1
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Wang Y, Kapula N, Yang CFJ, Manapat P, Elliott IA, Guenthart BA, Lui NS, Backhus LM, Berry MF, Shrager JB, Liou DZ. Comparison of failure to rescue in younger versus elderly patients following lung cancer resection. JTCVS OPEN 2023; 16:855-872. [PMID: 38204720 PMCID: PMC10774945 DOI: 10.1016/j.xjon.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/14/2023] [Accepted: 08/02/2023] [Indexed: 01/12/2024]
Abstract
Objective Failure to rescue (FTR), defined as in-hospital death following a major complication, has been increasingly studied in patients who undergo cardiothoracic surgery. This study tested the hypothesis that elderly patients undergoing lung cancer resection have greater rates of FTR compared with younger patients. Methods Patients who underwent surgery for primary lung cancer between 2011 and 2020 and had at least 1 major postoperative complication were identified using the National Surgical Quality Improvement Program database. Patients who died following complications (FTR) were compared with those who survived in an elderly (80+ years) and younger (<80 years) cohort. Results Of the 2823 study patients, the younger cohort comprised 2497 patients (FTR: n = 139 [5.6%]), whereas the elderly cohort comprised 326 patients (FTR: n = 39 [12.0%]). Pneumonia was the most common complication in younger (877/2497, 35.1%) and elderly patients (118/326, 36.2%) but was not associated with FTR on adjusted analysis. Increasing age was associated with FTR (adjusted odds ratio [AOR], 1.55 per decade, P < .001), whereas unplanned reoperation was associated with reduced risk (AOR, 0.55, P = .01). Within the elderly cohort, surgery conducted by a thoracic surgeon was associated with lower FTR risk (AOR, 0.29, P = .028). Conclusions FTR following lung cancer resection was more frequent with increasing age. Pneumonia was the most common complication but not a predictor of FTR. Unplanned reoperation was associated with reduced FTR, as was treatment by a thoracic surgeon for elderly patients. Surgical therapy for complications after lung cancer resection and elderly patients managed by a thoracic specialist may mitigate the risk of death following an adverse postoperative event.
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Affiliation(s)
- Yoyo Wang
- University of Michigan Medical School, Ann Arbor, Mich
| | - Ntemena Kapula
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Chi-Fu J. Yang
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Pooja Manapat
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Irmina A. Elliott
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Brandon A. Guenthart
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Natalie S. Lui
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Leah M. Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Mark F. Berry
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Joseph B. Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Douglas Z. Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
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2
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Pekala KR, Yabes JG, Bandari J, Yu M, Davies BJ, Sabik LM, Kahn JM, Jacobs BL. The centralization of bladder cancer care and its implications for patient travel distance. Urol Oncol 2021; 39:834.e9-834.e20. [PMID: 34162498 DOI: 10.1016/j.urolonc.2021.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/16/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the impact of centralized surgical and nonsurgical care (i.e., radiation and chemotherapy) on travel distances and survival outcomes for patients with advanced bladder cancer. Bladder cancer is a disease with high mortality for which treatment access is paramount and survival is superior in patients receiving surgery at high-volume centers. METHODS Using SEER-Medicare, we identified patients 66 years or older diagnosed with bladder cancer between 2004-2013. We categorized patients as treated with either surgical (i.e., radical cystectomy) or nonsurgical (i.e., radiation or chemotherapy) care. We fit a linear probability model to generate the predicted proportion of patients treated at the top quintile of volume over time and assessed travel distance, 1-year all-cause mortality, and 1-year bladder cancer-specific mortality over time. RESULTS A total of 6,756 and 10,383 patients underwent surgical and nonsurgical care, respectively. The percentage of patients treated at high-volume centers increased over the study period for both surgical care (53% to 62%) and nonsurgical care (47% to 55%), (both P< 0.001). Median travel distance increased (11.8 to 20.3 miles) for surgical care and (6.5 to 8.3 miles) for nonsurgical care, (both P < 0.001). The 1-year adjusted all-cause mortality and 1-year adjusted bladder-cancer specific mortality decreased significantly for both surgical and nonsurgical care (both P < 0.05). CONCLUSIONS Over time, centralization of surgical and nonsurgical care for bladder cancer patients increased, which was associated with increasing patient travel distance and decreased all-cause and bladder-cancer specific mortality.
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Affiliation(s)
| | - Jonathan G Yabes
- Center for Research on Health Care; Division of General Internal Medicine, Department of Medicine
| | | | | | | | - Lindsay M Sabik
- Center for Research on Health Care; Department of Health Policy and Management, Graduate School of Public Health
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology; Center for Research on Health Care
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3
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Urban D, Urban GE, Margalit O, Amit U, Jacobson G, Symon Z, Golan T, Boursi B, Lawrence YR. Mortality Among Neutropenic Cancer Patients Within the United States: The Association With Hospital Volume. JCO Oncol Pract 2021; 17:e582-e592. [PMID: 33439696 DOI: 10.1200/op.20.00115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
PURPOSE Neutropenia is a serious complication of chemotherapy in patients with solid tumors. The influence of hospital volume on outcomes in patients with neutropenia has been little investigated. We hypothesized that large-volume hospitals would have reduced mortality rates for neutropenic patients compared with small-volume institutions. METHODS We used the Nationwide Inpatient Sample database of the Healthcare Cost and Utilization Project, for the years 2007-2011. All adult inpatient episodes with a diagnosis of both neutropenia and solid-tumor malignancy were included. Hospital volume was defined as the number of neutropenic cancer episodes per institution per year. Mortality was defined as death during admission. A multilevel mixed-effects logistic regression model was applied. RESULTS Twenty thousand three hundred and ten hospitalizations were included in the study, from 1,869 different institutions. Median age was 62 years. The overall inpatient mortality was 2.3%, and was dependent on age (age 50-59 years-1.6% and age 80-89 years-5.3%). The median number of neutropenic inpatient episodes in each institution per year was 14 (range, 1-168). Mortality was 3.3%, 2.7%, 2.2%, 2.2%, and 1.2% for each quintile of hospital volume (from lowest to highest volume, P < .001). Likewise, the proportion discharged home was 85.7%, 90.3%, 91.5%, 92.7%, and 95.4% (P < .001). The association between hospital volume and mortality remained significant after adjustment for patient-level and hospital-level variables. DISCUSSION Patients with neutropenia hospitalized in large-volume institutions have a substantially lower mortality compared with those hospitalized at low-volume institutions. Further study is required to validate our findings or overcome potential biases, understand mechanism, and investigate how smaller institutions can improve outcomes.
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Affiliation(s)
- Damien Urban
- Institute of Oncology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | | | - Ofer Margalit
- Institute of Oncology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Uri Amit
- Institute of Oncology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Galia Jacobson
- Institute of Oncology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Zvi Symon
- Institute of Oncology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Talia Golan
- Institute of Oncology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Ben Boursi
- Institute of Oncology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Yaacov Richard Lawrence
- Institute of Oncology, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel.,Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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4
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Defining a “High Volume” Radical Cystectomy Hospital: Where Do We Draw the Line? Eur Urol Focus 2020; 6:975-981. [DOI: 10.1016/j.euf.2019.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/20/2019] [Accepted: 02/01/2019] [Indexed: 11/23/2022]
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5
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Antunez AG, Kanters AE, Regenbogen SE. Evaluation of Access to Hospitals Most Ready to Achieve National Accreditation for Rectal Cancer Treatment. JAMA Surg 2020; 154:516-523. [PMID: 30785616 DOI: 10.1001/jamasurg.2018.5521] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The American College of Surgeons National Accreditation Program for Rectal Cancer (NAPRC) promotes multidisciplinary care to improve oncologic outcomes in rectal cancer. However, accreditation requirements may be difficult to achieve for the lowest-performing institutions. Thus, it is unknown whether the NAPRC will motivate care improvement in these settings or widen disparities. Objectives To characterize hospitals' readiness for accreditation and identify differences in the patients cared for in hospitals most and least prepared for accreditation. Design, Setting, and Participants A total of 1315 American College of Surgeons Commission on Cancer-accredited hospitals in the National Cancer Database from January 1, 2011, to December 31, 2015, were sorted into 4 cohorts, organized by high vs low volume and adherence to process standards, and patient and hospital characteristics and oncologic outcomes were compared. The patients included those who underwent surgical resection with curative intent for rectal adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma. Data analysis was performed from November 2017 to January 2018. Exposures Hospitals' readiness for accreditation, as determined by their annual resection volume and adherence to 5 available NAPRC process standards. Main Outcomes and Measures Hospital characteristics, patient sociodemographic characteristics, and 5-year survival by hospital. Results Among the 1315 included hospitals, 38 (2.9%) met proposed thresholds for all 5 NAPRC process standards and 220 (16.7%) met the threshold on 4 standards. High-volume hospitals (≥20 resections per year) tended to be academic institutions (67 of 104 [64.4%] vs 159 of 1211 [13.1%]; P = .001), whereas low-volume hospitals (<20 resections per year) tended to be comprehensive community cancer programs (530 of 1211 [43.8%] vs 28 of 104 [26.9%]; P = .001). Patients in low-volume hospitals were more likely to be older (11 429 of 28 076 [40.7%] vs 4339 of 12 148 [35.7%]; P < .001) and have public insurance (13 054 of 28 076 [46.5%] vs 4905 of 12 148 [40.4%]; P < .001). Low-adherence hospitals were more likely to care for black and Hispanic patients (1980 of 19 577 [17.2%] vs 3554 of 20 647 [10.1%]; P < .001). On multivariable Cox proportional hazards model regression, high-volume hospitals had better 5-year survival outcomes than low-volume hospitals (hazard ratio, 0.99; 95% CI, 0.99-1.00; P < .001), but there was no significant survival difference by hospital process standard adherence. Conclusions and Relevance Hospitals least likely to receive NAPRC accreditation tended to be community institutions with worse survival outcomes, serving patients at a lower socioeconomic position. To possibly avoid exacerbating disparities in access to high-quality rectal cancer care, the NAPRC study findings suggest enabling access for patients with socioeconomic disadvantage or engaging in quality improvement for hospitals not yet achieving accreditation benchmarks.
