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Munir MM, Rashid Z, Endo Y, Dillhoff M, Tsai S, Pawlik TM. Association between quality metric adherence and overall survival among patients undergoing resection of pancreatic ductal adenocarcinoma. Surgery 2024; 176:873-879. [PMID: 38890100 DOI: 10.1016/j.surg.2024.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/16/2024] [Accepted: 04/29/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Process-based quality metrics are important for improving long-term outcomes after surgical resection. We sought to develop a practical surgical quality score for patients diagnosed with pancreatic ductal adenocarcinoma undergoing curative-intent resection. METHODS Patients who underwent surgical resection for pancreatic ductal adenocarcinoma between 2010 and 2017 were identified using the National Cancer Database. Five surgical quality metrics were defined: minimally invasive approach, adequate lymphadenectomy, negative surgical margins, receipt of adjuvant therapy, and no prolonged hospitalization. Log-rank test and multivariable Cox regression analysis were used to determine the association of quality metrics with overall survival. RESULTS A total of 38,228 patients underwent curative-intent resection for pancreatic ductal adenocarcinoma. Median age at diagnosis was 68 years (interquartile range = 61-75), and roughly half the cohort was male (n = 19,562; 51.2%). Quality metrics were achieved on a varied basis: minimally invasive approach (n = 5,701; 14.9%), adequate lymphadenectomy (n = 27,122; 80.0%), negative surgical margin (n = 29,248; 76.5%), receipt of adjuvant therapy (n = 26,006; 68.0%), and absence of prolonged hospitalization (n = 26,470; 69.2%). An integer-based surgical quality score from 0 (no quality metrics) to 16 (all quality metrics) was calculated. Patients with higher scores had progressively better overall survival. Median overall survival differed substantially among the score categories (score = 0-4 points, 8.7 [8.0-9.6] months; 5-8 points, 17.5 [16.9-18.2] months; 9-12 points, 22.1 [21.6-22.8] months; and 13-16 points, 30.8 [30.2-31.3] months; P < .001). On multivariable analysis, risk-adjusted mortality hazards decreased in a stepwise manner with higher scores (0-4 points: reference; 5-8 points: multivariable adjusted hazard ratio = 0.60; 95% CI, 0.57-0.63; 9-12 points: adjusted hazard ratio = 0.49; 95% CI, 0.47-0.52; 13-16 points: and adjusted hazard ratio = 0.37; 95% CI, 0.34-0.40; all P < .001). CONCLUSION Adherence to quality metrics may be associated with improved overall survival. Efforts aimed at increasing compliance with quality metric measures may help optimize long-term outcomes among patients undergoing surgical resection for pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Susan Tsai
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Lu PW, Lyu HG, Prakash LR, Chiang YJS, Maxwell JE, Snyder RA, Kim MP, Tzeng CWD, Katz MHG, Ikoma N. Effect of surgical approach on early return to intended oncologic therapy after resection for pancreatic ductal adenocarcinoma. Surg Endosc 2024:10.1007/s00464-024-11022-3. [PMID: 38987482 DOI: 10.1007/s00464-024-11022-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/30/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Although robotic pancreatectomy may facilitate an earlier functional recovery, the impact of a robotic pancreatectomy program during its early experience on the timing of return to intended oncologic therapy (RIOT) after surgery is unknown. METHODS In this retrospective cohort study, we used propensity score matching with a 1:2 ratio to compare patients who underwent robotic or open surgery (distal pancreatectomy or pancreatoduodenectomy) for pancreatic ductal adenocarcinoma (PDAC) during the first 3 years of our robotic pancreatectomy experience (January 2018-December 2021). Generalized estimating equations modeling was used to evaluate the effect of surgical approach on early RIOT, defined as adjuvant chemotherapy initiation within 8 weeks after surgery, and late RIOT, defined as initiation within 12 weeks after surgery. RESULTS The matched cohort included 26 patients who underwent robotic pancreatectomy and 52 patients who underwent open pancreatectomy. Rates of receipt of adjuvant chemotherapy were 96.2% and 78.9%, respectively. Rate of early RIOT in the robotic group (73.1% was higher than that in the open group (44.2%; P = 0.018). In multivariable analysis, a robotic approach was associated with early RIOT (odds ratio, 3.54; 95% confidence interval 1.08-11.62; P = 0.038). Surgical approach did not impact late RIOT (odds ratio, 3.21; 95% confidence interval 0.71-14.38; P = 0.128). CONCLUSIONS Compared with open pancreatectomy, robotic pancreatectomy did not delay RIOT. In fact, odds of early RIOT were increased, which supports the oncological safety of our robotic pancreatectomy program during its implementation.
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Affiliation(s)
- Pamela W Lu
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Heather G Lyu
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Yi-Ju Sabrina Chiang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
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Saadat LV, Wei AC. ASO Author Reflections: Improving Outcomes and Minimizing Variability in Pancreatic Cancer Care: A Study of Ontario and the United States. Ann Surg Oncol 2024; 31:1937-1938. [PMID: 37865939 DOI: 10.1245/s10434-023-14463-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 10/24/2023]
Affiliation(s)
- Lily V Saadat
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Are C, Murthy SS, Sullivan R, Schissel M, Chowdhury S, Alatise O, Anaya D, Are M, Balch C, Bartlett D, Brennan M, Cairncross L, Clark M, Deo SVS, Dudeja V, D'Ugo D, Fadhil I, Giuliano A, Gopal S, Gutnik L, Ilbawi A, Jani P, Kingham TP, Lorenzon L, Leiphrakpam P, Leon A, Martinez-Said H, McMasters K, Meltzer DO, Mutebi M, Zafar SN, Naik V, Newman L, Oliveira AF, Park DJ, Pramesh CS, Rao S, Subramanyeshwar Rao T, Bargallo-Rocha E, Romanoff A, Rositch AF, Rubio IT, Salvador de Castro Ribeiro H, Sbaity E, Senthil M, Smith L, Toi M, Turaga K, Yanala U, Yip CH, Zaghloul A, Anderson BO. Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide. Lancet Oncol 2023; 24:e472-e518. [PMID: 37924819 DOI: 10.1016/s1470-2045(23)00412-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 11/06/2023]
Abstract
The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.
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Affiliation(s)
- Chandrakanth Are
- Division of Surgical Oncology, Department of Surgery, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Shilpa S Murthy
- Division of Surgical Oncology, Department of Surgery, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Richard Sullivan
- Institute of Cancer Policy, School of Cancer Sciences, King's College London, London, UK
| | - Makayla Schissel
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sanjib Chowdhury
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Olesegun Alatise
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - Daniel Anaya
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Madhuri Are
- Division of Pain Medicine, Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Charles Balch
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX, Global Cancer Surgery: pragmatic solutions to improve USA
| | - David Bartlett
- Department of Surgery, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Murray Brennan
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lydia Cairncross
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Matthew Clark
- University of Auckland School of Medicine, Auckland, New Zealand
| | - S V S Deo
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Dudeja
- Division of Surgical Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Domenico D'Ugo
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | | | - Armando Giuliano
- Cedars-Sinai Medical Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, Washington DC, USA
| | - Lily Gutnik
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andre Ilbawi
- Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
| | - Pankaj Jani
- Department of Surgery, University of Nairobi, Nairobi, Kenya
| | | | - Laura Lorenzon
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Premila Leiphrakpam
- Division of Surgical Oncology, Department of Surgery, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Augusto Leon
- Department of Surgical Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Kelly McMasters
- Division of Surgical Oncology, Hiram C Polk, Jr MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - David O Meltzer
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University Hospital, Nairobi, Kenya
| | - Syed Nabeel Zafar
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Vibhavari Naik
- Department of Anesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India
| | - Lisa Newman
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | | | - Do Joong Park
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - C S Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Saieesh Rao
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - T Subramanyeshwar Rao
- Department of Surgical Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India
| | | | - Anya Romanoff
- Department of Global Health and Health System Design, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Isabel T Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | | | - Eman Sbaity
- Division of General Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Maheswari Senthil
- Division of Surgical Oncology, Department of Surgery, University of California, Irvine, Irvine, CA, USA
| | - Lynette Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Masakazi Toi
- Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, Tokyo, Japan
| | - Kiran Turaga
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ujwal Yanala
- Surgical Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Cheng-Har Yip
- Department of Surgery, University of Malaya, Kuala Lumpur, Malaysia
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Pearson EE, Chakraborty NM, Baum SE, Menzel JL, Dijkerman S, Chowdhury R, Chekol BM, Adojutelegan YA, Bercu C, Powell B, Montagu D, Sprockett A, Gerdts C. Developing and validating an abortion care quality metric for facility and out-of-facility settings: an observational cohort study in Bangladesh, Ethiopia, and Nigeria. EClinicalMedicine 2023; 66:102347. [PMID: 38125934 PMCID: PMC10730338 DOI: 10.1016/j.eclinm.2023.102347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/24/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023] Open
Abstract
Background Despite progress in assuring provision of safe abortion, substantial disparities remain in quality of abortion care around the world. However, no consistent, valid, reliable method exists to routinely measure quality in abortion care across facility and out-of-facility settings, impeding learning and improvement. To address this need, the Abortion Service Quality Initiative developed the first global standard for measuring quality of abortion care in low-income and middle-income countries. Methods This prospective cohort study was conducted in Bangladesh, Ethiopia, and Nigeria in 2020-2022. Participants included sites and providers offering abortion care, including health facilities, pharmacies, proprietary and patent medicine vendors (PPMVs), and hotlines, and clients aged 15-49 receiving abortion care from a selected site. 111 structure and process indicators were tested, which originated from a review of existing abortion quality indicators and from qualitative research to develop additional client-centred quality indicators. The indicators were tested against 12 clinical and client experience outcomes at the site-level (such as abortion-related deaths) and client-level (such as whether the client would recommend the service to a friend) that were expected to result from the abortion quality indicators. Indicators were selected for the final metric based on predictive validity assessed using Bayesian models to test associations between indicators and outcomes, content validity, and performance. Findings We included 1915 abortion clients recruited from 131 sites offering abortion care across the three countries. Among the 111 indicators tested, 44 were associated with outcomes in Bayesian analyses and an additional 8 were recommended for inclusion by the study's Resource Group for face validity. These 52 indicators were evaluated on content validity, predictive validity, and performance, and 29 validated indicators were included in the final abortion care quality metric. The 29 validated indicators were feasibility tested among 53 clients and 24 providers from 9 facility sites in Ethiopia and 57 clients and 6 PPMVs from 9 PPMV sites in Nigeria. The median time required to complete each survey instrument indicated feasibility: 10 min to complete the client exit survey, 16 min to complete the provider survey, and 11 min to complete the site checklist. Overall, the indicators performed well. However, all providers in the feasibility test failed two indicators of provider knowledge to competently complete the abortion procedure, and these indicators were subsequently revised to improve performance. Interpretation This study provides 29 validated abortion care quality indicators to assess quality in facility, pharmacy, and hotline settings in low-income and middle-income countries. Future research should validate the Abortion Care Quality (ACQ) Tool in additional abortion care settings, such as telemedicine, online medication abortion (MA) sellers, and traditional abortion providers, and in other geographical and legal settings. Funding The David and Lucile Packard Foundation and the Children's Investment Fund Foundation.
