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Han L, Sullivan R, Tree A, Lewis D, Price P, Sangar V, van der Meulen J, Aggarwal A. The impact of transportation mode, socioeconomic deprivation and rurality on travel times to radiotherapy and surgical services for patients with prostate cancer: A national population-based evaluation. Radiother Oncol 2024; 192:110092. [PMID: 38219910 DOI: 10.1016/j.radonc.2024.110092] [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: 09/08/2023] [Revised: 01/09/2024] [Accepted: 01/09/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND The distances that patients have to travel can influence their access to cancer treatment. We investigated the determinants of travel time, separately for journeys by car and public transport, to centres providing radical surgery or radiotherapy for prostate cancer. METHODS Using national cancer registry records linked to administrative hospital data, we identified patients who had radical surgery or radiotherapy for prostate cancer between January 2017 and December 2018 in the English National Health Service. Estimated travel times from the patients' residential area to the nearest specialist surgical or radiotherapy centre were estimated for journeys by car and by public transport. RESULTS We included 13,186 men who had surgery and 26,581 who had radiotherapy. Estimated travel times by public transport (74.4 mins for surgery and 69.4 mins for radiotherapy) were more than twice as long as by car (33.4 mins and 29.1mins, respectively). Patients living in more socially deprived neighbourhoods in rural areas had the longest travel times to the nearest cancer treatment centres by car (62.0 mins for surgery and 52.1 mins for radiotherapy). Conversely patients living in more affluent neighbourhoods in urban conurbations had the shortest (18.7 mins for surgery and 17.9 mins for radiotherapy). CONCLUSION Travel times to cancer centres vary widely according to mode of transport, socioeconomic deprivation, and rurality. Policies changing the geographical configuration of cancer services should consider the impact on the expected travel times both by car and by public transport to avoid enhancing existing inequalities in access to treatment and patient outcomes.
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Affiliation(s)
- Lu Han
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Alison Tree
- Royal Marsden Hospital and The Institute for Cancer Research, London, UK
| | - Daniel Lewis
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Pat Price
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Vijay Sangar
- The Christie NHS Trust and Manchester University NHS Foundation Trust, Manchester, UK; Manchester University, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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2
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Aigner C. Long segment stenosis-the narrow path to centralization in airway surgery. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae004. [PMID: 38216537 PMCID: PMC10858342 DOI: 10.1093/icvts/ivae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 01/09/2024] [Indexed: 01/14/2024]
Affiliation(s)
- Clemens Aigner
- Department of Thoracic Surgery, Comprehensive Center for Chest Disease, Medical University of Vienna—Vienna University Hospital, Vienna, Austria
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Hirpara DH, Irish J, Rashid M, Martin T, Zhu A, Hunter A, Jayaraman S, Wei AC, Coburn NG, Wright FC. Defining Standards for Hepatopancreatobiliary Cancer Surgery in Ontario, Canada: A Population-Based Cohort Study of Clinical Outcomes. J Am Coll Surg 2024; 238:157-165. [PMID: 37796140 DOI: 10.1097/xcs.0000000000000885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND In 2006, Cancer Care Ontario created Surgical Oncology Standards for the delivery of hepatopancreatobiliary (HPB) surgery including hepatectomy and pancreaticoduodenectomy (PD). Our objective was to identify the impact of standardization on outcomes after HPB surgery in Ontario, Canada. STUDY DESIGN This study was a population-level analysis of patients undergoing hepatectomy or PD (2003 to 2019). Logistic regression models were used to compare 30- and 90-day mortality and length of stay (LOS) before (2003 to 2006), during (2007 to 2011), and after (2012 to 2019) standardization. Interrupted time series models were used to co-analyze secular trends. RESULTS A total of 7,904 hepatectomies and 5,238 PDs were performed. More than 80% of all cases were performed at a designated center (DC) before standardization. This increased to >98% in the poststandardization era. Median volumes at DCs increased from 55 to 67 hepatectomies/year and from 22 to 50 PDs/year over time. In addition, 30-day mortality after hepatectomy was 2.6% before standardization and 2.3% after standardization (p = 0.9); 30-day mortality after PD was 3.6% before standardization and 2.4% after standardization (p = 0.1). Multivariable analyses revealed a significant difference in 90-day mortality following PD poststandardization (4.3% vs 6.3%; adjusted odds ratio, 0.7; p = 0.03). Median LOS was shorter for hepatectomy (6 days vs 8 days) and PD (9 days vs 14 days; p < 0.0001) after standardization. Immediate and late effects on mortality and LOS were likely attributable to secular trends, which predated standardization. CONCLUSIONS Standardization was associated with a higher volume of hepatectomy and PDs with further concentration of care at DCs. Pre-existing quality initiatives may have attenuated the effect of standardization on quality outcomes. Our data highlight the merits of a multifaceted provincial system for enabling consistent access to high quality HPB care throughout a region of 15 million people over a 16-year period.