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Affiliation(s)
- Alexis G Antunez
- University of Michigan Medical School, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Arielle E Kanters
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
| | - Scott E Regenbogen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.,Department of Surgery, University of Michigan, Ann Arbor
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6
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Bruins HM, Veskimäe E, Hernández V, Neuzillet Y, Cathomas R, Compérat EM, Cowan NC, Gakis G, Espinós EL, Lorch A, Ribal MJ, Rouanne M, Thalmann GN, Yuan Y, der Heijden AGV, Witjes JA. The Importance of Hospital and Surgeon Volume as Major Determinants of Morbidity and Mortality After Radical Cystectomy for Bladder Cancer: A Systematic Review and Recommendations by the European Association of Urology Muscle-invasive and Metastatic Bladder Cancer Guideline Panel. Eur Urol Oncol 2019; 3:131-144. [PMID: 31866215 DOI: 10.1016/j.euo.2019.11.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/11/2019] [Accepted: 11/27/2019] [Indexed: 12/23/2022]
Abstract
CONTEXT In bladder cancer patients treated with radical cystectomy (RC), controversy exists regarding the impact of the annual hospital volume (HV) and/or surgeon volume (SV) on oncological outcomes and quality of care. OBJECTIVE A systematic review was performed to evaluate the impact of HV and SV on clinical outcomes. Primary outcomes included in-hospital, 30-d, and 90-d mortality. Secondary outcomes included complications, long-term survival, positive surgical margin rate, lymphadenectomy performance, length of hospital stay, neobladder performance, and blood loss/transfusion rate. EVIDENCE ACQUISITION Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched. Comparative studies published after the year of 2000 including patients who underwent RC for bladder cancer were eligible for inclusion. Partial cystectomy was an exclusion criterion. Risk of bias (RoB) assessment was performed according to the ROBINS-1 tool. EVIDENCE SYNTHESIS After screening of 1190 abstracts, 39 studies recruiting 549 542 patients were included. All studies were retrospective observation cohort studies (level of evidence 3). Twenty-two studies reported on HV only, six studies on SV only, and 12 on both. Higher HV, specifically an HV of >10, was associated with improved primary and secondary outcomes in most studies. In addition, there is some evidence that an HV of >20 improves outcomes. For SV, limited and conflicting data are reported. Most studies had moderate to high RoB. The results were synthesized narratively. CONCLUSIONS Acknowledging the lower level of evidence, HV is likely associated with in-hospital, 30- and 90-d mortality, as well as the secondary outcomes assessed. Based on this study, the European Association of Urology Muscle-invasive and Metastatic Bladder Cancer Guideline Panel recommends hospitals to perform at least 10, and preferably >20, RCs annually or refer the patient to a center that reaches this number. For SV, limited and conflicting data are available. The available evidence suggests HV rather than SV to be the main driver of perioperative outcomes. PATIENT SUMMARY Current literature suggests that the number of bladder removal operations per hospital per year is associated with postoperative survival as well as the quality of care provided.
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Affiliation(s)
- Harman M Bruins
- Department of Urology, Zuyderland Medisch Centrum, Heerlen/Sittard-Geleen, The Netherlands.
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Virginia Hernández
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Yann Neuzillet
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Richard Cathomas
- Department of Medical Oncology, Kantonsspital Graubünden, Chur, Switzerland
| | - Eva M Compérat
- Department of Pathology, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hopital Tenon, Paris, France
| | - Nigel C Cowan
- Department of Radiology, The Queen Alexandra Hospital, Portsmouth, UK
| | - Georgios Gakis
- Department of Urology and Pediatric Urology, University of Würzburg, Würzburg, Germany
| | | | - Anja Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Maria J Ribal
- Uro-Oncology Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Mathieu Rouanne
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - George N Thalmann
- Department of Urology, Inselspital, University Hospital Bern, Switzerland
| | - Yuhong Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, Ontario, Canada
| | | | - J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
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7
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Kruse FM, van Nieuw Amerongen MC, Borghans I, Groenewoud AS, Adang E, Jeurissen PPT. Is there a volume-quality relationship within the independent treatment centre sector? A longitudinal analysis. BMC Health Serv Res 2019; 19:853. [PMID: 31752820 PMCID: PMC6868751 DOI: 10.1186/s12913-019-4467-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 08/27/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The number of independent treatment centres (ITCs) has grown substantially. However, little is known as to whether the volume-quality relationship exists within this sector and whether other possible organisational factors mediate this relationship. The aim of this study is to gain a better understanding of such possible relationships. METHODS Data originate from the Dutch Health and Youth Care Inspectorate (IGJ) and the Dutch Patients Association. We used longitudinal data from 4 years (2014-2017) including three different quality measures: 1) composite of structural and process indicators, 2) postoperative infections, and 3) patient satisfaction. We measured volume by the number of invasive treatments. We adjusted for three important organisational characteristics: (1) size of workforce, (2) chain membership, and (3) ownership status. For statistical inference, random effects analysis was used. We also ran several robustness checks for the volume-quality relationship, including a fractional logit model. RESULTS ITCs with higher volumes scored better on structure, process and outcome (i.e. postoperative infections) indicators compared to the low-volume ITCs - although only marginally on outcome. However, ITCs with higher volumes do not have higher patient satisfaction. There is a decreasing marginal effect of volume - in other words, an L-shaped curve. The effect of the intermediating structural factors on the volume-quality relationship (i.e. workforce size, chain membership and ownership status) is less clear. Our findings suggest that chain membership has a negative influence on patient satisfaction. Furthermore, for-profit providers scored better on the Net Promoter Score. CONCLUSIONS Our study shows with some certainty that the quality of care in low-volume ITCs is lower than in high-volume ITCs as measured by structural, process and outcome (i.e. postoperative infection) indicators. However, the size of the effect of volume on postoperative infections is small, and at higher volumes the marginal benefits (in terms of lower postoperative infections) decrease. In addition, volume is not related to patient satisfaction. Furthermore, the association between the structural intermediating factors and quality are tenuous.
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Affiliation(s)
| | | | - I Borghans
- Dutch Health and Youth Care Inspectorate, Utrecht, The Netherlands
| | - A S Groenewoud
- IQ healthcare, Radboud University and Medical Center, Nijmegen, The Netherlands
| | - E Adang
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P P T Jeurissen
- IQ healthcare, Radboud University and Medical Center, Nijmegen, The Netherlands
- Ministry of Health, Welfare and Sport, The Hague, The Netherlands
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8
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Effect of hospital volume on 90-day mortality after radical cystectomy for bladder cancer in Spain. World J Urol 2019; 38:1221-1228. [PMID: 31302754 DOI: 10.1007/s00345-019-02874-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/08/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To investigate 90-day mortality rate of RC for bladder cancer in a nationwide population-based study. DESIGN, SETTING, AND PARTICIPANTS We used mandatory hospital discharge forms of all patients submitted to RC due to bladder cancer in Spain during 2011-2015 (n = 12,154 in 196 hospitals). At present, a centralization policy for RC has not been issued by the health authorities. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We calculated in-hospital, 30-, 60- and 90-day mortality. Average annual RC volume was used as a continuous variable (log-transformed) and also grouped into deciles to identify any potential non-linear relationships. Logistic regression model with mixed effect was performed adjusting for year of surgery, comorbidity, surgical approach, type of admission, age, sex, and hospital size. RESULTS AND LIMITATION Overall 90-day mortality rate was 6.5%. Lowest mortality rates (3.3% at 90 days) are achieved in hospitals doing more than 38 cases per year. The 90-day adjusted mortality rate is associated with annual average RC volume with a 20.6% decrease per 10 extra RCs/year (95% CI 12.3-28.1% p < 0.001). High Charlson comorbidity index, advanced age, and open surgical approach were the clinical variables associated with higher mortality. CONCLUSIONS Our study identifies an inverse association between 90-day mortality and hospital volume. High-volume hospitals achieve lower mortality rate within 90 days.