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Affiliation(s)
| | | | - Sarah E. Baum
- Ibis Reproductive Health, Oakland, CA, United States
| | | | | | | | | | | | - Chiara Bercu
- Ibis Reproductive Health, Oakland, CA, United States
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Sugumar K, Hue JJ, Gupta S, Elshami M, Rothermel LD, Ocuin LM, Ammori JB, Hardacre JM, Winter JM. Trends in and Prognostic Significance of Time to Treatment in Pancreatic Cancer: A Population-Based Study. Ann Surg Oncol 2023; 30:8610-8620. [PMID: 37624518 DOI: 10.1245/s10434-023-14221-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION The association of time to treatment (TTT) with survival remains unclear in pancreatic adenocarcinoma (PDAC). In this study, we evaluate the recent trends in TTT, causes for delay, and its effect on survival. METHODS We included patients with PDAC of all stages from the National Cancer Database (2004-2020) who underwent either surgery or chemotherapy/radiotherapy (CT/RT). TTT was defined as the duration between tissue diagnosis and first treatment. Linear regression (β) was used to study the temporal trends in time delay. RESULTS A total of 239,638 patients were included. The median TTT was 25 days. Using multivariable analysis, we found that increasing age (OR 1.48), female gender (OR 1.04), Black race (OR 1.3), lower educational status (OR 1.2), Medicaid, Medicare insurance, and uninsured (OR 1.2, 1.5, and 1.2, respectively), treatment at academic centers (OR 1.3), higher Charlson-Deyo comorbidity index (OR 1.2), and CT/RT (OR 1.5) were associated with increased TTT. There was a steady rise in median TTT from 21 to 28 days between 2004 and 2020 (β = 0.3), suggestive of a worsening trend. Concurrently, there was an increasing trend in utilization of neoadjuvant CT/RT between 2004 and 2020 in early-stage PDAC. On Cox regression, TTT delay was associated with poor overall survival in stage I-IV patients (HR 1.1, 1.1, 1.09, and 1.53, respectively). CONCLUSIONS Delayed treatment approaching 2 months was observed in 10% of the population. The rising temporal trend in TTT may be attributed to the increasing shift toward neoadjuvant CT/RT in early-stage PDAC and/or the increasing use of tissue biopsy prior to surgery.
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Affiliation(s)
- Kavin Sugumar
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, University Hospitals Cleveland Medical, Cleveland, OH, USA.
| | - Jonathan J Hue
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, University Hospitals Cleveland Medical, Cleveland, OH, USA
| | - Shreya Gupta
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, University Hospitals Cleveland Medical, Cleveland, OH, USA
| | - Mohamedraed Elshami
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, University Hospitals Cleveland Medical, Cleveland, OH, USA
| | - Luke D Rothermel
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, University Hospitals Cleveland Medical, Cleveland, OH, USA
| | - Lee M Ocuin
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, University Hospitals Cleveland Medical, Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, University Hospitals Cleveland Medical, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, University Hospitals Cleveland Medical, Cleveland, OH, USA
| | - Jordan M Winter
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, University Hospitals Cleveland Medical, Cleveland, OH, USA
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Augustinus S, Mackay TM, Andersson B, Beane JD, Busch OR, Gleeson EM, Koerkamp BG, Keck T, van Santvoort HC, Tingstedt B, Wellner UF, Williamsson C, Besselink MG, Pitt HA. Ideal Outcome After Pancreatoduodenectomy: A Transatlantic Evaluation of a Harmonized Composite Outcome Measure. Ann Surg 2023; 278:740-747. [PMID: 37476990 PMCID: PMC10549886 DOI: 10.1097/sla.0000000000006037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVE The aim of this study is to define and assess Ideal Outcome in the national or multicenter registries of North America, Germany, the Netherlands, and Sweden. BACKGROUND Assessing outcomes after pancreatoduodenectomy among centers and countries requires a broad evaluation that cannot be captured by a single parameter. Previously, 2 composite outcome measures (textbook outcome and optimal pancreatic surgery) for pancreatoduodenectomy have been described from Europe and the United States. These composites were harmonized into ideal outcome (IO). METHODS This analysis is a transatlantic retrospective study (2018-2020) of patients after pancreatoduodenectomy within the registries from North America, Germany, The Netherlands, and Sweden. After 3 consensus meetings, IO for pancreatoduodenectomy was defined as the absence of all 6 parameters: (1) in-hospital mortality, (2) severe complications-Clavien-Dindo ≥3, (3) postoperative pancreatic fistula-International Study Group of Pancreatic Surgery (ISGPS) grade B/C, (4) reoperation, (5) hospital stay >75th percentile, and (6) readmission. Outcomes were evaluated using relative largest difference (RLD) and absolute largest difference (ALD), and multivariate regression models. RESULTS Overall, 21,036 patients after pancreatoduodenectomy were included, of whom 11,194 (54%) reached IO. The rate of IO varied between 55% in North America, 53% in Germany, 52% in The Netherlands, and 54% in Sweden (RLD: 1.1, ALD: 3%, P <0.001). Individual components varied with an ALD of 2% length of stay, 4% for in-hospital mortality, 12% severe complications, 10% postoperative pancreatic fistula, 11% reoperation, and 9% readmission. Age, sex, absence of chronic obstructive pulmonary disease, body mass index, performance status, American Society of Anesthesiologists (ASA) score, biliary drainage, absence of vascular resection, and histologic diagnosis were associated with IO. In the subgroup of patients with pancreatic adenocarcinoma, country, and neoadjuvant chemotherapy also was associated with improved IO. CONCLUSIONS The newly developed composite outcome measure "Ideal Outcome" can be used for auditing and comparing outcomes after pancreatoduodenectomy. The observed differences can be used to guide collaborative initiatives to further improve the outcomes of pancreatic surgery.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tara M. Mackay
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Joal D. Beane
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas G. Koerkamp
- Department of Surgery, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Tobias Keck
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ulrich F. Wellner
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Henry A. Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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8
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Ruangsin S, Sunpaweravong S, Laohawiriyakamol S. Achievement of benchmark outcomes by a young surgical attendant performing pancreatoduodenectomies. Langenbecks Arch Surg 2023; 408:404. [PMID: 37843626 DOI: 10.1007/s00423-023-03132-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
PURPOSE Pancreatoduodenectomy is a challenging procedure for young general surgeons, and no benchmark outcomes are currently available for young surgeons who have independently performed pancreatoduodenectomies after completing resident training. This study aimed to identify the competency of a young surgeon in performing pancreatoduodenectomies, while ensuring patient safety, from the first case following certification by a General Surgical Board. METHODS A retrospective review of data from the university hospital was performed to assess quality outcomes of a young surgical attendant who performed 150 open pancreatoduodenectomies between July 13, 2006, and July 13, 2020. Primary benchmark outcomes were hospital morbidity, mortality, postoperative pancreatic fistula, postoperative hospital stay, and disease-free survival. RESULTS All benchmark outcomes were achieved by the young surgeon. The 90-day mortality rate was 2.7%, and one patient expired in the hospital (0.7% in-hospital mortality). The overall morbidity rate was 34.7%. Postoperative pancreatic fistula grades B and C were observed in 5.3% and 0% of patients, respectively. The median postoperative hospital stay was 14 days. The 1- and 3-year disease-free survival were 71.3% and 51.4%, respectively. CONCLUSION Pancreatoduodenectomy requires good standards of care as it is associated with high morbidity and mortality. As only one surgeon could be included in this study, our benchmark outcomes must be compared with those of other institutions. CLINICAL TRIAL REGISTRATION The study was registered at Thai Clinical Trials Registry and approved by the United Nations (registration identification TCTR20220714002).
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Affiliation(s)
- Sakchai Ruangsin
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, 15 Kanjanawanich Road, Hat Yai, 90110, Songkhla, Thailand.
| | - Somkiat Sunpaweravong
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, 15 Kanjanawanich Road, Hat Yai, 90110, Songkhla, Thailand
| | - Supparerk Laohawiriyakamol
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, 15 Kanjanawanich Road, Hat Yai, 90110, Songkhla, Thailand
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Barzi A, Kim AJ, Liang CK, West H, Wong D, Wright C, Nathwani N, Vasko CM, Chung V, Rubinson DA, Sachs T. Pancreatic Adenocarcinoma: Real World Evidence of Care Delivery in AccessHope Data. J Pers Med 2023; 13:1377. [PMID: 37763145 PMCID: PMC10532778 DOI: 10.3390/jpm13091377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/02/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Pancreatic adenocarcinoma is an aggressive disease and the delivery of comprehensive care to individuals with this cancer is critical to achieve appropriate outcomes. The identification of gaps in care delivery facilitates the design of interventions to optimize care delivery and improve outcomes in this population. METHODS AccessHope™ is a growing organization that connects oncology subspecialists with treating providers through contracts with self-insured employers. Data from 94 pancreatic adenocarcinoma cases (August 2019-December 2022) in the AccessHope dataset were used to describe gaps in care delivery. RESULTS In all but 6% of cases, the subspecialist provided guideline-concordant recommendations anticipated to improve outcomes. Gaps in care were more pronounced in patients with non-metastatic pancreatic cancer. There was a significant deficiency in germline testing regardless of the stage, with only 59% of cases having completed testing. Only 20% of cases were receiving palliative care or other allied support services. There was no difference in observed care gaps between patients receiving care in the community setting vs. those receiving care in the academic setting. CONCLUSIONS There are significant gaps in the care delivered to patients with pancreatic adenocarcinoma. A concurrent subspecialist review has the opportunity to identify and address these gaps in a timely manner.
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Affiliation(s)
- Afsaneh Barzi
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA;
| | - Angela J. Kim
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
| | - Crystal K. Liang
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
| | - Howard West
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA;
| | - D. Wong
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA;
| | - Carol Wright
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
| | - Nitya Nathwani
- Department of Hematology and Hematopoietic Stem Cell Transplant, City of Hope, Duarte, CA 91011, USA;
| | - Catherine M. Vasko
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
| | - Vincent Chung
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA;
| | | | - Todd Sachs
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
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10
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Sugumar K, Gendi S, Quereshy HA, Gupta S, Hue JJ, Rothermel LD, Ocuin LM, Ammori JB, Hardacre JM, Winter JM. An analysis of time to treatment in patients with pancreatic adenocarcinoma. Surgery 2023; 174:83-90. [PMID: 37105784 DOI: 10.1016/j.surg.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/20/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Currently, no guidelines exist regarding the appropriate time from diagnosis to treatment among pancreatic adenocarcinoma patients. Herein, we aim to define the median time to treatment in pancreatic adenocarcinoma, factors associated with treatment delay, and prognostic significance. METHODS We conducted a retrospective study of pancreatic adenocarcinoma patients, stage I-IV, at a tertiary referral center (2017-2020). We subdivided time to treatment (days) into 4 components: (1) Ti: symptom onset to initial provider evaluation, (2) Tii: initial provider evaluation to diagnosis, (3) Tiii: diagnosis to specialist consultation, (4) Tiv: specialist visit to treatment. RESULTS In total, 217 patients met the inclusion criteria. The median Ti, Tii, Tiii, and Tiv were 20, 12, 4, and 14 days, respectively. The total time to treatment was 75 days. Patients with weight loss had longer Ti (β = 108.6). More frequent hospitalizations (β = 19.5) and misdiagnosis (β = 33.4) were associated with longer Tii. Patients with a history of malignancy (β = 15) or active treatment of a second disease (β = 19.4) had longer Tiii. Poor performance status (β = 6.2) or private insurance (β = 50.2) were associated with a longer Tiv. Black patients had longer Ti+ii+iii+iv (β = 100). Time to treatment was not associated with overall survival (P > .05). CONCLUSION It takes a median time of less than a month for a patient with pancreatic adenocarcinoma to start treatment, even after they visit a primary provider. The greatest opportunity to shorten the overall time to treatment is by having patients seek medical attention earlier (Ti).
