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Sakowitz S, Bakhtiyar SS, Mallick S, Cho NY, Kim S, Le NK, Lee H, Benharash P. Hospital Quality Mediates Impact of Care Fragmentation Following Elective Colectomy. Am Surg 2024; 90:2485-2493. [PMID: 38659168 DOI: 10.1177/00031348241248795] [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: 04/26/2024]
Abstract
BACKGROUND Readmission at a non-index hospital, or care fragmentation (CF), has been previously linked to greater morbidity and resource utilization. However, a contemporary evaluation of the impact of CF on readmission outcomes following elective colectomy is lacking. We additionally sought to evaluate the role of hospital quality in mediating the effect of CF. METHODS All records for adults undergoing elective colectomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Patients readmitted non-electively within 30 days to a non-index center comprised the CF cohort (others: Non-CF). Hierarchical mixed-effects models were constructed to ascertain risk-adjusted rates of major adverse events (MAEs, a composite of in-hospital mortality and any complication) attributable to center-level effects. Hospitals with risk-adjusted MAE rates ≥50th percentile were considered Low-Quality Hospitals (LQHs) (others: High-Quality Hospitals [HQHs]). RESULTS Of 68,185 patients readmitted non-electively within 30 days, 8968 (13.2%) were categorized as CF. On average, CF was older, of greater comorbidity burden, and more often underwent colectomy for cancer, relative to Non-CF. Following risk adjustment, CF remained independently associated with greater likelihood of MAE (adjusted odds ratio [AOR] 1.16, 95% Confidence Interval [CI] 1.05-1.27) and per-patient expenditures (β+$2,280, CI +$1080-3490). Further, readmission to non-index LQH was linked with significantly increased odds of MAE, following initial care at HQH (AOR 1.43, CI 1.03-1.99) and LQH (AOR 1.72, CI 1.30-2.28; Reference: Non-CF). CONCLUSIONS Care fragmentation was associated with greater morbidity and resource utilization at readmission following elective colectomy. Further, rehospitalization at non-index LQH conferred significantly inferior outcomes. Novel efforts are needed to improve continuity of care.
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Affiliation(s)
- Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
- Department of Surgery, University of Colorado, Denver, CO, USA
| | - Saad Mallick
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Nam Yong Cho
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Shineui Kim
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Nguyen K Le
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Hanjoo Lee
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
- Division of Colorectal Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrence, CA, USA
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, CA, USA
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Weeks KS, Gao X, Kahl AR, Engelbart J, Greteman BB, Hassan I, Kapadia MR, Nash SH, Charlton ME. Perspectives on Referring for Rectal Cancer Surgery: a Survey Study of Gastroenterologist and General Surgeons in Iowa. J Gastrointest Cancer 2024; 55:681-690. [PMID: 38151606 DOI: 10.1007/s12029-023-00998-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE To understand referral practices for rectal cancer surgical care and to secondarily determine differences in referral practices by two main hypothesized drivers of referral: the rurality of the community endoscopists' practice and their affiliation with a colorectal surgeon. METHODS Community gastroenterologists and general surgeons in Iowa completed a mailed questionnaire on practice demographics, volume, and referral practices for rectal cancer patients. Rurality was operationalized with RUCA codes. RESULTS Twenty-two of 53 gastroenterologists (42%) and 120 of 188 general surgeons (64%) (total 144/241, 60%) in Iowa responded. Most performed colonoscopies, including 22 gastroenterologists (100%) and 96 general surgeons (80%). Regular referral of rectal cancer patients to colorectal surgeons was reported for 57% of urban physicians affiliated with a colorectal surgeon, 33% of urban physicians not affiliated with a colorectal surgeon, and 57% and 72% of physicians in large and small rural areas, respectively, who were not affiliated with a colorectal surgeon. High surgeon volume, high hospital volume, and colorectal surgeon specialty were important factors in the referral decisions for over half the physicians. 69% of diagnosing urban general surgeons reported performing rectal cancer surgery about half the time or more, while 85% of small rural and 60% of large rural diagnosing general surgeons reported never or rarely performing rectal cancer surgery. CONCLUSIONS Diagnosing physicians have variable rectal cancer referral practices, including consistency in referred to surgeon and prioritization of volume and specialization. Prioritizing specialized or high-volume rectal cancer surgical care would require changing existing referring patterns.
