2% of practice time, with the remaining time equally split between benign and malignant thoracic diseases. Preoperative testing (49.4%) and insufficient operating time (49.5%) were the most common factors delaying delivery of care. More than 80% of respondents reported being satisfied with their careers, with 62.1% planning on retiring after age 60. CONCLUSION This survey characterizes Canadian thoracic surgeons by providing specific demographic, satisfaction and scope of practice information. Despite challenges in obtaining adequate resources for providing timely care, job satisfaction remains high, with a balanced workforce supply and demand anticipated for the foreseeable future.
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Affiliation(s)
- Sean C Grondin
- Division of Thoracic Surgery, Department of Surgery at the University of Calgary, Calgary, Alta.
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Sundaresan S, McLeod R, Irish J, Burns J, Hunter A, Meertens E, Langer B, Stern H, Sherar M. Early results after regionalization of thoracic surgical practice in a single-payer system. Ann Thorac Surg 2012; 95:472-8; discussion 478-9. [PMID: 23261113 DOI: 10.1016/j.athoracsur.2012.10.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 09/28/2012] [Accepted: 10/01/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Regionalization of the practice of thoracic surgery into designated centers was carried out in Ontario to manage volume, improve outcomes, and facilitate comprehensive care. This article describes the process used by Cancer Care Ontario (CCO) to regionalize thoracic surgery practice and reports early results. METHODS A thoracic surgery standard was created by CCO, specifying criteria for level I (tertiary) and level II (secondary) thoracic surgery centers based on current volumes and projected population growth and referral patterns, and then implemented the standard using various incentives and disincentives. RESULTS Before regionalization (2004), 46 hospitals performed thoracic surgical procedures compared with 13 level I and 2 level II centers in 2010. From 2007 to 2011, a mean $8.4 million was distributed annually to designated centers to fund a mean 625 additional thoracic operations annually. By 2009 to 2010, the number of esophagectomies performed at designated centers increased from 212 to 285 (89% being performed in designated centers). Correspondingly, the number of lung resections increased from 1,396 to 1,858 (94% being performed in designated centers). Median wait time for lung cancer resection did not change. Regionalization achieved a significant reduction in 30-day mortality after pneumonectomy (10.9%-5.6%; p = 0.03) but no change for esophagectomy (5.9%-5.8%; p = 0. 96) or lobectomy (2.2%-1.9%; p = 0. 37). CONCLUSIONS Regionalization was challenging but feasible and was associated with reduced 30-day mortality after pneumonectomy. More data are required to evaluate other short- and long-term outcome measures to further validate benefits from regionalization.
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Surgeons' volume-outcome relationship for lobectomies and wedge resections for cancer using video-assisted thoracoscopic techniques. Minim Invasive Surg 2012; 2012:760292. [PMID: 23213500 PMCID: PMC3504426 DOI: 10.1155/2012/760292] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 09/13/2012] [Indexed: 11/17/2022] Open
Abstract
This study examined the effect of surgeons' volume on outcomes in lung surgery: lobectomies and wedge resections. Additionally, the effect of video-assisted thoracoscopic surgery (VATS) on cost, utilization, and adverse events was analyzed. The Premier Hospital Database was the data source for this analysis. Eligible patients were those of any age undergoing lobectomy or wedge resection using VATS for cancer treatment. Volume was represented by the aggregate experience level of the surgeon in a six-month window before each surgery. A positive volume-outcome relationship was found with some notable features. The relationship is stronger for cost and utilization outcomes than for adverse events; for thoracic surgeons as opposed to other surgeons; for VATS lobectomies rather than VATS wedge resections. While there was a reduction in cost and resource utilization with greater experience in VATS, these outcomes were not associated with greater experience in open procedures.