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Affiliation(s)
- Kavin Sugumar
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH. http://www.twitter.com/KavinSugumar
| | - Steve Gendi
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Humzah A Quereshy
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Shreya Gupta
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Jonathan J Hue
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Luke D Rothermel
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Lee M Ocuin
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - John B Ammori
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Jeffrey M Hardacre
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH
| | - Jordan M Winter
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH.
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11
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Woodhouse B, Barreto SG, Soreide K, Stavrou GA, Teh C, Pitt H, Di Martino M, Herman P, Lopez-Lopez V, Berrevoet F, Talamonti M, Mikhnevich M, Khatkov I, Webber L, Kaldarov A, Windsor J, Costa Filho OP, Koea J, Soreide K, Teh C, Stavrou GA, Pitt H, Di Martino M, Herman P, Lopez-Lopez V, Barreto SG, Berrevoet F, Teh C, Talamonti M, Mikhnevich M, Di Martino M, Soreide K, Khatkov I, Webber L, Kaldarov A, Pitt H, Windsor J, Costa Filho OP, Stavrou GA, Teh C, Pitt H, Di Martino M, Stavrou GA, Lopez-Lopez V, Stavrou GA, Barreto SG, Di Martino M, Lopez-Lopez V, Koea J. A core set of quality performance indicators for HPB procedures: a global consensus for hepatectomy, pancreatectomy, and complex biliary surgery. HPB (Oxford) 2023:S1365-182X(23)00126-0. [PMID: 37198070 DOI: 10.1016/j.hpb.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/10/2023] [Accepted: 04/18/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Surgery for hepatopancreaticobiliary (HPB) conditions is performed worldwide. This investigation aimed to develop a set of globally accepted procedural quality performance indicators (QPI) for HPB surgical procedures. METHODS A systematic literature review generated a dataset of published QPI for hepatectomy, pancreatectomy, complex biliary surgery and cholecystectomy. Using a modified Delphi process, three rounds were conducted with working groups composed of self-nominating members of the International Hepatopancreaticobiliary Association (IHPBA). The final set of QPI was circulated to the full membership of the IHPBA for review. RESULTS Seven "core" indicators were agreed for hepatectomy, pancreatectomy, and complex biliary surgery (availability of specific services on site, a specialised surgical team with at least two certified HPB surgeons, a satisfactory institutional case volume, synoptic pathology reporting, undertaking of unplanned reintervention procedures within 90 days, the incidence of post-procedure bile leak and Clavien-Dindo grade ≥III complications and 90-day post-procedural mortality). Three further procedure specific QPI were proposed for pancreatectomy, six for hepatectomy and complex biliary surgery. Nine procedure-specific QPIs were proposed for cholecystectomy. The final set of proposed indicators were reviewed and approved by 102 IHPBA members from 34 countries. CONCLUSIONS This work presents a core set of internationally agreed QPI for HPB surgery.
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Affiliation(s)
- Braden Woodhouse
- Department of Oncology, The University of Auckland, Auckland, New Zealand
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Catherine Teh
- Department of Surgery, National Kidney and Transplant Institute, and Department of Surgery, Makati Medical Center and Department of Surgery, St Luke's Medical Center, Metro Manila, Philippines
| | - Henry Pitt
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Jersey, USA
| | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Paulo Herman
- Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Victor Lopez-Lopez
- Clinic and University Virgen de la Arrixaca Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Frederik Berrevoet
- Department for General and HPB Surgery and Liver Transplantation, University Hospital, Ghent, Belgium
| | - Mark Talamonti
- University of Chicago Pritzker School of Medicine, Chicago, USA
| | | | - Igor Khatkov
- Moscow Clinical Scientific Centre, Moscow, Russia
| | | | - Ayrat Kaldarov
- Vishnevsky Centre of Surgery, Ministry of Health, Russia, Moscow, Russian Federation
| | - John Windsor
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Omero P Costa Filho
- Universidade Luterana do Brasil and Hospital Militar de Área de Porto Alegre and Hospital de Clinicas de Porto Alegre, Brazil
| | - Jonathan Koea
- Department of Surgery, The University of Auckland, Auckland, New Zealand.
| | - Kjetil Soreide
- Universidade Luterana do Brasil and Hospital Militar de Área de Porto Alegre and Hospital de Clinicas de Porto Alegre, Brazil; Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Catherine Teh
- Department of Surgery, National Kidney and Transplant Institute, Metro Manila, Philippines; Department of Surgery, Makati Medical Center, Metro Manila, Philippines; Department of Surgery, St Luke's Medical Center, Metro Manila, Philippines
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Henry Pitt
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Jersey, United States of America
| | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Paulo Herman
- Hospital Das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Victor Lopez-Lopez
- Clinic and University Virgen de La Arrixaca Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Frederik Berrevoet
- Department for General and HPB Surgery and Liver Transplantation, University Hospital, Ghent, Belgium
| | - Catherine Teh
- Department of Surgery, National Kidney and Transplant Institute, Philippines; Department of Surgery, Makati Medical Center, Philippines; Department of Surgery, St Luke's Medical Center, Metro Manila, Philippines
| | - Mark Talamonti
- University of Chicago Pritzker School of Medicine, Chicago, United States of America
| | | | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Igor Khatkov
- Moscow Clinical Scientific Centre, Moscow, Russia
| | | | - Ayrat Kaldarov
- Vishnevsky Centre of Surgery, Ministry of Health, Russia, Moscow, Russian Federation
| | - Henry Pitt
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Jersey, United States of America
| | - John Windsor
- The Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Omero P Costa Filho
- Universidade Luterana Do Brazil, Brazil; Hospital Militar de Área de Porto Alegre, Brazil; Hospital de Clinicas de Porto Alegre, Brazil
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Catherine Teh
- Department of Surgery, National Kidney and Transplant Institute, Philippines; Department of Surgery, Makati Medical Center, Philippines; Department of Surgery, St Luke's Medical Center, Metro Manila, Philippines
| | - Henry Pitt
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Jersey, United States of America
| | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Victor Lopez-Lopez
- Clinic and University Virgen de La Arrixaca Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Victor Lopez-Lopez
- Clinic and University Virgen de La Arrixaca Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Jonathan Koea
- The Department of Surgery, The University of Auckland, Auckland, New Zealand
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12
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Sweigert PJ, Ramia JM, Villodre C, Carbonell-Morote S, De-la-Plaza R, Serradilla M, Pawlik TM. Textbook Outcomes in Liver Surgery: a Systematic Review. J Gastrointest Surg 2023:10.1007/s11605-023-05673-1. [PMID: 37069461 DOI: 10.1007/s11605-023-05673-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/26/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Assessment of the quality of care among patients undergoing hepatectomy may be inadequate using traditional "siloed" postoperative surgical outcome metrics. In turn, the combination of several quality metrics into a single composite Textbook Outcome in Liver Surgery (TOLS) may be more representative of "ideal" surgical care. METHODS Adhering to PRISMA guidelines, a search for primary articles on post-operative TOLS evaluation after hepatectomy was performed. Studies that did not present hepatectomy outcomes, pediatric or transplantation populations, duplicated series, and editorials were excluded. Studies were evaluated in aggregate for methodological variation, TOLS rates, factors associated with TOLS, hospital variation, and overall findings. RESULTS Among 207 identified publications, 32 observational cohort studies were selected for inclusion in the review. There was a total of 90,077 hepatic resections performed from 1993 to 2020 in the analytic cohort. While TOLS definitions varied widely, all studies used an "all-or-none" composite structure combining a median of 5 (range: 4-7) discrete parameters. Observed TOLS rates varied in the different reported populations from 11.2 to 77.0%. TOLS was associated with patient, hospital, and operative factors. CONCLUSIONS This systematic review summarizes the contemporary international experience with TOLS to assess surgical performance following hepatobiliary surgery. TOLS is a single composite metric that may be more patient-centered, as well as better suited to quantify "optimal" care and compare performance among centers performing liver surgery.
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Affiliation(s)
- Patrick J Sweigert
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jose M Ramia
- Department of Surgery, Hospital General Universitario Dr. Balmis, Pintor Baeza, 11, 03010, Alicante, Spain.
- Instituto de Investigacion Sanitaria y Biomedica de Alicante (ISABIAL), Alicante, Spain.
- Universidad Miguel Hernández, Alicante, Spain.
| | - Celia Villodre
- Department of Surgery, Hospital General Universitario Dr. Balmis, Pintor Baeza, 11, 03010, Alicante, Spain
- Instituto de Investigacion Sanitaria y Biomedica de Alicante (ISABIAL), Alicante, Spain
| | - Silvia Carbonell-Morote
- Department of Surgery, Hospital General Universitario Dr. Balmis, Pintor Baeza, 11, 03010, Alicante, Spain
- Instituto de Investigacion Sanitaria y Biomedica de Alicante (ISABIAL), Alicante, Spain
| | | | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
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13
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The Timing of Surgery Following Stereotactic Body Radiation Therapy Impacts Local Control for Borderline Resectable or Locally Advanced Pancreatic Cancer. Cancers (Basel) 2023; 15:cancers15041252. [PMID: 36831594 PMCID: PMC9954439 DOI: 10.3390/cancers15041252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
We aimed to evaluate the impact of time from stereotactic body radiation therapy (SBRT) to surgery on treatment outcomes and post-operative complications in patients with borderline resectable or locally advanced pancreatic cancer (BRPC/LAPC). We conducted a single-institutional retrospective analysis of patients with BRPC/LAPC treated from 2016 to 2021 with neoadjuvant chemotherapy followed by SBRT and surgical resection. Covariates were stratified by time from SBRT to surgery. A Cox regression model was used to identify variables associated with survival outcomes. In 171 patients with BRPC/LAPC, the median time from SBRT to surgery was 6.4 (range: 2.7-25.3) weeks. Hence, patients were stratified by the timing of surgery: ≥6 and <6 weeks after SBRT. In univariable Cox regression, surgery ≥6 weeks was associated with improved local control (LC, HR 0.55, 95% CI 0.30-0.98; p = 0.042), pathologic node positivity, elevated baseline CA19-9, and inferior LC if of the male sex. In multivariable analysis, surgery ≥6 weeks (p = 0.013; HR 0.46, 95%CI 0.25-0.85), node positivity (p = 0.019; HR 2.09, 95% CI 1.13-3.88), and baseline elevated CA19-9 (p = 0.002; HR 2.73, 95% CI 1.44-5.18) remained independently associated with LC. Clavien-Dindo Grade ≥3B complications occurred in 4/63 (6.3%) vs. 5/99 (5.5%) patients undergoing surgery <6 weeks and ≥6 weeks after SBRT (p = 0.7). In summary, the timing of surgery ≥6 weeks after SBRT was associated with improved local control and low post-operative complication rates, irrespective of the surgical timing. Further investigation of the influence of surgical timing following radiotherapy is warranted.