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9
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Liedberg F, Hagberg O, Aljabery F, Gårdmark T, Hosseini A, Jahnson S, Jancke G, Jerlström T, Malmström PU, Sherif A, Ströck V, Häggström C, Holmberg L. Period-specific mean annual hospital volume of radical cystectomy is associated with outcome and perioperative quality of care: a nationwide population-based study. BJU Int 2019; 124:449-456. [DOI: 10.1111/bju.14767] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Fredrik Liedberg
- Department of Urology; Skåne University Hospital; Malmö Sweden
- Institution of Translational Medicine; Lund University; Malmö Sweden
| | | | - Firas Aljabery
- Division of Urology; Department of Clinical and Experimental Medicine; Linköping University; Linköping Sweden
| | - Truls Gårdmark
- Department of Clinical Sciences; Karolinska Institute; Danderyd Hospital; Stockholm Sweden
| | - Abolfazl Hosseini
- Department of Urology; Karolinska University Hospital; Stockholm Sweden
| | - Staffan Jahnson
- Division of Urology; Department of Clinical and Experimental Medicine; Linköping University; Linköping Sweden
| | - Georg Jancke
- Department of Urology; Skåne University Hospital; Malmö Sweden
- Institution of Translational Medicine; Lund University; Malmö Sweden
| | - Tomas Jerlström
- Department of Urology; School of Health and Medical Sciences; Örebro University; Örebro Sweden
| | | | - Amir Sherif
- Department of Surgical and Perioperative Sciences; Urology and Andrology; Umeå University; Umeå Sweden
| | - Viveka Ströck
- Department of Urology; Sahlgrenska University Hospital; Gothenburg Sweden
- Institute of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - Christel Häggström
- Department of Surgical Sciences; Uppsala University; Uppsala Sweden
- Department of Biobank Research; Umeå University; Umeå Sweden
| | - Lars Holmberg
- Department of Surgical Sciences; Uppsala University; Uppsala Sweden
- School of Medicine; King's College London; London UK
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10
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Kilsdonk MJ, Siesling S, van Dijk BAC, Wouters MW, van Harten WH. What drives centralisation in cancer care? PLoS One 2018; 13:e0195673. [PMID: 29649250 PMCID: PMC5896991 DOI: 10.1371/journal.pone.0195673] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/27/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND To improve quality of care, centralisation of cancer services in high-volume centres has been stimulated. Studies linking specialisation and high (surgical) volumes to better outcomes already appeared in the 1990's. However, actual centralisation was a difficult process in many countries. In this study, factors influencing the centralisation of cancer services in the Netherlands were determined. MATERIAL AND METHODS Centralisation patterns were studied for three types of cancer that are known to benefit from high surgical caseloads: oesophagus-, pancreas- and bladder cancer. The Netherlands Cancer Registry provided data on tumour and treatment characteristics from 2000-2013 for respectively 8037, 4747 and 6362 patients receiving surgery. By plotting timelines of centralisation of cancer surgery, relations with the appearance of (inter)national scientific evidence, actions of medical specialist societies, specific regulation and other important factors on the degree of centralisation were ascertained. RESULTS For oesophagus and pancreas cancer, a gradual increase in centralisation of surgery is seen from 2005 and 2006 onwards following (inter)national scientific evidence. Centralisation steps for bladder cancer surgery can be seen in 2010 and 2013 anticipating on the publication of norms by the professional society. The most influential stimulus seems to have been regulations on minimum volumes. CONCLUSION Scientific evidence on the relationship between volume and outcome lead to the start of centralisation of surgical cancer care in the Netherlands. Once a body of evidence has been established on organisational change that influences professional practice, in addition some form of regulation is needed to ensure widespread implementation.
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Affiliation(s)
- Melvin J. Kilsdonk
- Netherlands Comprehensive Cancer Organisation, dept. of research, Utrecht, the Netherlands
- University of Twente, School for Management and Governance, dept. of Health Technology and Services Research, Enschede, The Netherlands
| | - Sabine Siesling
- Netherlands Comprehensive Cancer Organisation, dept. of research, Utrecht, the Netherlands
- University of Twente, School for Management and Governance, dept. of Health Technology and Services Research, Enschede, The Netherlands
| | - Boukje A. C. van Dijk
- Netherlands Comprehensive Cancer Organisation, dept. of research, Utrecht, the Netherlands
- University of Groningen, University Medical Centre Groningen, dept. of epidemiology, Groningen, the Netherlands
| | | | - Wim H. van Harten
- University of Twente, School for Management and Governance, dept. of Health Technology and Services Research, Enschede, The Netherlands
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
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11
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Evaluation of Contralateral and Bilateral Prophylactic Mastectomy and Reconstruction Outcomes. Ann Plast Surg 2018; 80:S144-S149. [DOI: 10.1097/sap.0000000000001358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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12
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Cahn DB, Foote C, Smaldone MC. Challenges facing regionalization of radical cystectomy. Transl Androl Urol 2018; 7:292-294. [PMID: 29733077 PMCID: PMC5911529 DOI: 10.21037/tau.2018.03.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- David B Cahn
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Christopher Foote
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Marc C Smaldone
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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13
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Xia L, Strother MC, Taylor BL, Chelluri RR, Pulido JE, Guzzo TJ. Hospital volume and short-term outcomes after cytoreductive nephrectomy. J Surg Oncol 2018; 117:1589-1596. [PMID: 29575038 DOI: 10.1002/jso.25047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/16/2018] [Indexed: 01/29/2023]
Abstract
PURPOSE To investigate the impact of hospital volume on short-term outcomes after cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC). METHODS We identified mRCC patients who underwent CN from 2006 to 2013 in the National Cancer Database. Annual hospital CN volume was categorized as high (top 20th percentile) and low. Multivariable logistic regressions were used to compare 30-day mortality, 90-day mortality, prolonged length of stay (PLOS, ≥7 days), and 30-day readmission rates. Sensitivity analyses were performed with hospital volume considered as a continuous variable. RESULTS A total of 9789 patients were included with high-volume (n = 1916) defined as ≥8 cases and low-volume (n = 7873) as 1-7 cases annually. Multivariable logistic regression showed that high-volume was associated with lower odds of 30-day mortality (OR = 0.69, P = 0.013), 90-day mortality (OR = 0.65, P < 0.001), PLOS (OR = 0.82, P = 0.002), and 30-day readmission (OR = 0.78, P = 0.028). Sensitivity analyses showed that increasing hospital volume (per case) was associated with lower odds of 30-day mortality (OR = 0.965, P = 0.008), 90-day mortality (OR = 0.966, P < 0.001), PLOS (OR = 0.982, P = 0.001), and 30-day readmission (OR = 0.975, P = 0.012). CONCLUSION Higher hospital volume was associated with better short-term outcomes after CN. Future studies are needed to validate our findings and explore the potential components leading to better outcomes in the higher volume hospitals.