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Affiliation(s)
- Dhruvin H Hirpara
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
| | - Jonathan Irish
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- the Division of Head and Neck Oncology and Reconstructive Surgery, University Health Network, Toronto, Ontario, Canada (Irish)
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Mohammed Rashid
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Tharsiya Martin
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Alice Zhu
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
| | - Amber Hunter
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Shiva Jayaraman
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- the Division of General Surgery, Unity Health, St Joseph's Health Center, Toronto, Ontario, Canada (Jayaraman)
| | - Alice C Wei
- Memorial Sloan Kettering Cancer Center, New York, NY (Wei)
| | - Natalie G Coburn
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- the Division of General Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (Coburn, Wright)
| | - Frances C Wright
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
- the Division of General Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (Coburn, Wright)
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Kyaw JYA, Rendall A, Gillespie EF, Roques T, Court L, Lievens Y, Tree AC, Frampton C, Aggarwal A. Systematic Review and Meta-analysis of the Association Between Radiation Therapy Treatment Volume and Patient Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:1063-1086. [PMID: 37227363 PMCID: PMC10680429 DOI: 10.1016/j.ijrobp.2023.02.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/15/2023] [Accepted: 02/20/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE Evidence of a volume-outcome association in cancer surgery has shaped the centralization of cancer services; however, it is unknown whether a similar association exists for radiation therapy. The objective of this study was to determine the association between radiation therapy treatment volume and patient outcomes. METHODS AND MATERIALS This systematic review and meta-analysis included studies that compared outcomes of patients who underwent definitive radiation therapy at high-volume radiation therapy facilities (HVRFs) versus low-volume facilities (LVRFs). The systematic review used Ovid MEDLINE and Embase. For the meta-analysis, a random effects model was used. Absolute effects and hazard ratios (HRs) were used to compare patient outcomes. RESULTS The search identified 20 studies assessing the association between radiation therapy volume and patient outcomes. Seven of the studies looked at head and neck cancers (HNCs). The remaining studies covered cervical (4), prostate (4), bladder (3), lung (2), anal (2), esophageal (1), brain (2), liver (1), and pancreatic cancer (1). The meta-analysis demonstrated that HVRFs were associated with a lower chance of death compared with LVRFs (pooled HR, 0.90; 95% CI, 0.87- 0.94). HNCs had the strongest evidence of a volume-outcome association for both nasopharyngeal cancer (pooled HR, 0.74; 95% CI, 0.62-0.89) and nonnasopharyngeal HNC subsites (pooled HR, 0.80; 95% CI, 0.75-0.84), followed by prostate cancer (pooled HR, 0.92; 95% CI, 0.86-0.98). The remaining cancer types showed weak evidence of an association. The results also demonstrate that some centers defined as HVRFs are undertaking very few procedures per annum (<5 radiation therapy cases per year). CONCLUSIONS An association between radiation therapy treatment volume and patient outcomes exists for most cancer types. Centralization of radiation therapy services should be considered for cancer types with the strongest volume-outcome association, but the effect on equitable access to services needs to be explicitly considered.