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14
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Ector GICG, Geelen IGP, Dinmohamed AG, Hoogendoorn M, Westerweel PE, Hermens RPMG, Blijlevens NMA. Adherence to quality indicators in chronic myeloid leukemia care: results from a population-based study in The Netherlands. Leuk Lymphoma 2023; 64:424-432. [PMID: 36369821 DOI: 10.1080/10428194.2022.2142055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Suboptimal guideline adherence in chronic myeloid leukemia (CML) care is associated with worse treatment outcomes. Current study focused on adherence to seven quality indicators (QIs) based on the European Leukemia Network guideline (one diagnostic, one therapeutic, and five monitoring indicators). Data were obtained from population-based registries in the Netherlands of 405 newly diagnosed chronic phase CML patients between January 2008 and April 2013. Compliance rates regarding diagnostic and therapeutic indicator were 83% and 78%, respectively. Monitoring indicators rates were lower: 21-27% for indicators concerning the first year and 58% and 62% for the second and third year, respectively. Noncompliance occurred mostly due to non-timely monitoring. Twenty cases did not comply with any indicator, 6% complied with all indicators. After adjustment for age, overall survival rates did not differ significantly between the groups. Adherence to guideline-based QIs was suboptimal. This demonstrates the evidence-practice gap, shows room for improvement and underscores the need for real-world data.
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Affiliation(s)
| | - Inge G P Geelen
- Department of Hematology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Avinash G Dinmohamed
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mels Hoogendoorn
- Department of Hematology, Medical Center Leeuwarden, on behalf of the HemoBase Population Registry Consortium, Leeuwarden, Netherlands
| | - Peter E Westerweel
- Department of Hematology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Rosella P M G Hermens
- Department of IQ Healthcare, Radboud Institute for Healthcare Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
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15
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Yadlapati R, Gawron AJ, Gyawali CP, Chen J, Clarke J, Fass R, Jain A, Lynch K, Khan A, Katz PO, Katzka DA, Richter J, Schnoll-Sussman F, Spechler SJ, Vaezi MF, Vela M, Pandolfino JE. Clinical role of ambulatory reflux monitoring in PPI non-responders: recommendation statements. Aliment Pharmacol Ther 2022; 56:1274-1283. [PMID: 35971888 PMCID: PMC10443620 DOI: 10.1111/apt.17180] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/14/2022] [Accepted: 07/28/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Optimal ambulatory reflux monitoring methodology in symptomatic reflux patients continues to be debated. AIMS To utilise published literature and expert opinion to develop recommendation statements addressing use of ambulatory reflux monitoring in clinical practice METHODS: The RAND Appropriateness Method (RAM) was utilised among 17 experts with discussion, revision and two rounds of ranking of recommendation statements. Ambulatory reflux monitoring protocol, methodology and thresholds ranked as appropriate by ≥80% of panellists met the criteria for appropriateness. RESULTS Prolonged (96-h recommended) wireless pH monitoring off proton pump inhibitor (PPI) was identified as the appropriate diagnostic tool to assess the need for acid suppression in patients with unproven gastro-oesophageal reflux disease (GERD) and persisting typical reflux symptoms despite once-daily PPI. Acid exposure time (AET) <4.0% on all days of monitoring with negative reflux-symptom association excludes GERD and does not support ongoing PPI treatment. Conversely, AET >6.0% across ≥2 days is conclusive evidence for GERD and supports treatment for GERD, while AET >10% across ≥2 days identifies severe acid burden that supports escalation of anti-reflux treatment. In previously proven GERD, impedance-pH monitoring on PPI is helpful in defining refractory GERD and mechanisms of continued symptoms; the presence of <40 reflux events, AET <2.0% and a negative reflux-symptom association does not support escalation of anti-reflux treatment. In contrast, AET > 4.0% and positive reflux-symptom association support escalation of anti-reflux treatment, including use of invasive therapeutics. CONCLUSIONS Statements meeting appropriateness for average clinical care have been identified when utilising reflux monitoring in patients with typical reflux symptoms and PPI non-response.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California, USA
| | - Andrew J. Gawron
- University of Utah, Salt Lake City, Utah, USA
- Salt Lake City VA Medical Center, Salt Lake City, Utah, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joan Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - John Clarke
- Division of Gastroenterology, Stanford University, Palo Alto, California, USA
| | - Ronnie Fass
- Division of Gastroenterology, MetroHealth System, Cleveland, Ohio, USA
| | - Anand Jain
- Division of Gastroenterology, Emory University, Atlanta, Georgia, USA
| | - Kristle Lynch
- Division of Gastroenterology & Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abraham Khan
- Center for Esophageal Health, Division of Gastroenterology & Hepatology, NYU Langone Health, New York City, New York, USA
| | - Philip O. Katz
- Division of Gastroenterology, Weill-Cornell Medical Center, New York City, New York, USA
| | - David A. Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology, Columbia Presbyterian Medical Center, New York City, New York, USA
| | - Joel Richter
- Division of Gastroenterology, University of South Florida, Tampa, Florida, USA
| | - Felice Schnoll-Sussman
- Division of Gastroenterology, Weill-Cornell Medical Center, New York City, New York, USA
| | - Stuart J. Spechler
- Division of Gastroenterology, Baylor Scott & White Health, Dallas, Texas, USA
| | - Michael F. Vaezi
- Division of Gastroenterology, Vanderbilt Medical Center, Nashville, Tennessee, USA
| | - Marcelo Vela
- Division of Gastroenterology, Mayo Clinic, Phoenix, Arizona, USA
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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16
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de Graaf N, Abu Hilal M. Outcome Measurement in Pancreatic Surgery-A Shift Toward Holistic Assessment. JAMA Surg 2022; 157:559-560. [PMID: 35442411 DOI: 10.1001/jamasurg.2022.0628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nine de Graaf
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy.,Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Mohammed Abu Hilal
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
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17
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Morrison ZD, van Steenburgh H, Gabel SA, Gabor R, Sharma R, Wernberg JA. Pancreaticoduodenectomy is safe in appropriately resourced rural hospitals. Surgery 2021; 170:1474-1480. [PMID: 34092374 DOI: 10.1016/j.surg.2021.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/25/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Research shows improved safety and treatment outcomes for patients undergoing pancreaticoduodenectomy at high-volume centers. Regionalization of pancreaticoduodenectomy to high-volume urban centers can result in unintended negative consequences for rural patients and communities. This report examines outcomes after pancreaticoduodenectomy performed at a rural hospital and compares them with national standards. METHODS A prospectively maintained database of pancreatic operations performed at a rural tertiary hospital was queried. Demographic and clinical information for patients undergoing pancreaticoduodenectomy (2007-2019) was analyzed. Primary outcomes were the rates of patient mortality and morbidity. Secondary outcomes were readmission rates, indications, and associations with clinical variables. RESULTS We included 118 patients in our study. There were 41 postoperative complications (34.7%), including 1 death (0.9%). The 90-day readmission rate was 24.6%. The most common indication for readmission was deep space infection (n = 7, 24.1%). Patients requiring an intraoperative transfusion were more likely to need hospital readmission (41.4% vs 9.0% of patients without transfusion, P = .016). Patients with postoperative complications required readmission more frequently (51.7% vs 29.2%, P = .093). These findings are similar to data from urban hospitals. CONCLUSION Patient safety and surgical outcomes after pancreaticoduodenectomy performed in appropriately resourced rural hospitals can be comparable with national standards. Safely treating rural patients near their home benefits patients and their communities.
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Affiliation(s)
- Zachary D Morrison
- Marshfield Clinic Health System-Marshfield Medical Center, Marshfield, WI.
| | | | | | - Rachel Gabor
- Marshfield Clinic Health System-Marshfield Clinic Research Institute, Marshfield, WI
| | - Rohit Sharma
- Marshfield Clinic Health System-Marshfield Medical Center, Marshfield, WI
| | - Jessica A Wernberg
- Marshfield Clinic Health System-Marshfield Medical Center, Marshfield, WI
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18
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Karunakaran M, Jonnada PK, Barreto SG. Systematic review and meta-analysis of the impact of deviations from a clinical pathway on outcomes following pancreatoduodenectomy. World J Clin Cases 2021; 9:3024-3037. [PMID: 33969088 PMCID: PMC8080740 DOI: 10.12998/wjcc.v9.i13.3024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/06/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery is steadily gaining importance in patients undergoing pancreatic surgery, including pancreatoduodenectomy (PD). While clinical pathways targeting enhanced-recovery can achieve their intended outcome in reducing length of stay, compliance to these pathways, and their relevance is poorly understood. The aim of this systematic review was to assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.
AIM To assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.
METHODS A systematic review of major reference databases was undertaken, according to preferred reporting items for systematic reviews and meta-analysis guidelines, between January 2000 and November 2020 relating to compliance with clinical pathways and its impact on outcomes in patients undergoing PD. A meta-analysis was performed using fixed-effects or random-effects models.
RESULTS Eleven studies including 1852 patients were identified. Median overall compliance to all components of the clinical pathway was 65.7% [interquartile range (IQR): 62.7%-72.3%] with median compliance to post-operative parameters of the clinical pathway being 44% (IQR: 34.5%-52.25%). Meta-analysis using a fixed-effects model showed that ≥ 50% compliance to a clinical pathway predicted significantly fewer post-operative complications [pooled odds ratio (OR): 9.46, 95% confidence interval (CI): 5.00-17.90; P < 0.00001] and a significantly shorter length of hospital stay [pooled mean difference (MD): 4.32, 95%CI: -3.88 to -4.75; P < 0.0001]. At 100% compliance which was associated with significantly fewer post-operative complications (pooled OR: 11.25, 95%CI: 4.71-26.84; P < 0.00001) and shorter hospital stay (pooled MD of 4.66, 95%CI: 2.81-6.51; P < 0.00001).
CONCLUSION Compliance to post-PD clinical pathways remains low. Deviations are associated with an increased risk of complications and length of hospital stay. Under-standing the relevance of deviations to clinical pathways post-PD presents pancreatic surgeons with opportunities to actively pursue an enhanced-recovery of their patients.
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Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Gurgaon 122001, Haryana, India
- Department of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon 122001, Haryana, India
| | - Pavan Kumar Jonnada
- Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru 560029, Karnataka, India
| | - Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park 5042, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park 5042, South Australia, Australia
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19
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Assessment of Cancer Center Variation in Textbook Oncologic Outcomes Following Colectomy for Adenocarcinoma. J Gastrointest Surg 2021; 25:775-785. [PMID: 32779080 DOI: 10.1007/s11605-020-04767-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traditional metrics may inadequately represent rates of attaining optimal oncologic care. We evaluated a composite "textbook oncologic outcome" (TOO) to assess the incidence of achieving an "optimal" clinical result after colon adenocarcinoma (CA) resection. METHODS The National Cancer Database (NCDB) was queried to identify patients undergoing colectomy for non-metastatic CA between 2010 and 2015. TOO was defined as a margin negative resection with an AJCC compliant lymph node evaluation, no prolonged length of stay (LOS) or 30-day readmission/mortality, as well as receipt of stage appropriate adjuvant chemotherapy. RESULTS Among 170,120 patients who underwent colectomy at 1315 hospitals, 93,204 (54.8%) achieved TOO with large variations observed among facilities. While certain factors were achieved nearly universally (R0 margin, 95.6%; no 30-day mortality, 97.2%), avoidance of prolonged LOS (77.3%) and appropriate adjuvant chemotherapy (83.0%) were achieved less consistently. On multivariable analysis, Black race/ethnicity (OR 0.82, 95% CI 0.80-0.85), Medicaid insurance (OR 0.64, 0.61-0.68), and low-volume facility (< 50/year) (OR 0.83, 0.77-0.89) were associated with decreased likelihood of TOO. Achievement of TOO was associated with improved long-term survival (HR 0.45; 95% CI 0.44-0.46). CONCLUSIONS Roughly one-half of patients undergoing resection of CA achieved an optimal clinical outcome. TOO may be a more useful quality metric to assess patient-centric composite outcomes following surgical procedures.