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Mahar AL, McLeod RS, Kiss A, Paszat L, Coburn NG. A Systematic Review of the Effect of Institution and Surgeon Factors on Surgical Outcomes for Gastric Cancer. J Am Coll Surg 2012; 214:860-8.e12. [DOI: 10.1016/j.jamcollsurg.2011.12.050] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 12/14/2011] [Accepted: 12/21/2011] [Indexed: 02/06/2023]
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Ivanovic J, Maziak DE, Gilbert S, Shamji FM, Sundaresan RS, Ramsay T, Seely AJE. Assessing the status of thoracic surgical research and quality improvement programs: a survey of the members of the Canadian Association of Thoracic Surgeons. JOURNAL OF SURGICAL EDUCATION 2011; 68:258-265. [PMID: 21708361 DOI: 10.1016/j.jsurg.2011.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 01/26/2011] [Accepted: 02/09/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Assessing the degree of involvement and participation in thoracic surgical research as well as surgical quality improvement conducted across Canadian institutions is difficult as no common data collection system and no prior studies exist. As a pilot investigation, we designed and conducted a membership survey of the Canadian Association of Thoracic Surgeons (CATS) to evaluate the extent of participation in research and quality improvement processes among thoracic surgeons. DESIGN, SETTING, AND PARTICIPANTS A 45-item needs assessment survey was mailed to all national members of CATS (n = 86) in August 2009. Questions primarily focused on clinical research programs and research activity, research funding, database use and interest, and other methods of quality monitoring. RESULTS The 49 completed surveys represented a 57.0% response rate and 28 institutions across Canada. Research in basic and clinical science is conducted by 17.0% and 80.9% of the respondents, respectively. The annual budget of research funds is most commonly between $5000 and $50,000. A total of 72.0% (n = 18) of institutions do not have a formal surgery quality assessment program and 92.3% (n = 24) do not participate in a national or international thoracic surgery database. Ten institutions (38.6%) have a local thoracic surgery database for quality monitoring. Other systems of monitoring surgical quality include formal morbidity and mortality rounds (69.2%; n = 8 institutions), formal evaluation of surgical wait times (73.1%; n = 19 institutions), and patient satisfaction surveys (71.4%; n = 10 institutions). Overall, 97.8% of surgeons would be willing to share data on morbidity and mortality with other centers, and 73.1% have a high or very high level of interest in participating in a national thoracic surgery quality database. CONCLUSIONS A high level of interest and participation exists in thoracic surgery research. However, more robust quality improvement processes are needed for thoracic surgical oncology services. A national thoracic surgery quality improvement database offers a potential means to improve practice effectiveness, standardize surgical outcomes, and promote thoracic research across Canada.
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Affiliation(s)
- Jelena Ivanovic
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa Hospital, Ottawa, Canada
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Tinmouth J, Green J, Ko YJ, Liu Y, Paszat L, Sutradhar R, Rabeneck L, Urbach D. A population-based analysis of esophageal and gastric cardia adenocarcinomas in Ontario, Canada: incidence, risk factors, and regional variation. J Gastrointest Surg 2011; 15:782-90. [PMID: 21409602 DOI: 10.1007/s11605-011-1450-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 01/30/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION In Western countries, the incidence of esophageal adenocarcinoma (EA) and gastric cardia adenocarcinoma (GCA) is increasing. This population-based study describes the incidence of, associated patient risk factors for, and regional variation in EA/GCA in Ontario, Canada. METHODS All adults with a new diagnosis of EA or GCA between 1972 and 2005 in Ontario were identified. Adjusted annual incidence rates were calculated, and multivariate models were used to identify patient risk factors. Maps were created to explore regional variation. RESULTS Over the study period, 8,245 persons were diagnosed with EA/CGA; incidence increased from 1.01 to 3.9 per 100,000. Age (>65 vs. <50 years; rate ratio (RR), 3.4; 95% confidence interval (CI), 2.8-4.1) and comorbidity (highest vs. lowest, RR, 3.5; 95% CI, 2.9-4.2) were most strongly associated with the development of EA/GCA. We found considerable regional variation in the rates of EA/GCA (North West vs. Central region, RR, 6.5; 95% CI, 4.4-9.6). Maps suggested ethnicity may explain some regional variation, and that the current allocation of designated surgical treatment centers for EA/CGA may be suboptimal. CONCLUSIONS The incidence of EA/GCA is rising dramatically in Ontario. Further investigation of observed regional variation is warranted, particularly for the allocation of cancer health resources.