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Affiliation(s)
- Leilei Xia
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Marshall C Strother
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Raju R Chelluri
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jose E Pulido
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Thomas J Guzzo
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Kim AH, Kim SP. Surviving travel or travelling to survive: the association of travel distance with survival in muscle invasive bladder cancer. Transl Androl Urol 2018; 7:S83-S85. [PMID: 29645020 PMCID: PMC5881221 DOI: 10.21037/tau.2018.01.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Albert H Kim
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Simon P Kim
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Cancer Outcomes and Public Policy Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, USA
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15
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Udovicich C, Perera M, Huq M, Wong LM, Lenaghan D. Hospital volume and perioperative outcomes for radical cystectomy: a population study. BJU Int 2017; 119 Suppl 5:26-32. [DOI: 10.1111/bju.13827] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Cristian Udovicich
- Department of Urology; St Vincent's Hospital; Melbourne Vic. Australia
- Department of Surgery; Western Health; Melbourne Vic. Australia
- Department of Surgery; Mildura Base Hospital; Mildura Vic. Australia
| | - Marlon Perera
- Department of Surgery; Austin Health; The University of Melbourne; Melbourne Vic. Australia
| | - Molla Huq
- Department of Rheumatology; St Vincent's Hospital; Melbourne Vic. Australia
- Department of Medicine; The University of Melbourne; Melbourne Vic. Australia
| | - Lih-Ming Wong
- Department of Urology; St Vincent's Hospital; Melbourne Vic. Australia
- Department of Surgery; St Vincent's Hospital; The University of Melbourne; Melbourne Vic. Australia
| | - Daniel Lenaghan
- Department of Urology; St Vincent's Hospital; Melbourne Vic. Australia
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16
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Waingankar N, Mallin K, Smaldone M, Egleston BL, Higgins A, Winchester DP, Uzzo RG, Kutikov A. Assessing the relative influence of hospital and surgeon volume on short-term mortality after radical cystectomy. BJU Int 2017; 120:239-245. [PMID: 28192632 DOI: 10.1111/bju.13804] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the relationship between surgeon (SV) and hospital volume (HV) on mortality after radical cystectomy (RC). PATIENTS AND METHODS We queried the National Cancer Database (NCDB) for adult patients undergoing RC between 2010 and 2013. We calculated average volume for each surgeon and hospital. Using propensity-scored weights for combined volume groups with a proportional hazards regression model, we compared the associations between HV and SV with 90-day survival after RC. RESULTS A total of 19 346 RCs were performed at 927 hospitals by 2 927 surgeons in the period 2010-2013. The median (interquartile range) HV and SV were 12.3 (5.0-35.5) and 4.3 (1.3-12.3) cases, respectively. For HV, 90-day unadjusted mortality was 8.5% in centres with <5 cases/year (95% confidence interval [CI] 7.7-9.3) and 5.6% in those with >30 cases/year (95% CI 5.0-6.2). For SV, 90-day mortality was 8.1% for surgeons with <5 cases/year (95% CI 7.6-8.6) and 4.0% for those with >30 cases/year (95% CI 2.8-5.2; all P < 0.05). The 30-day mortality rate was lowest for the combined HV-SV groups with HV >30, ranging from 1.6% to 2.1%. CONCLUSIONS In hospitals reporting to the NCDB, volume was associated with improved mortality after RC. These associations appear to be driven by hospital- rather than surgeon-level effects. An elevated SV had a beneficial effect on mortality at the highest-volume hospitals. These findings inform efforts to regionalize complex surgical care and improve quality at community and safety net hospitals.
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Affiliation(s)
| | - Katherine Mallin
- American College of Surgeons, National Cancer Database, Chicago, IL, USA
| | | | | | | | - David P Winchester
- American College of Surgeons, National Cancer Database, Chicago, IL, USA
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17
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Zafar SN, Shah AA, Zogg CK, Hashmi ZG, Greene WR, Haut ER, Cornwell EE, Haider AH. Morbidity or mortality? Variations in trauma centres in the rescue of older injured patients. Injury 2016; 47:1091-7. [PMID: 26724172 DOI: 10.1016/j.injury.2015.11.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 11/23/2015] [Accepted: 11/25/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Prior analysis demonstrates improved survival for older trauma patients (age>64years) treated at trauma centres that manage a higher proportion of geriatric patients. We hypothesised that 'failure to rescue' (death after a complication during an in-hospital stay) may be responsible for part of this variation. The objective of the study was to determine if trauma centre failure to rescue rates are associated with the proportion of older trauma seen. METHODS We analysed data from high volume level 1 and 2 trauma centres participating in the National Trauma Data Bank, years 2007-2011. Centres were categorised by the proportion of older trauma patients seen. Logistic regression analyses were used to provide risk-adjusted rates for major complications (MC) and, separately, for mortality following a MC. Models were adjusted for patient demographics, comorbid conditions, mechanism and type of injury, presenting vital signs, injury severity, and multiple facility-level covariates. Risk-adjusted rates were plotted against the proportion of older trauma seen and trends determined. RESULTS Of the 396,449 older patients at 293 trauma centres that met inclusion criteria, 30,761 (8%) suffered a MC. No difference was found in the risk-adjusted incidence of MC by proportion of older trauma seen. A MC was associated with 34% of all deaths. Of those that suffered a MC, 7413 (24%) died and 76% were successfully rescued. Centres treating higher proportions of older trauma were more successful at rescuing patients after a MC occurred. Patients seen at centres that treat >50% older trauma were 33% (OR=0.67, 95% CI 0.47-0.96) less likely to die following a MC than in centres treating a low proportion (10%) of older trauma. CONCLUSIONS Centres more experienced at managing geriatric trauma are more successful at rescuing older patients with serious complications. Processes of care at these centres need to be further examined and used to inform appropriate interventions.
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Affiliation(s)
- Syed Nabeel Zafar
- Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Adil A Shah
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA; Division of General Surgery, Mayo Clinic, Scottsdale, AZ, USA
| | - Cheryl K Zogg
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Zain G Hashmi
- Department of Surgery, Sinai Hospital, Baltimore, MD, USA
| | - Wendy R Greene
- Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edward E Cornwell
- Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA.
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Healy MA, Yin H, Wong SL. Multimodal cancer care in poor prognosis cancers: Resection drives long-term outcomes. J Surg Oncol 2016; 113:599-604. [PMID: 26953166 DOI: 10.1002/jso.24217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/20/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Hospitals with high complex oncologic surgical volume have improved short-term outcomes. However, for long-term outcomes, the influence of other therapies must be considered. We compared effects of resection with other therapies on long-term outcomes across U.S. hospitals. METHODS We examined claims in the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset for patients with esophageal (EC) and pancreatic (PC) cancers between 2005-2009, with follow-up through 2011, performing multivariable Cox proportional hazards analyses. We stratified hospitals by volume and compared rates of treatments in the context of survival. RESULTS We studied 905 EC and 3,293 PC patients at 138 and 375 hospitals, respectively. For EC, resection rates were significantly higher (32.9% vs. 9.5%, P < 0.001) in the highest versus lowest volume hospitals. Adjusted survival was also statistically significantly better (48.5% vs. 43.1%, P < 0.001). For PC, resection rates were also statistically significantly higher (30.1% vs. 12.0%, P < 0.001) with higher adjusted survival (21.5% vs. 19.9%, P = 0.01). We did not find variation in rates of other cancer treatments across hospitals. CONCLUSIONS A significant association exists between long-term survival and rates of cancer-directed surgery across hospitals, without variation in rates of other therapies. Access to resection appears to be key to reducing variation in long-term survival. J. Surg. Oncol. 2016;113:599-604. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Mark A Healy
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.,Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan
| | - Huiying Yin
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan
| | - Sandra L Wong
- Department of Surgery, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire
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Penson DF. Re: Exploring the Burden of Inpatient Readmissions after Major Cancer Surgery. J Urol 2015; 194:1068. [PMID: 26382809 DOI: 10.1016/j.juro.2015.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Indexed: 11/30/2022]
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20
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Mesman R, Westert GP, Berden BJ, Faber MJ. Why do high-volume hospitals achieve better outcomes? A systematic review about intermediate factors in volume–outcome relationships. Health Policy 2015; 119:1055-67. [DOI: 10.1016/j.healthpol.2015.04.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 02/01/2015] [Accepted: 04/08/2015] [Indexed: 11/30/2022]
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21
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Nielsen ME, Mallin K, Weaver MA, Palis B, Stewart A, Winchester DP, Milowsky MI. Association of hospital volume with conditional 90-day mortality after cystectomy: an analysis of the National Cancer Data Base. BJU Int 2014; 114:46-55. [PMID: 24219110 DOI: 10.1111/bju.12566] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To examine the association of hospital volume and 90-day mortality after cystectomy, conditional on survival for 30 days. PATIENTS AND METHODS The National Cancer Data Base was used to evaluate 30- and 90-day mortality for 35,055 patients who underwent cystectomy for bladder cancer at one of 1118 hospitals. Patient data were aggregated into hospital volume categories based on the mean annual number of procedures (low-volume hospital: <10 procedures; intermediate-volume hospital: 10-19 procedures; high-volume hospital: ≥20 procedures). Associations between mortality and clinical, demographic and hospital characteristics were analysed using hierarchical logistic regression models. To assess the association between hospital volume and 90-day mortality independently of shorter-term mortality, 90-day mortality conditional on 30-day survival was assessed in the multivariate modelling. RESULTS Unadjusted 30- and 90-day mortality rates were 2.7 and 7.2% overall, 1.9 and 5.7% among high-volume hospitals, and 3.2 and 8.0% among low-volume hospitals, respectively. Compared with high-volume hospitals, the adjusted risks among low-volume hospitals (odds ratio [95% CI]) of 30- and 90-day mortality, conditional on having survived for 30 days, from the hierarchical models were 1.5 (1.3-1.9), and 1.2 (1.0-1.4), respectively. CONCLUSIONS A low hospital volume was associated with greater 30- and 90-day mortality. These data support the need for further research to better understand the relatively high mortality rates seen between 30 and 90 days, which are high and less variable across hospital volume strata. The stronger association between volume and 30-day mortality suggests that quality-reporting efforts should focus on shorter-term outcomes.