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20
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Ou C, Rektorysova M, Othman B, Windsor JA, Pandanaboyana S, Loveday BPT. Benchmarking Performance in Pancreatic Surgery: a Systematic Review of Published Quality Metrics. J Gastrointest Surg 2021; 25:834-842. [PMID: 33159243 DOI: 10.1007/s11605-020-04827-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/08/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic surgery is performed in relatively few centres. There are validated quality benchmarks for pancreatic surgery, although it remains unclear how published benchmarks compare with each other. This study aimed to systematically review published literature to summarise metrics that define quality benchmarks for pancreatic surgery. METHOD A search of MEDLINE, EMBASE and CENTRAL was undertaken until June 2019. Articles that developed or validated published quality benchmarks for pancreatic surgery were included. Benchmarks were classified into three domains using the Donabedian framework, and their quality assessed using the AIRE Instrument. RESULTS Nineteen studies included 55 quality metrics, of which 8 developed new metrics, and 11 studies validated previously published metrics. The methodology of metric development was either expert opinion-driven or data-driven. All metrics demonstrated moderate quality scores. There was partial agreement in some metrics (e.g. < 10 h total operative duration), but lack of consensus for most others (e.g. lymph node yield ≥ 10, ≥ 12, ≥ 15, ≥ 16). No metrics related to patient reported outcomes. CONCLUSIONS Published quality benchmarks for pancreatic surgery predominantly arise from eight studies, with heterogeneity in how the metrics were developed. There was not consensus for all metrics. Metrics need to be reviewed as new data emerge, technologies develop and opinions change.
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Affiliation(s)
- Cindy Ou
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Bushra Othman
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - John A Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland District Health Board, Auckland, New Zealand
| | | | - Benjamin P T Loveday
- Department of Surgery, University of Auckland, Auckland, New Zealand.
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Australia.
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21
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Vidri RJ, Olsen WT, Clark DE, Fitzgerald TL. Upfront resection versus neoadjuvant therapy for T1/T2 pancreatic cancer. HPB (Oxford) 2021; 23:279-289. [PMID: 32698950 DOI: 10.1016/j.hpb.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of neoadjuvant therapy remains controversial for resectable pancreatic neoplasms. We evaluated treatment outcomes for T1/T2 tumors. METHODS Retrospective study of patients with T1/T2 (Stage I-II) pancreatic cancer within the NCDB. Treatment-sequence variables were used for classification: "surgery + chemotherapy" (S+C), "chemotherapy + surgery" (C+S), "surgery only" (SO), and "chemotherapy only" (CO). RESULTS 13 412 patients were included; the majority had T2 tumors. 8 490 received upfront surgery; 4 922 preoperative chemotherapy. In the surgery branch, 5 684 received surgery and chemotherapy (S+C); 2 806 did not receive chemotherapy (SO). Of those intended to receive preoperative chemotherapy, 3 804 received only chemotherapy (CO); 1 118 proceeded to surgery (C+S). Median survival for S+C and C+S groups was similar (25.9 vs 26.2) [HR 0.92, p= 0.41]. Compared to the CO group, the SO group had improved median survival (13.5 vs. 10.8) [HR 0.63, p<0.001]. Branched analyses demonstrated improved median and 5-year (20.8% vs 12.7%) survival for patients receiving upfront resection [HR 0.77, p<0.001]. CONCLUSION Patients with T1/T2 pancreatic cancer have similar survival irrespective of the timing of chemotherapy and surgery, if they receive both. Upfront resection ensures surgery is delivered, increasing the possibility of long-term survival.
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Affiliation(s)
- Roberto J Vidri
- Department of Surgery, Maine Medical Center, 887 Congress St #400, Portland, ME, 04102, USA; Department of Surgery, St. Mary's Regional Medical Center, 99 Campus Avenue, 4th Floor, Suite 401, Lewiston, ME, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | - David E Clark
- Center for Outcomes Research and Evaluation, Maine Medical Center, 509 Forest Avenue, Ste. 200, Portland, ME, 04101, USA
| | - Timothy L Fitzgerald
- Department of Surgery, Maine Medical Center, 887 Congress St #400, Portland, ME, 04102, USA; Tufts University School of Medicine, Boston, MA, USA.
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22
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Nicholas E, van Roessel S, de Burlet K, Hore T, Besselink MG, Connor S. Using Textbook Outcomes to benchmark practice in pancreatic surgery. ANZ J Surg 2021; 91:361-366. [PMID: 33475226 DOI: 10.1111/ans.16555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 12/25/2020] [Accepted: 12/26/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Textbook Outcome (TO) is a novel composite measure of clinical outcomes that can be used to measure the quality of surgical outcomes. TOs for pancreatic surgery were published by the Dutch Pancreatic Cancer Group (DPCG) in 2020. The aim of this study was to explore how a medium volume hepatopancreaticobiliary unit could use TO to benchmark local outcomes following pancreatic surgery. METHODS Retrospective analysis of prospectively collected data from patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between March 2005 and February 2020 at Christchurch Hospital (CH). Analysis of TO items as defined by the DPCG was performed and compared to nationwide Dutch outcomes (2014-2017), including cumulative analysis using CuSum. RESULTS In total, 273 patients were included (median age 63 years; 51% female) of which 182 (67%) underwent PD and 91 (33%) underwent DP (median annual volume 12 PDs/6 DPs). Overall, 58% of patients undergoing PD and 74% of patients undergoing DP achieved TO, compared with 58% and 67%, P = 0.944 and P = 0.231, respectively, for the Netherlands (median annual volume 33 PDs/8 DPs per hospital). CONCLUSIONS TO offers a useful quality measure to benchmark local outcomes following pancreatic surgery against an external nationwide analysis. The results show that as a medium volume centre performance was comparable to previously published Dutch results, which included high volume centres. Applying CuSum methodology to the TO metric allows a continuous measure of performance. This offers the potential to provide feedback for quality improvement strategies.
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Affiliation(s)
- Ella Nicholas
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Stijn van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kirsten de Burlet
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Todd Hore
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Saxon Connor
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
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23
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Staerkle RF, Vuille-Dit-Bille RN, Soll C, Troller R, Samra J, Puhan MA, Breitenstein S. Extended lymph node resection versus standard resection for pancreatic and periampullary adenocarcinoma. Cochrane Database Syst Rev 2021; 1:CD011490. [PMID: 33471373 PMCID: PMC8094380 DOI: 10.1002/14651858.cd011490.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pancreatic and periampullary adenocarcinomas account for some of the most aggressive malignancies, and the leading causes of cancer-related mortalities. Partial pancreaticoduodenectomy (PD) with negative resection margins is the only potentially curative therapy. The high prevalence of lymph node metastases has led to the hypothesis that wider excision with the removal of more lymphatic tissue could result in an improvement of survival, and higher rates of negative resection margins. OBJECTIVES To compare overall survival following standard (SLA) versus extended lymph lymphadenectomy (ELA) for pancreatic head and periampullary adenocarcinoma. We also compared secondary outcomes, such as morbidity, mortality, and tumour involvement of the resection margins between the two procedures. SEARCH METHODS We searched CENTRAL, MEDLINE, PubMed, and Embase from 1973 to September 2020; we applied no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCT) comparing PD with SLA versus PD with ELA, including participants with pancreatic head and periampullary adenocarcinoma. DATA COLLECTION AND ANALYSIS Two review authors independently screened references and extracted data from study reports. We calculated pooled risk ratios (RR) for most binary outcomes except for postoperative mortality, for which we estimated a Peto odds ratio (Peto OR), and mean differences (MD) for continuous outcomes. We used a fixed-effect model in the absence of substantial heterogeneity (I² < 25%), and a random-effects model in cases of substantial heterogeneity (I² > 25%). Two review authors independently assessed risk of bias, and we used GRADE to assess the quality of the evidence for important outcomes. MAIN RESULTS We included seven studies with 843 participants (421 ELA and 422 SLA). All seven studies included Kaplan-Meier curves for overall survival. There was little or no difference in survival between groups (log hazard ratio (log HR) 0.12, 95% confidence interval (CI) -3.06 to 3.31; P = 0.94; seven studies, 843 participants; very low-quality evidence). There was little or no difference in postoperative mortality between the groups (Peto odds ratio (OR) 1.20, 95% CI 0.51 to 2.80; seven studies, 843 participants; low-quality evidence). Operating time was probably longer for ELA (mean difference (MD) 50.13 minutes, 95% CI 19.19 to 81.06 minutes; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 88%; P < 0.00001). There may have been more blood loss during ELA (MD 137.43 mL, 95% CI 11.55 to 263.30 mL; two studies, 463 participants; very low-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P = 0.02). There may have been more lymph nodes retrieved during ELA (MD 11.09 nodes, 95% CI 7.16 to 15.02; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P < 0.00001). There was little or no difference in the incidence of positive resection margins between groups (RR 0.81, 95% CI 0.58 to 1.13; six studies, 783 participants; very low-quality evidence). AUTHORS' CONCLUSIONS There is no evidence of an impact on survival with extended versus standard lymph node resection. However, the operating time may have been longer and blood loss greater in the extended resection group. In conclusion, current evidence neither supports nor refutes the effect of extended lymph lymphadenectomy in people with adenocarcinoma of the head of the pancreas.
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Affiliation(s)
- Ralph F Staerkle
- Visceral Surgery, Hirslanden Klinik St. Anna, Luzern, Switzerland
- University Basel, Basel, Switzerland
| | - Raphael Nicolas Vuille-Dit-Bille
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
- Department of Pediatric Surgery, Children's University Hospital, Basel, Switzerland
| | - Christopher Soll
- Visceral Surgery, Hirslanden Klinik St. Anna, Luzern, Switzerland
| | - Rebekka Troller
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Jaswinder Samra
- Gastrointestinal Surgery, Royal North Shore Hospital, St. Leonards, Australia
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Stefan Breitenstein
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
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24
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Quality performance indicators for hepato-pancreatico-biliary procedures: a systematic review. HPB (Oxford) 2021; 23:1-10. [PMID: 33158749 DOI: 10.1016/j.hpb.2020.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 09/03/2020] [Accepted: 10/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND This systematic review was undertaken to define and summarize existing, proposed quality performance indicators (QPI) for hepato-pancreatico-biliary (HPB) procedures. METHODS A systematic literature review identified studies reporting on quality indicators for cholecystectomy, hepatectomy, pancreatectomy and complex biliary surgical procedures. The databases searched were MEDLINE, EMBASE, PubMed, and SCOPUS, with all literature available until the search date of 1 May 2020 included. The reference lists of all included papers, as well as related review articles, were manually searched to identify further relevant studies. RESULTS Forty-five publications report quality indicators for pancreatectomy (n = 22), hepatectomy (n = 7), HPB resections in general (n = 12), and cholecystectomy (n = 6). No publications proposed QPI for complex biliary surgery. The 45 papers used national audit (n = 18), consensus methodology (n = 5), state-wide audit (n = 3), unit audit (n = 9), review methodology (n = 9), and survey methodology (n = 1). Sixty-one QPI were reported for pancreatectomy, 22 reported for hepatectomy, and 14 reported for HPB resections in general, in domains of infrastructure, provider, and documentation. Fourteen infrastructure and provider-based QPI were reported for cholecystectomy. CONCLUSIONS There are few internationally agreed QPI for HPB procedures that allow global comparison of provider performance and that set aspirational goals for patient care and experience.