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Affiliation(s)
| | - Alice Rendall
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Tom Roques
- Norfolk and Norwich University Hospitals, Norwich, United Kingdom
| | - Laurence Court
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Alison C Tree
- Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | | | - Ajay Aggarwal
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Levaillant M, Rony L, Hamel-Broza JF, Soula J, Vallet B, Lamer A. In France, distance from hospital and health care structure impact on outcome after arthroplasty of the hip for proximal fractures of the femur. J Orthop Surg Res 2023; 18:418. [PMID: 37296484 DOI: 10.1186/s13018-023-03893-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Hip arthroplasty is a frequently performed procedure in orthopedic surgery, carried out in almost all health structures for two main issues: fracture and coxarthrosis. Even if volume-outcome relationship appeared associated in many surgeries recently, data provided are not sufficient to set surgical thresholds neither than closing down low-volumes centers. QUESTION With this study, we wanted to identify surgical, health care-related and territorial factors influencing patient' mortality and readmission after a HA for a femoral fracture in 2018 in France. PATIENTS AND METHODS Data were anonymously collected from French nationwide administrative databases. All patients who underwent a hip arthroplasty for a femoral fracture through 2018 were included. Patient outcome was 90-day mortality and 90-day readmission rate after surgery. RESULTS Of the 36,252 patients that underwent a HA for fracture in France in 2018, 0.7% died within 90-day year and 1.2% were readmitted. Male and Charlson comorbidity index were associated with a higher 90-day mortality and readmission rate in multivariate analysis. High volume was associated with a lower mortality rate. Neither time of travel nor distance upon health facility were associated with mortality nor with readmission rate in the analysis. CONCLUSION Even if volume appears to be associated with lower mortality rate even for longer distance and time of travel, the persistence of exogenous factors not documented in the French databases suggests that regionalization of hip arthroplasty should be organized with caution. CLINICAL RELEVANCE As volume-outcome relationship must be interpreted with caution, policy makers should not regionalize such surgery without further investigation.
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Affiliation(s)
- Mathieu Levaillant
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, 59000, Lille, France.
- Centre Hospitalier Universitaire d'Angers, Angers, France.
| | - Louis Rony
- Centre Hospitalier Universitaire d'Angers, Angers, France
| | | | - Julien Soula
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
| | - Benoît Vallet
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
| | - Antoine Lamer
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, 59000, Lille, France
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6
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Contrera KJ, Tam S, Pytynia K, Diaz EM, Hessel AC, Goepfert RP, Lango M, Su SY, Myers JN, Weber RS, Eguia A, Pisters PWT, Adair DK, Nair AS, Rosenthal DI, Mayo L, Chronowski GM, Zafereo ME, Shah SJ. Impact of Cancer Care Regionalization on Patient Volume. Ann Surg Oncol 2023; 30:2331-2338. [PMID: 36581726 DOI: 10.1245/s10434-022-13029-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/12/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cancer centers are regionalizing care to expand patient access, but the effects on patient volume are unknown. This study aimed to compare patient volumes before and after the establishment of head and neck regional care centers (HNRCCs). METHODS This study analyzed 35,394 unique new patient visits at MD Anderson Cancer Center (MDACC) before and after the creation of HNRCCs. Univariate regression estimated the rate of increase in new patient appointments. Geospatial analysis evaluated patient origin and distribution. RESULTS The mean new patients per year in 2006-2011 versus 2012-2017 was 2735 ± 156 patients versus 3155 ± 207 patients, including 464 ± 78 patients at HNRCCs, reflecting a 38.4 % increase in overall patient volumes. The rate of increase in new patient appointments did not differ significantly before and after HNRCCs (121.9 vs 95.8 patients/year; P = 0.519). The patients from counties near HNRCCs, showed a 210.8 % increase in appointments overall, 33.8 % of which were at an HNRCC. At the main campus exclusively, the shift in regional patients to HNRCCs coincided with a lower rate of increase in patients from the MDACC service area (33.7 vs. 11.0 patients/year; P = 0.035), but the trend was toward a greater increase in out-of-state patients (25.7 vs. 40.3 patients/year; P = 0.299). CONCLUSIONS The creation of HNRCCs coincided with stable increases in new patient volume, and a sizeable minority of patients sought care at regional centers. Regional patients shifted to the HNRCCs, and out-of-state patient volume increased at the main campus, optimizing access for both local and out-of-state patients.