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Affiliation(s)
- Matthew E Nielsen
- University of North Carolina Lineberger Comprehensive Cancer Center, USA; Department of Urology, University of North Carolina School of Medicine, USA; Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
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22
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Gray PJ, Lin CC, Jemal A, Shipley WU, Fedewa SA, Kibel AS, Rosenberg JE, Kamat AM, Virgo KS, Blute ML, Zietman AL, Efstathiou JA. Clinical-pathologic stage discrepancy in bladder cancer patients treated with radical cystectomy: results from the national cancer data base. Int J Radiat Oncol Biol Phys 2014; 88:1048-56. [PMID: 24661658 DOI: 10.1016/j.ijrobp.2014.01.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 12/26/2013] [Accepted: 01/04/2014] [Indexed: 02/03/2023]
Abstract
PURPOSE To examine the accuracy of clinical staging and its effects on outcome in bladder cancer (BC) patients treated with radical cystectomy (RC), using a large national database. METHODS AND MATERIALS A total of 16,953 patients with BC without distant metastases treated with RC from 1998 to 2009 were analyzed. Factors associated with clinical-pathologic stage discrepancy were assessed by multivariate generalized estimating equation models. Survival analysis was conducted for patients treated between 1998 and 2004 (n=7270) using the Kaplan-Meier method and Cox proportional hazards models. RESULTS At RC 41.9% of patients were upstaged, whereas 5.9% were downstaged. Upstaging was more common in females, the elderly, and in patients who underwent a more extensive lymphadenectomy. Downstaging was less common in patients treated at community centers, in the elderly, and in Hispanics. Receipt of preoperative chemotherapy was highly associated with downstaging. Five-year overall survival rates for patients with clinical stages 0, I, II, III, and IV were 67.2%, 62.9%, 50.4%, 36.9%, and 27.2%, respectively, whereas those for the same pathologic stages were 70.8%, 75.8%, 63.7%, 41.5%, and 24.7%, respectively. On multivariate analysis, upstaging was associated with increased 5-year mortality (hazard ratio [HR] 1.80, P<.001), but downstaging was not associated with survival (HR 0.88, P=.160). In contrast, more extensive lymphadenectomy was associated with decreased 5-year mortality (HR 0.76 for ≥10 lymph nodes examined, P<.001), as was treatment at an National Cancer Institute-designated cancer center (HR 0.90, P=.042). CONCLUSIONS Clinical-pathologic stage discrepancy in BC patients is remarkably common across the United States. These findings should be considered when selecting patients for preoperative or nonoperative management strategies and when comparing the outcomes of bladder sparing approaches to RC.
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Affiliation(s)
- Phillip J Gray
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Radiation Oncology Program, Boston, Massachusetts
| | - Chun Chieh Lin
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
| | - William U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Stacey A Fedewa
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
| | - Adam S Kibel
- Division of Urology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jonathan E Rosenberg
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ashish M Kamat
- Division of Surgery, Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Katherine S Virgo
- Department of Health Policy and Management, Emory University, Atlanta, Georgia
| | - Michael L Blute
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Anthony L Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
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Tuggle CT, Patel A, Broer N, Persing JA, Sosa JA, Au AF. Increased hospital volume is associated with improved outcomes following abdominal-based breast reconstruction. J Plast Surg Hand Surg 2014; 48:382-8. [DOI: 10.3109/2000656x.2014.899241] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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24
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Scales CD, Saigal CS, Hanley JM, Dick AW, Setodji CM, Litwin MS. The impact of unplanned postprocedure visits in the management of patients with urinary stones. Surgery 2013; 155:769-75. [PMID: 24787103 DOI: 10.1016/j.surg.2013.12.013] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/10/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Unplanned follow-up care is the focus of intense health policy interest, as evidenced by recent financial penalties imposed under the Affordable Care Act. To date, however, unplanned postoperative care remains poorly characterized, particularly for patients with kidney stones. Our objective was to describe the frequency, variation, and financial impact of unplanned, high-acuity, follow-up visits in the treatment of patients with urinary stone disease. METHODS We identified privately insured patients undergoing percutaneous nephrostolithotomy, ureteroscopy, or shock-wave lithotripsy for stone disease. The primary outcome was occurrence of an emergency department visit or hospital admission within 30 days of the procedure. Multivariable models estimated the odds of an unplanned visit and the incremental cost of those visits, controlling for important covariates. RESULTS We identified 93,523 initial procedures to fragment or remove stones. Overall, 1 in 7 patients had an unplanned postprocedural visit. Unplanned visits were least common after shock-wave lithotripsy (12%) and occurred with similar frequency after ureteroscopy and percutaneous nephrostolithotomy (15%). Procedures at high-volume facilities were substantially less likely to result in an unplanned visit (odds ratio 0.80, 95% confidence interval [95% CI] 0.74-0.87, P < .001). When an unplanned visit occurred, adjusted incremental expenditures per episode were greater after shock-wave lithotripsy ($32,156 [95% CI $30,453-33,859]) than after ureteroscopy ($23,436 [95% CI $22,281-24,590]). CONCLUSION Patients not infrequently experience an unplanned, high-acuity visit after low-risk procedures to remove urinary stones, and the cost of these encounters is substantial. Interventions are indicated to identify and reduce preventable unplanned visits.
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Affiliation(s)
- Charles D Scales
- Robert Wood Johnson Foundation Clinical Scholars Program and US Department of Veterans Affairs; Department of Urology, University of California, Los Angeles, CA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.
| | | | | | | | | | - Mark S Litwin
- Department of Urology, University of California, Los Angeles, CA; RAND Corporation, Santa Monica, CA; Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, CA
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25
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Kates M, Gorin MA, Deibert CM, Pierorazio PM, Schoenberg MP, McKiernan JM, Bivalacqua TJ. In-hospital death and hospital-acquired complications among patients undergoing partial cystectomy for bladder cancer in the United States. Urol Oncol 2013; 32:53.e9-14. [PMID: 24239467 DOI: 10.1016/j.urolonc.2013.08.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 08/17/2013] [Accepted: 08/19/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Partial cystectomy (PC) is a therapeutic option for select patients with bladder cancer, but its associated perioperative risks and costs are unknown. We estimated annual rates of PC in a nationally representative sample of hospitals, and analyzed whether hospital volume affects postoperative outcomes and costs in patients undergoing PC. METHODS From the Nationwide Inpatient Sample, we selected a weighted cohort of patients with bladder cancer who underwent PC between 2002 and 2008. Differences in length of stay, charges, and clinical outcomes were calculated based on operative volume, and univariate and multivariate regression models were fitted to predict in-hospital mortality (IHM) and hospital-acquired conditions. RESULTS A total of 10,780 patients with bladder cancer who underwent PC were identified with an annual rate between 1457 and 1628 cases. IHM rates were 1.8%, constituting 195 patients (between 9 and 46 annually). A total of 417 patients (3.9%) experienced a "never event" complication, which Medicare no longer reimburses. The mean annual hospital volume of patients who died was 1.7 cases/y compared with 2.4 cases/y among those without fatal complications. No cases of IHM were identified among hospitals performing at least 5 partial cystectomies/y. In a multivariate regression model increased hospital volume was independently associated with decreased mortality (odds ratio = 0.70, 95% confidence interval; 0.60-0.80). CONCLUSIONS Approximately 1 in 25 patients undergoing PC experience a hospital-acquired complication, and nearly 1 in 50 die as a result of the operation. For each additional case a hospital performs annually, the risk of IHM decreases by 30%.
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Affiliation(s)
- Max Kates
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Michael A Gorin
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Phillip M Pierorazio
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Mark P Schoenberg
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - James M McKiernan
- Department of Urology, Columbia University Medical Center, New York, NY
| | - Trinity J Bivalacqua
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD
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26
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Smaldone MC, Simhan J, Kutikov A, Canter DJ, Starkey R, Zhu F, Nielsen ME, Stitzenberg KB, Greenberg RE, Uzzo RG. Trends in regionalization of radical cystectomy in three large northeastern states from 1996 to 2009. Urol Oncol 2013; 31:1663-9. [DOI: 10.1016/j.urolonc.2012.04.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 03/24/2012] [Accepted: 04/20/2012] [Indexed: 02/06/2023]
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27
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Trinh VQ, Trinh QD, Tian Z, Hu JC, Shariat SF, Perrotte P, Karakiewicz PI, Sun M. In-hospital mortality and failure-to-rescue rates after radical cystectomy. BJU Int 2013; 112:E20-7. [PMID: 23795794 DOI: 10.1111/bju.12214] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To show the underlying variability in peri-operative mortality after radical cystectomy (RC) by analysing failure-to-rescue (FTR) rates, i.e. deaths after complications. MATERIALS AND METHODS Patients undergoing RC for non-metastatic bladder cancer (BCa) were identified from the Nationwide Inpatient Sample, 1999-2009, resulting in a weighted estimate of 79,972 patients. The FTR rates were assessed according to patient and hospital characteristics, as well as complication type. Generalized linear regression analyses were performed. RESULTS Overall, 26,740 patients had a complication, corresponding to a FTR rate of 5.5%. Septicaemia (odds ratio [OR]: 13.41, P < 0.001) and cardiac (OR: 3.97, P < 0.001), wound-related (OR: 2.12, P < 0.001), genitourinary (OR: 1.62, P = 0.045) and haematological (OR: 1.78, P = 0.008) complications were associated with FTR. Older age (OR: 1.05, P < 0.001), increasing comorbidities (OR: 1.33, P < 0.001), Medicare (OR: 1.52, P = 0.016), and Medicaid insurance status (OR: 2.10, P = 0.029) were associated with higher odds of FTR. Conversely, increasing hospital volume (OR: 0.992, P = 0.014) reduced the odds of FTR. CONCLUSIONS Whereas both patient and hospital characteristics were associated with increased odds of FTR, the occurrence of septicaemia and cardiac complications were the most strongly associated with a higher risk of in-hospital mortality.