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25
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Wiseman JT, Abdel-Misih S, Beal EW, Zaidi MY, Staley CA, Grotz T, Leiting J, Fournier K, Lee AJ, Dineen S, Powers B, Veerapong J, Baumgartner JM, Clarke C, Patel SH, Dhar V, Hendrix RJ, Lambert L, Abbott DE, Pokrzywa C, Raoof M, Eng O, Fackche N, Greer J, Pawlik TM, Cloyd JM. A multi-institutional analysis of Textbook Outcomes among patients undergoing cytoreductive surgery for peritoneal surface malignancies. Surg Oncol 2020; 37:101492. [PMID: 33465587 DOI: 10.1016/j.suronc.2020.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 11/10/2020] [Accepted: 11/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND While recent studies have introduced the composite measure of a textbook outcome (TO) for measuring postoperative outcomes, the incidence of a TO has not been characterized among patients undergoing cytoreductive surgery (CRS) for peritoneal surface malignancies (PSM). STUDY DESIGN All patients who underwent CRS ± hyperthermic intraperitoneal chemotherapy (HIPEC) between 1999 and 2017 from 12 institutions were included. A TO was defined as the absence of any of the following criteria: completeness of cytoreduction >1, reoperation within 90-days, readmission within 90-days, mortality within 90-days, any grade ≥2 complication, hospital stay >75th percentile, and non-home discharge. RESULTS Among 1904 patients who underwent CRS, only 30.9% achieved a TO while 69.1% failed to achieve a TO most commonly because of postoperative complications. On multivariable analysis, factors associated with achieving a TO were age <65 years (OR: 1.5), albumin ≥3.5 g/dl (OR: 5.7), receipt of HIPEC (OR: 4.5), PCI ≤14 (OR: 2.2), intravenous fluid volume ≤10,000 ml (OR: 2.1), blood loss ≤1000 ml (OR: 4.2) and operative time <7 h (OR: 1.9); while receipt of neoadjuvant therapy (OR: 0.7) and liver resection (OR: 0.4) were associated with not achieving a TO (all p < 0.05). TO was associated with improved overall survival (median 159 months vs 56 months, p < 0.01) even after controlling for confounders on Cox regression (hazard ratio: 2.5, p < 0.01). CONCLUSION Among patients undergoing CRS ± HIPEC for PSM, failure to achieve a TO is common and independently associated with worse overall survival.
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Affiliation(s)
- Jason T Wiseman
- Department of Surgery, The Ohio State University, Columbus, OH, USA.
| | | | - Eliza W Beal
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | | | | | - Travis Grotz
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Keith Fournier
- Department of Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Lee
- Department of Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Sean Dineen
- Department of Surgery, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Benjamin Powers
- Department of Surgery, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Jula Veerapong
- Department of Surgery, University of California, San Diego, San Diego, CA, USA
| | - Joel M Baumgartner
- Department of Surgery, University of California, San Diego, San Diego, CA, USA
| | - Callisia Clarke
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Vikrom Dhar
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Ryan J Hendrix
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Laura Lambert
- Department of Surgery, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Courtney Pokrzywa
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Mustafa Raoof
- Department of Surgery, City of Hope Cancer Center, Duarte, CA, USA
| | - Oliver Eng
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Nadege Fackche
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan Greer
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University, Columbus, OH, USA.
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26
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Fitzgerald TL, Seymore NM, Kachare SD, Zervos EE, Wong JH. Measuring the Impact of Multidisciplinary Care on Quality for Pancreatic Surgery: Transition to a Focused, Very High-volume Program. Am Surg 2020. [DOI: 10.1177/000313481307900817] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Outcomes are superior for pancreatic resection at high-volume centers. To assess the impact of focused high-volume multidisciplinary care, a quality index (QI) was used to review our experience. Data from 1996 to July 2012 were analyzed in three groups: 1) early (1996 to 2007); 2) transition (2008 to 2009); and 3) mature (2010 to July 2012). A total of 239 patients were included with a mean age of 63.4 years and the majority were white (65.7%). The number of patients with Charlson comorbidity index greater than 2 and age older than 80 years increased comparing Group 1 with latter groups. Volume increased over time: Group 1 (n = 93) 7.75/year, Group 2 (n = 51) 25.5/year, and Group 3 (n = 95) 39/year. Overall mortality was 5.9 per cent: Group 1, 4.3 per cent; Group 2, 11.5 per cent; and Group 3, 3.9 per cent ( P = 0.0454). The QI score incorporates documentation, chemotherapy, resection for Stage I/II, time to treatment, margins, lymph nodes, mortality, and surgical volume with a maximum possible score 10. The QI increased over time: 3 in Group 1; 4 in Group 2; and 6 in Group 3. An improvement was noted for the quality indicators: surgical resection ( P = 0.0125) and use of palliative and adjuvant therapy ( P = 0.0144 and < 0.0001). Implementation of a focused multidisciplinary pancreatic surgery program increases quality.
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Affiliation(s)
- Timothy L. Fitzgerald
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina; and
- Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Noah M. Seymore
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina; and
| | - Swapnil D. Kachare
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina; and
| | - Emmanuel E. Zervos
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina; and
- Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Jan H. Wong
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina; and
- Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
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27
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Abstract
BACKGROUND Textbook outcome (TO) is a multidimensional measure for quality assurance, reflecting the "ideal" surgical outcome. METHODS Post-hoc analysis of patients who underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between 2014 and 2017, queried from the nationwide prospective Dutch Pancreatic Cancer Audit. An international survey was conducted among 24 experts from 10 countries to reach consensus on the requirements for TO in pancreatic surgery. Univariable and multivariable logistic regression was performed to identify TO predictors. Between-hospital variation in TO rates was compared using observed-versus-expected rates. RESULTS Based on the survey (92% response rate), TO was defined by the absence of postoperative pancreatic fistula, bile leak, postpancreatectomy hemorrhage (all ISGPS grade B/C), severe complications (Clavien-Dindo ≥III), readmission, and in-hospital mortality. Overall, 3341 patients were included (2633 (79%) PD and 708 (21%) DP) of whom 60.3% achieved TO; 58.3% for PD and 67.4% for DP. On multivariable analysis, ASA class 3 predicted a worse TO rate after PD (ASA 3 OR 0.59 [0.44-0.80]), whereas a dilated pancreatic duct (>3 mm) and pancreatic ductal adenocarcinoma (PDAC) were associated with a better TO rate (OR 2.22 [2.05-3.57] and OR 1.36 [1.14-1.63], respectively). For DP, female sex and the absence of neoadjuvant therapy predicted better TO rates (OR 1.38 [1.01-1.90] and OR 2.53 [1.20-5.31], respectively). When comparing institutions, the observed-versus-expected rate for achieving TO varied from 0.71 to 1.46 per hospital after casemix-adjustment. CONCLUSIONS TO is a novel quality measure in pancreatic surgery. TO varies considerably between pancreatic centers, demonstrating the potential benefit of quality assurance programs.
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Sweigert PJ, Eguia E, Baker MS, Paredes AZ, Tsilimigras DI, Dillhoff M, Ejaz A, Cloyd J, Tsung A, Pawlik TM. Assessment of textbook oncologic outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma. J Surg Oncol 2020; 121:936-944. [DOI: 10.1002/jso.25861] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/19/2020] [Indexed: 12/15/2022]
Affiliation(s)
| | - Emanuel Eguia
- Department of SurgeryLoyola University Medical CenterMaywood Illinois
| | - Marshall S. Baker
- Department of SurgeryLoyola University Medical CenterMaywood Illinois
| | - Anghela Z. Paredes
- Department of SurgeryOhio State University Wexner Medical CenterColumbus Ohio
| | | | - Mary Dillhoff
- Department of SurgeryOhio State University Wexner Medical CenterColumbus Ohio
| | - Aslam Ejaz
- Department of SurgeryOhio State University Wexner Medical CenterColumbus Ohio
| | - Jordan Cloyd
- Department of SurgeryOhio State University Wexner Medical CenterColumbus Ohio
| | - Allan Tsung
- Department of SurgeryOhio State University Wexner Medical CenterColumbus Ohio
| | - Timothy M. Pawlik
- Department of SurgeryOhio State University Wexner Medical CenterColumbus Ohio
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DePeralta DK, Ogami T, Zhou JM, Schell MJ, Powers BD, Hodul PJ, Malafa MP, Fleming JB. Completion of adjuvant therapy in patients with resected pancreatic cancer. HPB (Oxford) 2020; 22:241-248. [PMID: 31563326 PMCID: PMC7771530 DOI: 10.1016/j.hpb.2019.07.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 07/18/2019] [Accepted: 07/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adjuvant chemotherapy is the standard of care for resected pancreatic ductal adenocarcinoma (PDAC). It is estimated that only 40-80% eligible patients initiate intended adjuvant chemotherapy. Completion rates are largely unknown. METHODS A retrospective analysis of outcomes of patients with resected PDAC over an 8-year period at H. Lee Moffitt Cancer Center (MCC) was performed. RESULTS From a total of 309 patients, 299 were included for further analysis. 242 (81%) initiated adjuvant therapy (AT) and 195 (65%) completed the intended course. The median time-to-initiation of AT was 53 days (7.6 weeks). The most common reasons for early discontinuation of AT (n = 47) were toxicity (n = 29), disease recurrence (n = 9), patient decision (n = 4), unrelated comorbidities (n = 3), and death (n = 1). Completion of AT was an independent predictor of overall survival (OS) and recurrence-free survival (RFS) on multivariable analysis (OS: HR 0.41, CI 0.27-0.61, p < 0.001; RFS: HR 0.52, CI 0.36-0.76, p < 0.001). Factors associated with early termination of AT were vascular resection (OR 0.29, CI 0.13-0.67, p = 0.004) and administration of AT with local oncologist as opposed to MCC (OR 0.41, CI 0.21-0.82, p = 0.010). CONCLUSION Completion of AT is associated with improved survival in patients with resected PDAC. Factors associated with an inability to complete AT include vascular resection and administration of AT with local care team in the patient's community.