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Affiliation(s)
- Kristin S Weeks
- Department of Internal Medicine, The Ohio State University Medical Center, 410 W Tenth Ave, 43210, Columbus, OH, USA
| | - Xiang Gao
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Amanda R Kahl
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA
| | - Jacklyn Engelbart
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Breanna B Greteman
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA
| | - Imran Hassan
- Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 52242, Iowa City, IA, USA
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina at Chapel Hill, 101 Manning Drive, 27599, Chapel Hill, NC, USA
| | - Sarah H Nash
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA
| | - Mary E Charlton
- State Health Registry of Iowa, University of Iowa, 2600 UCC, 52242, Iowa City, IA, USA.
- College of Public Health, Department of Epidemiology, University of Iowa, 145 N Riverside Dr, 52242, Iowa City, IA, USA.
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Endo Y, Sasaki K, Moazzam Z, Woldesenbet S, Yang J, Araujo Lima H, Alaimo L, Munir MM, Shaikh CF, Schenk A, Kitago M, Pawlik TM. The Impact of a Liver Transplant Program on the Outcomes of Hepatocellular Carcinoma. Ann Surg 2023; 278:230-238. [PMID: 36994716 DOI: 10.1097/sla.0000000000005849] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE We sought to evaluate the impact of liver transplantation (LT) programs on the prognosis of hepatocellular carcinoma (HCC) patients who underwent liver resection (LR) and noncurative intent treatment. BACKGROUND LT programs have an array of resources and services that would positively affect the prognosis of patients with HCC. METHODS Patients who underwent LT, LR, radiotherapy (RT), or chemotherapy (CTx) for HCC between 2004 and 2018 were included in the National Cancer Database. Institutions with LT programs were defined as those that performed 1 or more LT for at least 5 years. Centers were stratified by hospital volume. The impact of LT programs was assessed after propensity score matching to achieve covariate balance. RESULTS A total of 71,735 patients were identified, of which 7997 received LT (11.1%), 12,683 LR (17.7%), 15,675 RT (21.9%), and 35,380 CTx (49.3%). Among a total of 1267 distinct institutions, 94 (7.4%) were categorized as LT programs. Designation as an LT program was also associated with a high volume of LR and noncurative intent treatment (both P <0.001). After propensity score matching, LT programs were associated with better survival among LR and noncurative intent treatment patients. Although hospital volume was also associated with improved prognosis, LT programs were associated with additional survival benefits in noncurative intent treatment. On the other hand, no such benefit was noted in patients who underwent LR. CONCLUSIONS The presence of an LT program was associated with a higher volume of LR and noncurative intent treatment. Furthermore, designation as an LT program had a "halo effect" on the prognosis of patients undergoing RT/CTx that went beyond the procedure-volume effect.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | | | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Jason Yang
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Henrique Araujo Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Chanza F Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Austin Schenk
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Minoru Kitago
- Department of Surgery, Keio University, Tokyo, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
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Ray MA, Akinbobola O, Fehnel C, Saulsberry A, Dortch K, Wolf B, Valaulikar G, Patel HD, Ng T, Robbins T, Smeltzer MP, Faris NR, Osarogiagbon RU. Surgeon Quality and Patient Survival After Resection for Non-Small-Cell Lung Cancer. J Clin Oncol 2023; 41:3616-3628. [PMID: 37267506 PMCID: PMC10325770 DOI: 10.1200/jco.22.01971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 03/06/2023] [Accepted: 04/12/2023] [Indexed: 06/04/2023] Open
Abstract
PURPOSE The quality and outcomes of curative-intent lung cancer surgery vary in populations. Surgeons are key drivers of surgical quality. We examined the association between surgeon-level intermediate outcomes differences, patient survival differences, and potential mitigation by processes of care. PATIENTS AND METHODS Using a baseline population-based surgical resection cohort, we derived surgeon-level cut points for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections. Applying the baseline cut points to a subsequent cohort from the same population-based data set, we assign surgeons into three performance categories in reference to each metric: 1 (<25th percentile), 2 (25th-75th percentile), and 3 (>75th percentile). The sum of performance scores created three surgeon quality tiers: 1 (4-6, low), 2 (7-9, intermediate), and 3 (10-12, high). We used chi-squared, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests to compare patient characteristics between the baseline and subsequent cohorts and across surgeon tiers. We applied Cox proportional hazards models to examine the association between patient survival and surgeon performance tier, sequentially adjusting for clinical stage, patient characteristics, and four specific processes. RESULTS From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among 31 subsequent cohort surgeons, five were tier 1, five were tier 2, and 21 were tier 3. Tier 1 and 2 surgeons had significantly worse outcomes than tier 3 surgeons (hazard ratio [HR], 1.37; 95% CI, 1.10 to 1.72 and 1.19; 95% CI, 1.00 to 1.43, respectively). Adjustment for specific processes mitigated the surgeon-tiered survival differences, with adjusted HRs of 1.02 (95% CI, 0.8 to 1.3) and 0.93 (95% CI, 0.7 to 1.25), respectively. CONCLUSION Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.