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Affiliation(s)
- Vincent Q Trinh
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI 48202, USA.
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Jacobs BL, Miller DC. The Volume Outcome Relationship in Urology: Moving the Field Forward. J Urol 2012; 188:2037-8. [DOI: 10.1016/j.juro.2012.09.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Bruce L. Jacobs
- Department of Urology, Divisions of Oncology and Health Services Research, University of Michigan, Ann Arbor, Michigan
| | - David C. Miller
- Department of Urology, Divisions of Oncology and Health Services Research, University of Michigan, Ann Arbor, Michigan
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Smith MD, Patterson E, Wahed AS, Belle SH, Courcoulas AP, Flum D, Khandelwal S, Mitchell JE, Pomp A, Pories WJ, Wolfe B. Can technical factors explain the volume-outcome relationship in gastric bypass surgery? Surg Obes Relat Dis 2012; 9:623-9. [PMID: 23274125 DOI: 10.1016/j.soard.2012.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 07/19/2012] [Accepted: 09/14/2012] [Indexed: 01/14/2023]
Abstract
BACKGROUND The existence of a relationship between surgeon volume and patient outcome has been reported for different complex surgical operations. This relationship has also been confirmed for patients undergoing Roux-en-Y gastric bypass (RYGB) in the Longitudinal Assessment of Bariatric Surgery (LABS) study. Despite multiple studies demonstrating volume-outcome relationships, fewer studies investigate the causes of this relationship. OBJECTIVE The purpose of the present study is to understand possible explanations for the volume-outcome relationship in LABS. METHODS LABS includes a 10-center, prospective study examining 30-day outcomes after bariatric surgery. The relationship between surgeon annual RYGB volume and incidence of a composite endpoint (CE) has been published previously. Technical aspects of RYGB surgery were compared between high and low volume surgeons. The previously published model was adjusted for select technical factors. RESULTS High-volume surgeons (>100 RYGBs/yr) were more likely to perform a linear stapled gastrojejunostomy, use fibrin sealant, and place a drain at the gastrojejunostomy compared with low-volume surgeons (<25 RYGBs/yr), and less likely to perform an intraoperative leak test. After adjusting for the newly identified technical factors, the relative risk of CE was .93 per 10 RYGB/yr increase in volume, compared with .90 for clinical risk adjustment alone. CONCLUSION High-volume surgeons exhibited certain differences in technique compared with low-volume surgeons. After adjusting for these differences, the strength of the volume-outcome relationship previously found was reduced only slightly, suggesting that other factors are also involved.
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Yap SA, Horovitz D, Alibhai SMH, Abouassaly R, Timilshina N, Finelli A. Predictors of early mortality after radical nephrectomy with renal vein or inferior vena cava thrombectomy - a population-based study. BJU Int 2012; 110:1283-8. [PMID: 22500493 DOI: 10.1111/j.1464-410x.2012.11125.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
UNLABELLED Study Type - Prognosis (cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Surgical volume has been well established as a predictor of outcomes for several complex surgical procedures, yet few studies have evaluated this relationship with regards to radical nephrectomy with either renal vein or inferior vena cava thrombectomy. In addition, most published literature consists of single-institution series from centres of excellence. We performed a population-level analysis and identified surgeon volume as a significant predictor of short-term mortality for this procedure. Such findings have potential implications regarding future policy and regionalization of care. OBJECTIVE • To study the short-term mortality associated with radical nephrectomy with renal vein or inferior vena cava thrombectomy and the variables associated with this adverse outcome. METHODS • Using the Ontario Cancer Registry, we identified 433 patients in the province of Ontario, Canada undergoing radical nephrectomy with venous thrombectomy between 1995 and 2004. • We determined mortality rates at postoperative days 30 and 90. • Other variables analysed include pathological tumour characteristics, surgeon graduation year, hospital/surgeon academic status, surgery year and hospital/surgeon volume. • We used multivariable logistic regression to assess outcomes. RESULTS • Overall mortality was 2.8% (30-day) and 5.8% (90-day). • Surgeons performing a single nephrectomy with venous thrombectomy performed 14% of the cases and had the highest 30-day (6.7%) and 90-day (10%) mortality. The mortality rate for surgeons performing more than one surgery was 2.1% (30-day) and 5.1% (90-day). • In recent years, this procedure was performed more commonly by the highest volume surgeons - 67% of cases in 2004 vs 40% in 1995. • Significant predictors of 30-day mortality included procedure year and low surgeon volume. • Significant predictors of 90-day mortality included procedure year, low surgeon volume, left-sided tumour and increasing hospital volume. CONCLUSIONS • For radical nephrectomy with venous thrombectomy, surgeon volume predicts short-term mortality, emphasizing the importance of experience in patient outcome. • Despite a shift towards high-volume surgeons, 13.8% of cases continued to be performed by low-volume providers. • If these results are confirmed in other jurisdictions, radical nephrectomy with venous thrombectomy should be regionalized and performed by surgeons who manage these cases regularly.
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Affiliation(s)
- Stanley A Yap
- Division of Urologic Oncology, Princess Margaret Hospital and Department of Health Policy, University of Toronto, Toronto, Ontario, Canada
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de Vries R, Kauer P, van Tinteren H, van der Poel H, Bex A, Meinhardt W, van Haarst E, Horenblas S. Short-Term Outcome after Cystectomy: Comparison of Two Different Perioperative Protocols. Urol Int 2012; 88:383-9. [DOI: 10.1159/000336155] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 12/27/2011] [Indexed: 11/19/2022]
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Liedberg F, Holmberg E, Holmäng S, Ljungberg B, Malmström PU, Månsson W, Nunez L, Wessman C, Wijkström H, Jahnson S. Long-term follow-up after radical cystectomy with emphasis on complications and reoperations: A Swedish population-based survey. ACTA ACUST UNITED AC 2011; 46:14-8. [DOI: 10.3109/00365599.2011.609835] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | - Erik Holmberg
- Department of Urology,
Sahlgrenska University Hospital Göteborg, Sweden
| | - Sten Holmäng
- Department of Surgical and Perioperative Sciences,
Urology and Andrology, Umeå, Sweden
| | - Börje Ljungberg
- Department of Urology,
Akademiska University Hospital, Uppsala, Sweden
| | | | - Wiking Månsson
- Department of Urology,
Karolinska University Hospital, Stockholm, Sweden
| | - Leyla Nunez
- Oncologic Centre Sahlgrenska University Hospital, Göteborg, Sweden
| | - Catrin Wessman
- Oncologic Centre Sahlgrenska University Hospital, Göteborg, Sweden
| | - Hans Wijkström
- Oncologic Centre Sahlgrenska University Hospital, Göteborg, Sweden
| | - Staffan Jahnson
- Department of Urology,
Linköping University Hospital, Linköping, Sweden
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Stitzenberg KB, Wong YN, Nielsen ME, Egleston BL, Uzzo RG. Trends in radical prostatectomy: centralization, robotics, and access to urologic cancer care. Cancer 2011; 118:54-62. [PMID: 21717436 DOI: 10.1002/cncr.26274] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 03/11/2011] [Accepted: 03/14/2011] [Indexed: 11/07/2022]
Abstract
BACKGROUND Robotic surgery has been widely adopted for radical prostatectomy. We hypothesized that this change is rapidly shifting procedures away from hospitals that do not offer robotics and consequently increasing patient travel. METHODS A population-based observational study of all prostatectomies for cancer in New York, New Jersey, and Pennsylvania from 2000 to 2009 was performed using hospital discharge data. Hospital procedure volume was defined as the number of prostatectomies performed for cancer in a given year. Straight-line travel distance to the treating hospital was calculated for each case. Hospitals were contacted to determine the year of acquisition of the first robot. RESULTS From 2000 to 2009, the total number of prostatectomies performed annually increased substantially. The increase occurred almost entirely at the very high-volume centers (≥ 106 prostatectomies/year). The number of hospitals performing prostatectomy fell 37% from 2000 to 2009. By 2009, the 9% (21/244) of hospitals that had very high volume performed 57% of all prostatectomies, and the 35% (86/244) of hospitals with a robot performed 85% of all prostatectomies. The median travel distance increased 54% from 2000 to 2009 (P<.001). The proportion of patients traveling ≥ 15 miles increased from 24% to 40% (P < .001). CONCLUSIONS Over the past decade, the number of radical prostatectomies performed has risen substantially. These procedures have been increasingly centralized at high-volume centers, leading to longer patient travel distances. Few prostatectomies are now performed at hospitals that do not offer robotic surgery.