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Affiliation(s)
- Kevin J Contrera
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Samantha Tam
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Kristen Pytynia
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo M Diaz
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy C Hessel
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ryan P Goepfert
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Miriam Lango
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arturo Eguia
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | | | - Deborah K Adair
- Department of Global Business Development, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ajith S Nair
- Department of Global Business Development, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren Mayo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory M Chronowski
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark E Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Shalin J Shah
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Pfisterer-Heise S, Scharfe J, Kugler CM, Shehu E, Wolf T, Mathes T, Pieper D. Protocol for the development of a core outcome set for studies on centralisation of healthcare services. BMJ Open 2023; 13:e068138. [PMID: 36944460 PMCID: PMC10032414 DOI: 10.1136/bmjopen-2022-068138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Centralisation defined as the reorganisation of healthcare services into fewer specialised units serving a higher volume of patients is a potential measure for healthcare reforms aiming at reducing costs while improving quality. Research on centralisation of healthcare services is thus essential to inform decision-makers. However, so far studies on centralisation report a variability of outcomes, often neglecting outcomes at the health system level. Therefore, this study aims at developing a core outcome set (COS) for studies on centralisation of hospital procedures, which is intended for use in observational as well as in experimental studies. METHODS AND ANALYSIS We propose a five-stage study design: (1) systematic review, (2) focus group, (3) interview studies, (4) online survey, (5) Delphi survey. The study will be conducted from March 2022 to November 2023. First, an initial list of outcomes will be identified through a systematic review on reported outcomes in studies on minimum volume regulations. We will search MEDLINE, EMBASE, CENTRAL, CINHAL, EconLIT, PDQ-Evidence for Informed Health Policymaking, Health Systems Evidence, Open Grey and also trial registries. This will be supplemented with relevant outcomes from published studies on centralisation of hospital procedures. Second, we will conduct a focus group with representatives of patient advocacy groups for which minimum volume regulations are currently in effect in Germany or are likely to come into effect to identify outcomes important to patients. Furthermore, two interview studies, one with representatives of the German medical societies and one with representatives of statutory health insurance funds, as well as an online survey with health services researchers will be conducted. In our analyses of the suggested outcomes, we will largely follow the categorisation scheme developed by the Cochrane EPOC group. Finally, a two-round online Delphi survey with all stakeholder groups using predefined score criteria for consensus will be employed to first prioritise outcomes and then agree on the final COS. ETHICS AND DISSEMINATION This study has been approved by the Research Ethics Committee at the Brandenburg Medical School Theodor Fontane (MHB). The final COS will be disseminated to all stakeholders involved and through peer-reviewed publications and conferences.
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Affiliation(s)
- Stefanie Pfisterer-Heise
- Institute for Health Services and Health System Research, Center for Health Services Research Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
| | - Julia Scharfe
- Institute for Health Services and Health System Research, Center for Health Services Research Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
| | - Charlotte Mareike Kugler
- Institute for Health Services and Health System Research, Center for Health Services Research Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
| | - Eni Shehu
- Institute for Health Services and Health System Research, Center for Health Services Research Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
| | - Tobias Wolf
- Institute for Health Services and Health System Research, Center for Health Services Research Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
| | - Tim Mathes
- Institute for Medical Statistics, University Medical Center Goettingen, Göttingen, Germany
| | - Dawid Pieper
- Institute for Health Services and Health System Research, Center for Health Services Research Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
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Bernard A, Cottenet J, Pages PB, Quantin C. Is there variation between hospitals within each region in postoperative mortality for lung cancer surgery in France? A nationwide study from 2013 to 2020. Front Med (Lausanne) 2023; 10:1110977. [PMID: 36999073 PMCID: PMC10043397 DOI: 10.3389/fmed.2023.1110977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
IntroductionThe practice of thoracic surgery for lung cancer is subject to authorization in France. We evaluated the performance of hospitals using 30-day post-operative mortality as a quality indicator, estimating its distribution within each region and measuring its variability between regions.Material and methodsAll data for patients who underwent pulmonary resection for lung cancer in France (2013–2020) were collected from the national hospital administrative database. Thirty-day mortality was defined as any patient who died in hospital (including transferred patients) within the first 30 days after the operation and those who died later during the initial hospitalization. The Standardized Mortality ratio (SMR) was the smoothed, adjusted, hospital-specific mortality rate divided by the expected mortality. To describe the variation in hospital mortality between hospitals in each region, we used different commonly used indicators of variation such as coefficients of variation (CV), interquartile interval or range (IQR), extreme ratio, and systematic component of variance (SCV).ResultsIn 2013–2020, 87,232 patients underwent lung resection for cancer in France. The number of deaths was 2,537, a rate of 2.91%. The median SMR of 199 hospitals was 0.99 with an IQR of 0.86 to 1.18 and a CV of 0.25. Among the regions that had the most hospitals performing lung resections for cancer, the extreme ratio was >2, which means that the maximum value is twice as high as the minimum value. The SCV between hospitals was >10 for two of these regions, which is considered indicative of very high variation. For the other regions (with few hospitals performing lung resections for cancer), the variation between hospitals was lower. Globally, the variability between regions concerning the SMR was moderate, 6% of the variance was due to differences across regions. On the contrary, the hospital volume was significantly related to the SMR (p = 0.003) with a negative linear trend, whatever the region.ConclusionThis work shows significant differences in the practices of the various hospitals within regions. However, overall, the variability in the 30-day mortality rate between regions was moderate. Our findings raises questions regarding the regionalization of major surgical procedures in France.