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Affiliation(s)
- Danielle K. DePeralta
- Division of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Takuya Ogami
- Division of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Jun-Min Zhou
- Biostatistics and Bioinformatics Department, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Michael J. Schell
- Biostatistics and Bioinformatics Department, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Benjamin D. Powers
- Division of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Pamela J. Hodul
- Division of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Mokenge P. Malafa
- Division of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Jason B. Fleming
- Division of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
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Sandini M, Negreros-Osuna AA, Qadan M, Hank T, Patino M, Ferrone CR, Warshaw AL, Lillemoe KD, Sahani D, Castillo CFD. Main Pancreatic Duct to Parenchymal Thickness Ratio at Preoperative Imaging is Associated with Overall Survival in Upfront Resected Pancreatic Cancer. Ann Surg Oncol 2019; 27:1606-1612. [PMID: 31722071 DOI: 10.1245/s10434-019-08040-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreatic cancer induces parenchymal atrophy and duct dilation. The aim of this study was to evaluate whether these radiologic modifications are associated with outcomes. METHODS Upfront pancreaticoduodenectomy patients with available preoperative contrast enhanced CT scan imaging were retrospectively analyzed. Thickness of the pancreas, size of the main pancreatic duct (MPD), and distance of the tumor from the ampulla were assessed. A training cohort was selected, including short- (3-12 months following surgery) and long-term (≥ 36 months) survivors. Identified survival determinants were validated in the overall cohort. RESULTS Two-hundred-sixteen patients were analyzed. In the training cohort (N = 118), 68 patients (57.6%) were in the short-term and 50 (42.4%) in the long-term survival group. The short-term survival group had significantly higher CA 19-9 levels (p = 0.027), larger tumors (32.6 ± 12.1 mm vs. 26.5 ± 11.6 mm, p = 0.007), poorer differentiation (p = 0.003), higher rate of R < 1 mm resections (54% vs. 32%, p = 0.008), and reduced receipt of adjuvant chemotherapy (p = 0.020). The MPD-to-pancreatic thickness ratio was significantly lower in the short-term survivors (3.6 ± 6.2 vs. 8.2 ± 12.0, p = 0.016). In the entire cohort, an MPD-to-pancreatic thickness ratio ≥ 3.5 was associated with improved OS [median 33.0 months IQR (19.7-48.1) versus 17 months IQR (14.8-19.2), p = 0.004], and confirmed by a Cox-proportional hazards model independently associated with OS (HR = 0.58; p = 0.009), together with tumor size (HR = 1.02; p =0.012), R1/R2 status (HR = 1.53; p = 0.029), and receipt of adjuvant treatment (HR = 0.61; p = 0.021). CONCLUSIONS High MPD-to-pancreatic thickness ratio was associated with improved long-term survival in pancreaticoduodenectomy for cancer. Whether these features are related to tumor chronicity, indolent biology, or local growth over metastasis remains to be determined.
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Affiliation(s)
- Marta Sandini
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adrian A Negreros-Osuna
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Hank
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Manuel Patino
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dushyant Sahani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Chikhladze S, Lederer AK, Kousoulas L, Reinmuth M, Sick O, Fichtner-Feigl S, Wittel UA. Adjuvant chemotherapy after surgery for pancreatic ductal adenocarcinoma: retrospective real-life data. World J Surg Oncol 2019; 17:185. [PMID: 31706323 PMCID: PMC6842534 DOI: 10.1186/s12957-019-1732-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/23/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The recommendation for postoperative chemotherapy in pancreatic ductal adenocarcinoma (PDAC) is based on prospective randomized trials. However, patients included in clinical trials do not often reflect the overall patient population treated in clinical practice. MATERIALS AND METHODS A retrospective review of all patients undergoing pancreas resection for PDAC between 2001 and 2013 was performed. Follow-up data from oncologists, general practitioners, or hospital patient files were available for 92% of patients. RESULTS A total of 251 patients were included in our analysis. Chemotherapy was recommended for 223 patients, but 86 patients did not follow the recommendation. The application of the recommended chemotherapy, consisting of 6 cycles of gemcitabine, was only applied to 45 patients. Forty patients received the recommended number of cycles with dose reduction or prolonged intervals between cycles, and adjuvant chemotherapy was terminated prior to the intended completion of all 6 cycles in 54 patients. Survival of patients after adjuvant chemotherapy was increased compared to that of patients without chemotherapy (with recurrence 25.6 vs. 14.3 months, p = 0.001, and without recurrence 27.4 vs. 14.3 months, p < 0.001). Terminating chemotherapy prior to completion (p = 0.009) as well as a lower number of chemotherapy cycles (p = 0.026) was associated with a decreased survival. CONCLUSION Adjuvant chemotherapy improves overall and disease-free survival after curative pancreatic resection, but only a small fraction of patients completes the recommended 6 cycles of adjuvant chemotherapy. Our data indicates that performance status of patients after pancreas resections for PDAC requires not only highly biologically active but also well-tolerated adjuvant chemotherapy regimens.
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Affiliation(s)
- Sophia Chikhladze
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg im Breisgau, Germany
| | - Ann-Kathrin Lederer
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg im Breisgau, Germany
- Center for Complementary Medicine, Institute for Infection Prevention and Hospital Epidemiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 115b, 79106 Freiburg im Breisgau, Germany
| | - Lampros Kousoulas
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg im Breisgau, Germany
| | - Marilena Reinmuth
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg im Breisgau, Germany
| | - Olivia Sick
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg im Breisgau, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg im Breisgau, Germany
| | - Uwe A. Wittel
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg im Breisgau, Germany
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Lu S, Khatri R, Tanner B, Shebrain S, Munene G. Short term outcomes and unintended benefits of establishing a HPB program at a university-affiliated community hospital. Am J Surg 2019; 218:946-951. [DOI: 10.1016/j.amjsurg.2019.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 03/09/2019] [Accepted: 03/13/2019] [Indexed: 12/12/2022]
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Acute Pancreatitis Task Force on Quality: Development of Quality Indicators for Acute Pancreatitis Management. Am J Gastroenterol 2019; 114:1322-1342. [PMID: 31205135 DOI: 10.14309/ajg.0000000000000264] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Detailed recommendations and guidelines for acute pancreatitis (AP) management currently exist. However, quality indicators (QIs) are required to measure performance in health care. The goal of the Acute Pancreatitis Task Force on Quality was to formally develop QIs for the management of patients with known or suspected AP using a modified version of the RAND/UCLA Appropriateness Methodology. METHODS A multidisciplinary expert panel composed of physicians (gastroenterologists, hospitalists, and surgeons) who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity was convened. A literature review was conducted, and a list of proposed QIs was developed. In 3 rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets. RESULTS Supporting literature and a list of 71 proposed QIs across 10 AP domains (Diagnosis, Etiology, Initial Assessment and Risk Stratification, etc.) were sent to the expert panel to review and independently rate in round 1 (95% of panelists participated). Based on a round 2 face-to-face discussion of QIs (75% participation), 41 QIs were classified as valid. During round 3 (90% participation), panelists rated the 41 valid QIs for necessity and proposed performance thresholds. The final classification determined that 40 QIs were both valid and necessary. DISCUSSION Hospitals and providers managing patients with known or suspected AP should ensure that patients receive high-quality care and desired outcomes according to current evidence-based best practices. This physician-led initiative formally developed 40 QIs and performance threshold targets for AP management. Validated QIs provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected AP.
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Solomon D, DeNicola N, Feferman Y, Feingold D, Aycart SN, Magge DR, Golas BJ, Attiyeh F, Labow DM, Sarpel U. Assessing the Implementation of American College of Surgeons Quality Indicators for Pancreatic Cancer Across an Integrated Health System. J Oncol Pract 2019; 15:e739-e745. [PMID: 31260384 DOI: 10.1200/jop.18.00587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The American College of Surgeons (ACS) recently published quality assurance (QA) indicators for pancreatic cancer care. Implementing quality indicators in a newly formed health system may lead to better patient selection and standardized cancer care. METHODS Select ACS and internal quality indicators were implemented system wide in 2014. We compared compliance with these measures before and after their implementation at the main hospital and two new affiliate institutions. RESULTS A total of 506 patients with pancreatic cancer were included. At the main hospital in the pre-QA period, 11 (12.6%) of 87 patients were discussed at our institutional multidisciplinary tumor board meeting; this number rose to 89 (49.7%) of 179 patients (P < .001) after the implementation. Clinical TNM stage was documented in the electronic medical record in 75 patients (86.2%) in the pre-QA group; this number rose to 170 (94.9%; P = .026) in the post-QA era. External imaging of patients undergoing resection was uploaded in 10 (66.7%) of 15 patient cases in the pre-QA period; this number rose to 33 (93.4%) of 35 (P = .020). Rates of time from diagnosis to treatment initiation shorter than 60 days were similar between eras (n = 26, 96.3% v n = 57, 95%). Implementation of QA measures at the affiliate institutions did not result in measurable differences. There were no differences in margin-negative resection rate, lymph node yield, or perioperative mortality after QA implementation at any site. CONCLUSION The implementation of ACS quality indicators at our main hospital was feasible and effective for several measures, without delaying treatment. Instituting these indicators at lower-volume affiliates was more challenging.
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Affiliation(s)
| | | | - Yael Feferman
- 1Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Deepa R Magge
- 1Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Fadi Attiyeh
- 1Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Umut Sarpel
- 1Icahn School of Medicine at Mount Sinai, New York, NY
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Maharaj AD, Ioannou L, Croagh D, Zalcberg J, Neale RE, Goldstein D, Merrett N, Kench JG, White K, Pilgrim CHC, Chantrill L, Cosman P, Kneebone A, Lipton L, Nikfarjam M, Philip J, Sandroussi C, Tagkalidis P, Chye R, Haghighi KS, Samra J, Evans SM. Monitoring quality of care for patients with pancreatic cancer: a modified Delphi consensus. HPB (Oxford) 2019; 21:444-455. [PMID: 30316625 DOI: 10.1016/j.hpb.2018.08.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 08/02/2018] [Accepted: 08/31/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Best practise care optimises survival and quality of life in patients with pancreatic cancer (PC), but there is evidence of variability in management and suboptimal care for some patients. Monitoring practise is necessary to underpin improvement initiatives. We aimed to develop a core set of quality indicators that measure quality of care across the disease trajectory. METHODS A modified, three-round Delphi survey was performed among experts with wide experience in PC care across three states in Australia. A total of 107 potential quality indicators were identified from the literature and divided into five areas: diagnosis and staging, surgery, other treatment, patient management and outcomes. A further six indicators were added by the panel, increasing potential quality indicators to 113. Rated on a scale of 1-9, indicators with high median importance and feasibility (score 7-9) and low disagreement (<1) were considered in the candidate set. RESULTS From 113 potential quality indicators, 34 indicators met the inclusion criteria and 27 (7 diagnosis and staging, 5 surgical, 4 other treatment, 5 patient management, 6 outcome) were included in the final set. CONCLUSIONS The developed indicator set can be applied as a tool for internal quality improvement, comparative quality reporting, public reporting and research in PC care.
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Affiliation(s)
- Ashika D Maharaj
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Liane Ioannou
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Daniel Croagh
- Monash University, Melbourne, Victoria, Australia; Monash Health, Clayton, Victoria, Australia; Epworth Healthcare, Richmond, Australia
| | - John Zalcberg
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Rachel E Neale
- QIMR Berghofer Medical Research Institute, Herston, Australia
| | - David Goldstein
- Prince of Wales Clinical School, UNSW Medicine, NSW, Australia
| | - Neil Merrett
- School of Medicine, Western Sydney University, NSW, Australia
| | - James G Kench
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Central Clinical School, University of Sydney, NSW, Australia
| | - Kate White
- Sydney Nursing School, University of Sydney, Australia
| | - Charles H C Pilgrim
- Alfred Health, Melbourne, Victoria, Australia; Cabrini, Malvern, Victoria, Australia; Peninsula Health, Frankston, Victoria, Australia; Peninsula Private Hospital, Frankston, Victoria, Australia
| | - Lorraine Chantrill
- Kinghorn Cancer Centre, St Vincent's Hospital, NSW, Australia; Garvan Institute of Medical Research and University of New South Wales, NSW, Australia
| | - Peter Cosman
- School of Medicine, Faculty of Science, Medicine & Health, University of Wollongong, NSW, Australia
| | | | - Lara Lipton
- Cabrini, Malvern, Victoria, Australia; Royal Melbourne Hospital, Parkville, Victoria, Australia; Western Health, Sunshine, Victoria, Australia
| | - Mehrdad Nikfarjam
- Melbourne University, Parkville, Victoria, Australia; Austin Health, Heidelberg, Australia
| | | | | | - Peter Tagkalidis
- Alfred Health, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Richard Chye
- St Vincent's Private Hospital, Darlinghurst, NSW, Australia; Faculty of Health, University of Technology, NSW, Australia
| | - Koroush S Haghighi
- Prince of Wales Clinical School, UNSW Medicine, NSW, Australia; Kinghorn Cancer Centre, St Vincent's Hospital, NSW, Australia
| | - Jaswinder Samra
- Department of Upper GI Surgery, Royal North Shore Hospital, NSW, Australia; Macquarie University Hospital, Macquarie University, Australia
| | - Sue M Evans
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia.