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Affiliation(s)
- Karyn B Stitzenberg
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina 27599-7213, USA.
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Tan HJ, Wolf JS, Ye Z, Wei JT, Miller DC. Population-level comparative effectiveness of laparoscopic versus open radical nephrectomy for patients with kidney cancer. Cancer 2011; 117:4184-93. [PMID: 21365632 DOI: 10.1002/cncr.26014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 01/27/2011] [Accepted: 01/31/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND Because there is limited population-based evidence supporting the comparative effectiveness of laparoscopic radical nephrectomy (LRN) after its widespread adoption, we compared trends in hospital-based outcomes among patients with kidney cancer treated with LRN or open radical nephrectomy (ORN). METHODS Using linked SEER-Medicare data, the authors identified patients with kidney cancer who were treated with LRN or ORN from 2000 through 2005. The authors measured 4 primary outcomes: intensive care unit (ICU) admission, prolonged length of stay, 30-day hospital readmission, and in-hospital mortality. The authors then estimated the association between surgical approach and each outcome, adjusting for patient demographics, tumor characteristics, and year of surgery. RESULTS The authors identified 2108 (26%) and 5895 (74%) patients treated with LRN and ORN, respectively. Patients treated with LRN were more likely to be white, female, of higher socioeconomic position, and to have tumor sizes of ≤4 cm (all P < .05). The adjusted probability of ICU admission and prolonged length of stay was 41% and 46% lower, respectively, for patients undergoing LRN (P < .001). Although uncommon for both groups, the adjusted probability of in-hospital mortality was 51% higher (2.3% vs 1.5%, P = .04) for patients treated with a laparoscopic approach. CONCLUSIONS At a population level, patients treated with LRN have a lower likelihood of ICU admission and prolonged length of stay, supporting the convalescence benefits of laparoscopy. In-hospital mortality, however, was higher among patients treated with LRN. The latter finding suggests a potentially unanticipated consequence of this technique and highlights the need for long-term monitoring during and after the widespread adoption of new surgical technologies.
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Affiliation(s)
- Hung-Jui Tan
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan 48109-2800, USA
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Mayer EK, Bottle A, Aylin P, Darzi AW, Athanasiou T, Vale JA. The volume-outcome relationship for radical cystectomy in England: an analysis of outcomes other than mortality. BJU Int 2011; 108:E258-65. [PMID: 21314812 DOI: 10.1111/j.1464-410x.2010.10010.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE •To evaluate the volume-outcome relationship for radical cystectomy in England using outcomes other than mortality. PATIENTS AND METHODS •Patients undergoing an elective radical cystectomy were extracted from administrative hospital data for financial years 2000/1 to 2006/7. •Institutional and surgeon volume was assessed against postoperative re-intervention, postoperative complications and emergency readmission within 28 days, using a set of models accounting for patient case-mix, the 'clustered' nature of the data and structural and process of care measures. RESULTS •In the final model, the odds of re-intervention within 14 and 30 days of operation for medium-volume institutions compared to low-volume institutions were found to be 63% (odds ratio, OR, 1.63; 95% CI 1.15-2.32; P= 0.01) and 52% (OR, 1.52; 95% CI, 1.13-2.04; P= 0.01) higher, respectively. •In the summary of adjusted probabilities, low-volume institutions appeared to have a lower re-intervention rate than both medium- and high-volume institutions. •By contrast, high-volume surgeons were associated with a reduced odds (OR, 0.68; 95% CI, 0.51-0.91; P= 0.01) of early re-intervention (within 14 days) compared to low-volume surgeons. •This surgeon volume-outcome effect became apparent only after adjusting for the influence of the institution and structural and process of care confounders. •There was no statistically significant relationship between volume and complication or readmission rates. CONCLUSIONS •Radical cystectomy measures of re-intervention rates can be used as outcome measures to discern differences across institutional or surgeon volume providers when the institutional and surgeon volume are co-examined and adjustment for structural and process of care confounders is performed. •The finding of a lower risk of re-intervention in low-volume institutions needs to be explored further.
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Affiliation(s)
- Erik K Mayer
- Department of Surgery and Cancer, 10th Floor QEQM Building, St Mary’s Hospital Campus, Imperial College London, London W2 1NY, UK.
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Porter MP, Gore JL, Wright JL. Hospital volume and 90-day mortality risk after radical cystectomy: a population-based cohort study. World J Urol 2010; 29:73-7. [DOI: 10.1007/s00345-010-0626-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 11/19/2010] [Indexed: 11/28/2022] Open
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Mayer EK, Bottle A, Darzi AW, Athanasiou T, Vale JA. The volume-mortality relation for radical cystectomy in England: retrospective analysis of hospital episode statistics. BMJ 2010; 340:c1128. [PMID: 20305302 PMCID: PMC2842924 DOI: 10.1136/bmj.c1128] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the relation between volume and mortality after adjustment for case mix for radical cystectomy in the English healthcare setting using improved statistical methodology, taking into account the institutional and surgeon volume effects and institutional structural and process of care factors. DESIGN Retrospective analysis of hospital episode statistics using multilevel modelling. SETTING English hospitals carrying out radical cystectomy in the seven financial years 2000/1 to 2006/7. PARTICIPANTS Patients with a primary diagnosis of cancer undergoing an inpatient elective cystectomy. MAIN OUTCOME MEASURE Mortality within 30 days of cystectomy. RESULTS Compared with low volume institutions, medium volume ones had a significantly higher odds of in-hospital and total mortality: odds ratio 1.72 (95% confidence interval 1.00 to 2.98, P=0.05) and 1.82 (1.08 to 3.06, P=0.02). This was only seen in the final model, which included adjustment for structural and processes of care factors. The surgeon volume-mortality relation showed weak evidence of reduced odds of in-hospital mortality (by 35%) for the high volume surgeons, although this did not reach statistical significance at the 5% level. CONCLUSIONS The relation between case volume and mortality after radical cystectomy for bladder cancer became evident only after adjustment for structural and process of care factors, including staffing levels of nurses and junior doctors, in addition to case mix. At least for this relatively uncommon procedure, adjusting for these confounders when examining the volume-outcome relation is critical before considering centralisation of care to a few specialist institutions. Outcomes other than mortality, such as functional morbidity and disease recurrence may ultimately influence towards centralising care.
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Affiliation(s)
- Erik K Mayer
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital Campus, London W2 1NY.