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Affiliation(s)
- Jill Tinmouth
- Sunnybrook Health Sciences Centre, 2075 Bayview Ave Rm HG40, Toronto, ON, M4N 3M5, Canada.
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Treatment of the Elderly When Cure is the Goal: The Influence of Age on Treatment Selection and Efficacy for Stage III Non-small Cell Lung Cancer. J Thorac Oncol 2011; 6:537-44. [DOI: 10.1097/jto.0b013e31820b8b9b] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Detterbeck F, Puchalski J, Rubinowitz A, Cheng D. Classification of the Thoroughness of Mediastinal Staging of Lung Cancer. Chest 2010; 137:436-42. [DOI: 10.1378/chest.09-1378] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Duvalko KM, Sherar M, Sawka C. Creating a System for Performance Improvement in Cancer Care: Cancer Care Ontario's Clinical Governance Framework. Cancer Control 2009; 16:293-302. [DOI: 10.1177/107327480901600403] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Katya M. Duvalko
- Cancer Quality Council of Ontario at Cancer Care Ontario, Toronto, Ontario, Canada
| | - Michael Sherar
- Planning and Regional Programs at Cancer Care Ontario, Toronto, Ontario, Canada
| | - Carol Sawka
- Clinical Programs and Quality Initiatives at Cancer Care Ontario, Toronto, Ontario, Canada
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Postoperative care after pulmonary resection: postanesthesia care unit versus intensive care unit. Curr Opin Anaesthesiol 2009; 22:50-5. [PMID: 19295292 DOI: 10.1097/aco.0b013e32831d7b25] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW In an effort to maximize resource utilization and contain costs, immediate postoperative care after noncardiac thoracic surgery is often done in either the postanesthesia care unit or dedicated step down units, leaving the ICU for complex surgical cases, overtly high-risk patients, or the treatment of severe postoperative complications. This review analyzes the current modalities affecting length of stay and costs, mainly by allocating patients after elective lung resection to different postoperative areas according to their needs. RECENT FINDINGS Several surgical models have been published in recent years with the goal of optimizing perioperative patient care and subsequently decreasing hospital costs and length of stay. The main focus has been on elective lung resection for lung cancer. Preoperative evaluation, changes in surgical and anesthetic techniques as well as careful planning on where to recover these patients seem to make a clinical and financial impact. SUMMARY The development of models to help predict elective ICU admission should facilitate optimal care, cutting costs and shortening length of stay after lung resection.
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Li WWL, de Mol BAJM. Hospital volume as a quality standard in lung cancer surgery: an unfinished debate. Ann Thorac Surg 2008; 85:1840-1; author reply 1841-2. [PMID: 18442611 DOI: 10.1016/j.athoracsur.2007.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Revised: 08/21/2007] [Accepted: 10/03/2007] [Indexed: 10/22/2022]
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Sundaresan S, Oliver T, Schwartz F, Stern H, Langer B, Brouwers M. Reply. Ann Thorac Surg 2008. [DOI: 10.1016/j.athoracsur.2008.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Dobrow MJ, Sullivan T, Sawka C. Shifting clinical accountability and the pursuit of quality: aligning clinical and administrative approaches. Healthc Manage Forum 2008; 21:6-19. [PMID: 19086481 DOI: 10.1016/s0840-4704(10)60269-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
This paper presents a narrative review of the literature on clinical accountability, and draws particularly on England's experience establishing "clinical governance" as a base to examine the establishment of a clinical accountability framework for cancer services in Ontario. The review suggests that clinical governance and accountability approaches that actively mesh clinical and administrative approaches at both system and local levels are more likely to be effective in improving quality of care.
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Affiliation(s)
- Mark J Dobrow
- Cancer Services and Policy Research Unit, Cancer Care Ontario, Canada
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