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Performance of a Multidisciplinary Pancreatic Cancer Conference in Predicting and Managing Resectable Pancreatic Cancer. Pancreas 2019; 48:80-84. [PMID: 30451791 DOI: 10.1097/mpa.0000000000001209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Surgery is the curative treatment for pancreatic ductal adenocarcinoma (PDA). Guidelines recommend utilizing a multidisciplinary pancreatic cancer conference (MDPC) in treatment; however, data are limited. The objective of this study was to assess the accuracy of an MDPC. METHODS Patients with PDA presented at an MDPC were prospectively collected from April 2013 to August 2016. Patients were included if the MDPC predicted them to have resectable PDA and underwent upfront surgery. Secondary aims were to compare differences in tumor characteristics, time to surgery, and resection rates with patients prior to MDPC implementation (pre-MDPC). RESULTS A total of 278 patients were presented at the MDPC. After excluding borderline and nonresectable cases, 91 patients were predicted as resectable on evaluation, and 70 were fit for surgery. The MDPC predicted resection in 91.4%. The MDPC had larger tumor size (32.6 vs 24.0 mm), greater proportion of stage II tumor, and a shorter time from diagnosis to resection (27.3 vs 35.5 days) compared with the pre-MDPC. Microscopically negative resections were similar between MDPC and pre-MDPC (85.9% vs 88.0%) despite advanced tumor size and stage. CONCLUSIONS The MDPC demonstrates a high resection rate. Compared with a pre-MDPC, MDPC provides shorter time to surgery and selects for advanced tumors.
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The Impact of Postoperative Complications on a Timely Return to Intended Oncologic Therapy (RIOT): the Role of Enhanced Recovery in the Cancer Journey. Int Anesthesiol Clin 2018; 54:e33-46. [PMID: 27623128 DOI: 10.1097/aia.0000000000000113] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kueder-Pajares T, Descalzo M, García-Doval I, Ríos-Buceta L, Moreno-Ramírez D. Evaluación de indicadores de estructura en la atención al paciente con cáncer de piel en los servicios de dermatología. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:807-812. [DOI: 10.1016/j.ad.2018.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 04/20/2018] [Accepted: 06/03/2018] [Indexed: 11/24/2022] Open
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Kueder-Pajares T, Descalzo M, García-Doval I, Ríos-Buceta L, Moreno-Ramírez D. Evaluation of Structure Indicators for Assessing Skin Cancer Quality of Care in Dermatology Departments. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Abstract
Recent debate has focused on which quality measures are appropriate for surgical oncology and how they should be implemented and incentivized. Current quality measures focus primarily on process measures (use of adjuvant therapy, pathology reporting) and patient-centered outcomes (health-related quality of life). Pay for performance programs impacting surgical oncology patients focus primarily on preventing postoperative complications, but are not specific to cancer surgery. Future pay for performance programs in surgical oncology will likely focus on incentivizing high-quality, low-cost cancer care by evaluating process measures, patient-centered measures, and costs of care specific to cancer surgery.
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Affiliation(s)
- Jay S Lee
- Department of Surgery, University of Michigan, 2210A Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Hari Nathan
- Department of Surgery, University of Michigan, 2210A Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Abstract
OBJECTIVE All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements. DESIGN Systematic review without meta-analysis. SETTING All care settings. SEARCH STRATEGY CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included. ANALYSIS Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others). RESULTS 2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'. CONCLUSIONS This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.
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Affiliation(s)
- Kenji Fujita
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rebekah J Moles
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Timothy F Chen
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Estándares de calidad en la cirugía oncológica pancreática en España. Cir Esp 2018; 96:342-351. [DOI: 10.1016/j.ciresp.2018.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/02/2018] [Accepted: 03/06/2018] [Indexed: 12/18/2022]
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Chazapis M, Gilhooly D, Smith A, Myles P, Haller G, Grocott M, Moonesinghe S. Perioperative structure and process quality and safety indicators: a systematic review. Br J Anaesth 2018; 120:51-66. [DOI: 10.1016/j.bja.2017.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 12/12/2022] Open
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Wani S, Muthusamy VR, Shaheen NJ, Yadlapati R, Wilson R, Abrams JA, Bergman J, Chak A, Chang K, Das A, Dumot J, Edmundowicz SA, Eisen G, Falk GW, Fennerty MB, Gerson L, Ginsberg GG, Grande D, Hall M, Harnke B, Inadomi J, Jankowski J, Lightdale CJ, Makker J, Odze RD, Pech O, Sampliner RE, Spechler S, Triadafilopoulos G, Wallace MB, Wang K, Waxman I, Komanduri S. Development of Quality Indicators for Endoscopic Eradication Therapies in Barrett's Esophagus: The TREAT-BE (Treatment With Resection and Endoscopic Ablation Techniques for Barrett's Esophagus) Consortium. Am J Gastroenterol 2017; 112:1032-1048. [PMID: 28570552 DOI: 10.1038/ajg.2017.166] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Sachin Wani
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - V Raman Muthusamy
- University of California in Los Angeles, Los Angeles, California, USA
| | | | | | - Robert Wilson
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | | | | | | | - Kenneth Chang
- University of California in Irvine, Irvine, California, USA
| | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, Arizona, USA
| | - John Dumot
- University Hospitals, Cleveland, Ohio, USA
| | | | | | - Gary W Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Lauren Gerson
- California Pacific Medical Center, San Francisco, California, USA
| | - Gregory G Ginsberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Matt Hall
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Ben Harnke
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - John Inadomi
- University of Washington, Seattle, Washington, USA
| | | | | | - Jitin Makker
- University of California in Los Angeles, Los Angeles, California, USA
| | - Robert D Odze
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Oliver Pech
- St. John of God Hospital, Regensburg, Germany
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Development of quality indicators for endoscopic eradication therapies in Barrett's esophagus: the TREAT-BE (Treatment with Resection and Endoscopic Ablation Techniques for Barrett's Esophagus) Consortium. Gastrointest Endosc 2017; 86:1-17.e3. [PMID: 28576294 DOI: 10.1016/j.gie.2017.03.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 12/11/2022]
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Buanes TA. Role of surgery in pancreatic cancer. World J Gastroenterol 2017; 23:3765-3770. [PMID: 28638216 PMCID: PMC5467062 DOI: 10.3748/wjg.v23.i21.3765] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/17/2017] [Accepted: 04/21/2017] [Indexed: 02/06/2023] Open
Abstract
Treatment of pancreatic cancer is multimodal and surgery is an essential part, mandatory for curative potential. Also chemotherapy is essential, and serious postoperative complications or rapid disease progression may preclude completion of multimodal treatment. The sequence of treatment interventions has therefore become an important concern, and numerous ongoing randomized controlled trials compare clinical outcome after upfront surgery and neoadjuvant treatment with subsequent resection. In previous years, borderline resectable and locally advanced pancreatic cancer was most often considered unresectable. More effective chemotherapy together with the latest improvements in surgical expertise has resulted in extended operations, pushing the borders of resectability. Multivisceral resections with or without resection of major mesenteric vessels are now performed in numerous patients, resulting in better outcome, recorded as overall survival and/or patient reported outcome. But postoperative morbidity increases concurrently, and clinical benefit must be carefully evaluated against risk of potential harm, associated with new comprehensive multimodal treatment sequences. Even though cost/utility analyses are deficient, extended surgery has resulted in significantly longer and better life for many patients with no other treatment alternative. Improved selection of patients to surgery and/or chemotherapy will in the near future be possible, based on better tumor biology insight. Clinically available biomarkers enabling personalized treatment are forthcoming, but these options are still limited. The importance of surgical resection for each patient’s prognosis is presently increasing, justifying sustained expansion of the surgical treatment modality.
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Wellner UF, Keck T. Quality Indicators in Pancreatic Surgery: Lessons Learned from the German DGAV StuDoQ|Pancreas Registry. Visc Med 2017; 33:126-130. [PMID: 28560227 DOI: 10.1159/000456045] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Political and public interest in quality management in surgery is increasing. The German Society for General and Visceral Surgery (DGAV) established the DGAV StuDoQ, a nationwide registry for quality assessment in visceral surgery, with the organ-specific module DGAV StuDoQ|Pancreas. The first prerequisite for the measurement of quality is the definition of quality indicators. These can be related to risk factors which are also documented in the registry. METHODS Quality indicators for pancreatic surgery were developed by review of the current literature and expert consensus. After ranking the potential quality indicators, three essential indicators for outcome quality were selected for further review of the literature. Current figures were extracted from the DGAV StuDoQ|Pancreas registry and the correlation with selected risk factors was tested. RESULTS Three essential outcome quality indicators were selected: in-hospital mortality, TV30, and severe complications according to the Clavien-Dindo Classification. Preliminary data confirms the validity of risk factors included in the DGAV StuDoQ|Pancreas registry. CONCLUSION Essential quality indicators were defined for pancreatic surgery. The DGAV StuDoQ|Pancreas constitutes a valid platform for risk-adjusted quality assessment in Germany.
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Affiliation(s)
- Ulrich F Wellner
- Clinic for Surgery, German Society for General and Visceral Surgery (DGAV), Berlin, Germany.,Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Tobias Keck
- Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lübeck, Germany
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Bassi C, Andrianello S. Identifying key outcome metrics in pancreatic surgery, and how to optimally achieve them. HPB (Oxford) 2017; 19:178-181. [PMID: 28110832 DOI: 10.1016/j.hpb.2016.12.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 12/17/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Indicators of effectiveness and quality of care are of greatest importance in gauging the direct benefit of a new surgical technique, such as minimally-invasive pancreatic resections, when being compared with established approaches. METHODS Current expert opinion on minimally-invasive pancreatic resection (MIPR) was presented at the first MIPR state of the art conference during 12th world congress of the International Hepato-Pancreato-Biliary Association. RESULTS Studies exploring outcome of the minimally-invasive approach, alone or compared with open surgery, should consider all the necessary indicators of quality ensuring a high level of clinical care. Such studies should be implemented in a context that guarantees the correct indication for surgery, lower mortality rates, a low burden of post-operative morbidity through early recognition of adverse events and prevention of predictable complications, high standards of oncological "radicality", prompt recovery with access to adjuvant therapy as soon as possible, and reduction of health-care related costs. DISCUSSION Only by integrating MIPR with the outcome-improving effect of a dedicated pancreatic team will it be possible to assess more precisely the putative benefits of this minimally-invasive approach.
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Affiliation(s)
- Claudio Bassi
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Stefano Andrianello
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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