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Chade DC, Laudone VP, Bochner BH, Parra RO. Oncological Outcomes After Radical Cystectomy for Bladder Cancer: Open Versus Minimally Invasive Approaches. J Urol 2010; 183:862-69. [PMID: 20083269 DOI: 10.1016/j.juro.2009.11.019] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Indexed: 11/28/2022]
Affiliation(s)
- Daher C. Chade
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
- Division of Urology, University of Sao Paulo, Sao Paulo, Brazil
| | - Vincent P. Laudone
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Bernard H. Bochner
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Raul O. Parra
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
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40
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Outcome of treatment of bladder cancer: a comparison between low-volume hospitals and an oncology centre. World J Urol 2010; 28:431-7. [DOI: 10.1007/s00345-010-0512-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 01/19/2010] [Indexed: 10/19/2022] Open
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Smaldone MC, Corcoran AT, Hayn M, Konety BR, Hrebinko RL, Davies BJ. Estimating Postoperative Mortality and Morbidity Risk of Radical Cystectomy With Continent Diversion Using Predictor Equations. J Urol 2009; 182:2619-24. [DOI: 10.1016/j.juro.2009.08.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Marc C. Smaldone
- Departments of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and University of California-San Francisco and Helen Diller Family Comprehensive Cancer Center, San Francisco (BRK), California
| | - Anthony T. Corcoran
- Departments of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and University of California-San Francisco and Helen Diller Family Comprehensive Cancer Center, San Francisco (BRK), California
| | - Matthew Hayn
- Departments of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and University of California-San Francisco and Helen Diller Family Comprehensive Cancer Center, San Francisco (BRK), California
| | - Badrinath R. Konety
- Departments of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and University of California-San Francisco and Helen Diller Family Comprehensive Cancer Center, San Francisco (BRK), California
| | - Ronald L. Hrebinko
- Departments of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and University of California-San Francisco and Helen Diller Family Comprehensive Cancer Center, San Francisco (BRK), California
| | - Benjamin J. Davies
- Departments of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and University of California-San Francisco and Helen Diller Family Comprehensive Cancer Center, San Francisco (BRK), California
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Abstract
The surgical management of clinically localized bladder cancer is challenging, and the quality of care delivered to patients with bladder cancer is a subject of increasing interest. Multiple large studies have examined the association between surgical volume and outcomes after radical cystectomy. These studies generally find lower mortality and complication rates at high-volume centers, though interpretation of the data must be tempered by limitations of the datasets driving the studies. Benefits of regionalization of care also must be weighed against other measures proven to predict outcomes; a delay in time to cystectomy beyond 3 months, for example, is strongly associated with increased mortality. Other candidate process measures supported by existing literature include adequacy of lymphadenectomy as measured by nodal yield and availability or offering of orthotopic diversion when appropriate. Assessment and reporting of bladder cancer outcomes should be risk adjusted based on oncologic risk factors and patient comorbid illness. Perioperative morbidity and mortality, cause-specific survival, and overall survival are all key measures. Assessment of health-related quality of life after bladder cancer treatment should also be standardized for reporting. Multiple survey instruments have been developed in recent years, but none has yet been well validated or widely adopted. In particular, capturing variation in quality of life outcomes between patients undergoing bladder-sparing protocols vs. continent diversion vs. incontinent diversion is an important but difficult goal that has not yet been met. The urologic oncology community should take a strong lead in achieving consensus regarding the definition, assessment, and reporting of quality of care data for bladder cancer.
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Affiliation(s)
- Matthew R Cooperberg
- Department of Urology, University of California, San Francisco, San Francisco, CA 94143, USA
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Fradet V, Allareddy V, Aaronson DS, Konety BR. Is the Complication Rate of Radical Cystectomy Predictive of the Complication Rate of Other Urological Procedures? J Urol 2009; 181:1054-9; discussion 1059-60. [DOI: 10.1016/j.juro.2008.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Indexed: 11/26/2022]
Affiliation(s)
- Vincent Fradet
- Departments of Urology and Epidemiology, University of California-San Francisco, San Francisco, California, and Department of Epidemiology, Iowa University (VA), Iowa City, Iowa
| | - Veerasathpurush Allareddy
- Departments of Urology and Epidemiology, University of California-San Francisco, San Francisco, California, and Department of Epidemiology, Iowa University (VA), Iowa City, Iowa
| | - David S. Aaronson
- Departments of Urology and Epidemiology, University of California-San Francisco, San Francisco, California, and Department of Epidemiology, Iowa University (VA), Iowa City, Iowa
| | - Badrinath R. Konety
- Departments of Urology and Epidemiology, University of California-San Francisco, San Francisco, California, and Department of Epidemiology, Iowa University (VA), Iowa City, Iowa
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Housri N, Weil RJ, Shalowitz DI, Koniaris LG. Should informed consent for cancer treatment include a discussion about hospital outcome disparities? PLoS Med 2008; 5:e214. [PMID: 18942888 PMCID: PMC2570421 DOI: 10.1371/journal.pmed.0050214] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Several studies have found disparities in the outcome of medical procedures across different hospitals--better outcomes have been associated with higher procedure volume. An Institute of Medicine workshop found such a "volume-outcome relationship" for two types of cancer surgery: resection of the pancreas and esophagus (http://www.iom.edu/?id=31508). This debate examines whether physicians have an ethical obligation to inform patients of hospital outcome disparities for these cancers.
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Mayer EK, Purkayastha S, Athanasiou T, Darzi A, Vale JA. Assessing the quality of the volume-outcome relationship in uro-oncology. BJU Int 2008; 103:341-9. [PMID: 18990134 DOI: 10.1111/j.1464-410x.2008.08021.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess systematically the quality of evidence for the volume-outcome relationship in uro-oncology, and thus facilitate the formulating of health policy within this speciality, as 'Implementation of Improving Outcome Guidance' has led to centralization of uro-oncology based on published studies that have supported a 'higher volume-better outcome' relationship, but improved awareness of methodological drawbacks in health service research has questioned the strength of this proposed volume-outcome relationship. METHODS We systematically searched previous relevant reports and extracted all articles from 1980 onwards assessing the volume-outcome relationship for cystectomy, prostatectomy and nephrectomy at the institution and/or surgeon level. Studies were assessed for their methodological quality using a previously validated rating system. Where possible, meta-analytical methods were used to calculate overall differences in outcome measures between low and high volume healthcare providers. RESULTS In all, 22 studies were included in the final analysis; 19 of these were published in the last 5 years. Only four studies appropriately explored the effect of both the institution and surgeon volume on outcome measures. Mortality and length of stay were the most frequently measured outcomes. The median total quality scores within each of the operation types were 8.5, 9 and 8 for cystectomy, prostatectomy and nephrectomy, respectively (possible maximum score 18). Random-effects modelling showed a higher risk of mortality in low-volume institutions than in higher-volume institutions for both cystectomy and nephrectomy (odds ratio 1.88, 95% confidence interval 1.54-2.29, and 1.28, 1.10-1.49, respectively). CONCLUSION The methodological quality of volume-outcome research as applied to cystectomy, prostatectomy and nephrectomy is only modest at best. Accepting several limitations, pooled analysis confirms a higher-volume, lower-mortality relationship for cystectomy and nephrectomy. Future research should focus on the development of a quality framework with a validated scoring system for the bench-marking of data to improve validity and facilitate rational policy-making within the speciality of uro-oncology.
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Affiliation(s)
- Erik K Mayer
- Department of Urology, St Mary's Hospital Campus, Imperial College Healthcare NHS Trust, London, UK.
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47
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Abstract
Extensive literature supports the correlation between surgical volume and improved clinical outcome in the management of various cancers. It is this evidence that has catalysed the creation of centres of excellence. However, on closer inspection, many of these studies are poor quality, low weight and use vastly heterogenous end points in assessment of both volume and outcome. We critically appraise the English language literature published over the last ten years pertaining to the volume outcome relationship in the context of cancer care. Future balanced unbiased studies may enable equipoise in planning international cancer management strategies.
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Affiliation(s)
- A M Hogan
- Institute of Clinical Outcomes in Research and Education (ICORE), St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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48
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May M, Fuhrer S, Braun KP, Brookman-Amissah S, Richter W, Hoschke B, Vogler H, Siegsmund M. Results from three municipal hospitals regarding radical cystectomy on elderly patients. Int Braz J Urol 2007; 33:764-73; discussion 774-6. [DOI: 10.1590/s1677-55382007000600004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2007] [Indexed: 11/22/2022] Open
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49
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Cooperberg MR, Modak S, Konety BR. Trends in regionalization of inpatient care for urological malignancies, 1988 to 2002. J Urol 2007; 178:2103-8; discussion 2108. [PMID: 17870128 DOI: 10.1016/j.juro.2007.07.040] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE Higher hospital and clinician volumes may be associated with improved patient outcomes for complex surgical and medical care, although the strength and consistency of this association varies markedly across specific conditions and procedures. Pressures from payors and policymakers exist to move complex care to high volume hospitals. The net effect of these pressures may be the regionalization of care. We quantified trends in the regionalization of inpatient care for urological oncology in a national administrative database. MATERIALS AND METHODS The Nationwide Inpatient Sample, a 20% stratified sample of United States community hospital admissions, was queried for surgical and nonsurgical admissions for bladder, renal and prostate cancer care between 1988 and 2002. Hospitals were grouped into tertiles by annual surgical volume. Trends over time in the annual discharge rate by hospital volume tertile, geographic region and insurance status were analyzed. RESULTS High volume hospitals were defined by at least 22, 12 and 26 cases per year for bladder, renal and prostate cancer, respectively. High volume hospital discharges increased significantly as a proportion of all discharges for bladder (67% to 70%) and renal (67% to 73%) cancer surgery, and they were essentially constant for prostate surgery (76%). Trends were similar for Medicare and Medicaid patients except high volume hospital discharges for prostate cancer decreased during the study period. Significant regional variation was observed for the regionalization of surgical and nonsurgical care. CONCLUSIONS Nationwide Inpatient Sample data demonstrate the ongoing regionalization of urological oncology care. The policy implications of this trend are complex with potentially important benefits and risks in terms of access to and quality of care.
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Affiliation(s)
- Matthew R Cooperberg
- Urologic Outcomes Research Group, Program in Urologic Oncology, Department of Urology, University of California-San Francisco Comprehensive Cancer Center, California 94115-1711, USA
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