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Affiliation(s)
| | | | - Carrie Fehnel
- Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, TN
| | - Andrea Saulsberry
- Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, TN
| | - Kourtney Dortch
- Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, TN
| | | | | | | | - Thomas Ng
- Methodist University Hospital, Memphis, TN
| | - Todd Robbins
- Baptist Memorial Hospital—Memphis, Memphis TN
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN
| | | | - Nicholas R. Faris
- Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, TN
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN
| | - Raymond U. Osarogiagbon
- Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, TN
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN
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Baum P, Lenzi J, Taber S, Winter H, Wiegering A. Reply to A. Saraswathula et al and Z.V. Fong et al. J Clin Oncol 2022; 40:2998-3000. [PMID: 35671419 DOI: 10.1200/jco.22.00606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Philip Baum
- Philip Baum, MD, Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany; Jacopo Lenzi, PhD, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Samantha Taber, MD, Department of Thoracic Surgery, Heckeshorn Lung Clinic, HELIOS Klinikum Emil von Behring, Berlin, Germany; Hauke Winter, MD, Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany; and Armin Wiegering, MD, Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany, Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany, Theodor Boveri Institute, Biocenter, University of Wuerzburg, Wuerzburg, Germany
| | - Jacopo Lenzi
- Philip Baum, MD, Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany; Jacopo Lenzi, PhD, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Samantha Taber, MD, Department of Thoracic Surgery, Heckeshorn Lung Clinic, HELIOS Klinikum Emil von Behring, Berlin, Germany; Hauke Winter, MD, Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany; and Armin Wiegering, MD, Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany, Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany, Theodor Boveri Institute, Biocenter, University of Wuerzburg, Wuerzburg, Germany
| | - Samantha Taber
- Philip Baum, MD, Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany; Jacopo Lenzi, PhD, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Samantha Taber, MD, Department of Thoracic Surgery, Heckeshorn Lung Clinic, HELIOS Klinikum Emil von Behring, Berlin, Germany; Hauke Winter, MD, Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany; and Armin Wiegering, MD, Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany, Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany, Theodor Boveri Institute, Biocenter, University of Wuerzburg, Wuerzburg, Germany
| | - Hauke Winter
- Philip Baum, MD, Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany; Jacopo Lenzi, PhD, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Samantha Taber, MD, Department of Thoracic Surgery, Heckeshorn Lung Clinic, HELIOS Klinikum Emil von Behring, Berlin, Germany; Hauke Winter, MD, Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany; and Armin Wiegering, MD, Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany, Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany, Theodor Boveri Institute, Biocenter, University of Wuerzburg, Wuerzburg, Germany
| | - Armin Wiegering
- Philip Baum, MD, Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany; Jacopo Lenzi, PhD, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Samantha Taber, MD, Department of Thoracic Surgery, Heckeshorn Lung Clinic, HELIOS Klinikum Emil von Behring, Berlin, Germany; Hauke Winter, MD, Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany; and Armin Wiegering, MD, Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany, Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany, Theodor Boveri Institute, Biocenter, University of Wuerzburg, Wuerzburg, Germany
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Definition of the Surgical Case Complexity in the Treatment of Soft Tissue Tumors of the Extremities and Trunk. Cancers (Basel) 2022; 14:cancers14061559. [PMID: 35326712 PMCID: PMC8946284 DOI: 10.3390/cancers14061559] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Soft tissue tumors are heterogeneous tumor entities that often require surgical intervention for treatment. While some tumors are easy to resect, others require extremely complex, interdisciplinary surgery depending on the tumor type, localization and biological behavior. Up to now, there has not been an instrument able to objectify the complexity of such a surgery; therefore, we attempted to establish a complexity score for the description of soft tissue tumor surgeries. Furthermore, we aimed to categorize surgeries in such a way that patients can be assigned the best treatment such that a cost-effective approach can be taken. Abstract Background: We intend to establish a complexity score for soft tissue tumor surgeries to compare the complexities of different soft tissue tumor surgeries and to ultimately assign affected patients to appropriate treatments. Methods: We developed a soft tissue tumor complexity score (STS-SCS) based on three pillars: in addition to patient-related factors, tumor biology and surgery-associated parameters were taken into account. The STS-SCS was applied to our sampling group of 711 patients. Results: The minimum STS-SCS was 4, the maximum score was 34 and the average score 11.4 ± 5.9. The scores of patients with malignant diagnoses were notably higher and more widely scattered than those of patients with benign or intermediate malignant tumors. To better categorize the complexities of individual surgeries, we established four categories using the collected data as a reference dataset. Each of the categories contained approximately one-quarter of the registered patients. Discussion: The STS-SCS allows soft tissue tumor surgeries to be retrospectively evaluated for their complexity and forms the basis for the creation of a prospective concept to provide patients with the right intervention in the right geographic location, which can lead to better results and provision of the most cost-effective overall treatment.
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Baum P, Lenzi J, Diers J, Rust C, Eichhorn ME, Taber S, Germer CT, Winter H, Wiegering A. Risk-Adjusted Mortality Rates as a Quality Proxy Outperform Volume in Surgical Oncology-A New Perspective on Hospital Centralization Using National Population-Based Data. J Clin Oncol 2022; 40:1041-1050. [PMID: 35015575 DOI: 10.1200/jco.21.01488] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery to safer hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume. METHODS We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for any of five major cancer types, splitting the data into training (2010-2015) and validation sets (2016-2018). For each surgical group, we calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modeled a market exit of low-performing hospitals, and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance or time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure. RESULTS Between 2016 and 2018, 158,079 patients were treated in 974 hospitals. At least 50% of high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In an RSMR centralization model, an average of 32 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, whereas 47 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery ranged from 10 minutes for colorectal cancer to 24 minutes for pancreatic cancer. Centralization on the basis of RSMR compared with volume would ensure lower median travel times for all cancer types, and these times would be lower than those observed. CONCLUSION RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.
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Affiliation(s)
- Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph Rust
- Department of Econometrics, University of Regensburg, Regensburg, Germany.,Department of Finance, Accounting and Statistics, Vienna University of Economics and Business, Vienna, Austria
| | - Martin E Eichhorn
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Samantha Taber
- Department of Thoracic Surgery, Heckeshorn Lung Clinic, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.,Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.,Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany.,Theodor Boveri Institute, Biocenter, University of Wuerzburg, Am Hubland, Würzburg, Germany
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Osarogiagbon RU, Sineshaw HM, Lin CC, Jemal A. Institutional-Level Differences in Quality and Outcomes of Lung Cancer Resections in the United States. Chest 2021; 159:1630-1641. [PMID: 33197400 PMCID: PMC8147100 DOI: 10.1016/j.chest.2020.10.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/03/2020] [Accepted: 10/29/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Institutional-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC. RESEARCH QUESTION How do reversible differences in oncologic quality of care contribute to institutional-level disparities in early-stage NSCLC survival? STUDY DESIGN AND METHODS We retrospectively analyzed patients in the National Cancer Data Base who underwent NSCLC resection from 2004 through 2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted ORs for six potentially avoidable poor-quality markers: incomplete resection, nonexamination of lymph nodes, nonanatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy, and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact. RESULTS Of 169,775 patients, 7%, 46%, 10%, 24%, and 12% underwent surgery at Community, Comprehensive Community, Integrated Network, Academic, and NCI-Designated Cancer Programs, with 5-year overall survival rates of 52%, 56%, 58%, 60% and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as a reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95% CI, 1.41-1.53), 1.29 (95% CI, 1.25-1.33), 1.18 (95% CI, 1.14-1.23), and 1.20 (95% CI, 1.16-1.24) for Community, Comprehensive Community, Integrated Networks, and Academic Cancer Programs to 1.35 (95% CI, 1.28-1.42), 1.22 (95% CI, 1.17-1.26), 1.16 (95% CI, 1.11-1.22), and 1.17 (95% CI, 1.12-1.21), respectively (P < .001 for all comparisons with NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11% to 26% of the interinstitutional survival disparities. INTERPRETATION Targeting six readily identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized to eliminate them.
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Affiliation(s)
- Raymond U Osarogiagbon
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN.
| | - Helmneh M Sineshaw
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
| | - Chun Chieh Lin
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
| | - Ahmedin Jemal
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA
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