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Affiliation(s)
- Alain Bernard
- Department of Thoracic and Cardiovascular Surgery, Dijon University Hospital, Dijon, France
| | - Jonathan Cottenet
- Service de Biostatistiques et d'Information Médicale (DIM), CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Pierre-Benoit Pages
- Department of Thoracic and Cardiovascular Surgery, Dijon University Hospital, Dijon, France
| | - Catherine Quantin
- Service de Biostatistiques et d'Information Médicale (DIM), CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- Université Paris-Saclay, Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), Inserm, Centre de recherche en Epidémiologie et Santé des Populations (CESP), Villejuif, France
- *Correspondence: Catherine Quantin
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Rygalski CJ, Huttinger ZM, Zhao S, Brock G, VanKoevering K, Old MO, Teknos TN, Rocco JW, Puram SV, Seim NB, Swendseid B, Haring CT, Eskander A, Kang SY. High surgical volume is associated with improved survival in head and neck cancer. Oral Oncol 2023; 138:106333. [PMID: 36746098 DOI: 10.1016/j.oraloncology.2023.106333] [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: 11/01/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Examine the relationship between hospital volume and overall mortality in a surgical cohort of head and neck squamous cell carcinoma (HNSCC) patients. MATERIALS & METHODS A retrospective review of the NCDB was completed for adults with previously untreated HNSCC diagnosed between 2004 and 2016. Mean annual hospital volume was calculated using the number of head and neck cancer cases treated at a given facility divided by the number of years the facility reported to the NCDB. Facilities were separated into three categories based on their volume percentile, informed by inflection points from a natural cubic spline: Hospital Group 1 (<50%); Hospital Group 2 (50-90%); Hospital Group 3 (90%+). Cox proportional hazard models were used to examine the association between volume percentiles (continuous or categorical) with patient overall survival, adjusting for important patient and facility variables known to impact survival. RESULTS Risk of death decreased by 2.97% for every 10% increase in facility percentile after adjusting for other risk factors. Patients treated at facilities in Hospital Group 1 had a 23.1% increase in risk of mortality (HR 1.231 [95% CI 1.12-1.35]) relative those at facilities in Hospital Group 3. No significant difference in mortality risk was found between Hospital Group 2 versus Hospital Group 3 (HR 1.031 [95% CI 0.97-1.10]). CONCLUSIONS Survival of HNSCC patients is significantly improved when treated at facilities >50th percentile in annual hospital volume. This may support the regionalization of care to high volume head and neck centers with comprehensive facilities and supportive services to maximize patient outcomes.
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Affiliation(s)
- Chandler J Rygalski
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W 10(th) Avenue, 5(th) floor, Columbus, OH 43210, United States
| | - Zachary M Huttinger
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W 10(th) Avenue, 5(th) floor, Columbus, OH 43210, United States
| | - Songzhu Zhao
- Department of Biomedical Informatics and Center for Biostatistics, The Ohio State University, 320 Lincoln Tower, 1800 Cannon Drive, Columbus, OH 43210, United States
| | - Guy Brock
- Department of Biomedical Informatics and Center for Biostatistics, The Ohio State University, 320 Lincoln Tower, 1800 Cannon Drive, Columbus, OH 43210, United States
| | - Kyle VanKoevering
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W 10(th) Avenue, 5(th) floor, Columbus, OH 43210, United States
| | - Matthew O Old
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W 10(th) Avenue, 5(th) floor, Columbus, OH 43210, United States
| | - Theodoros N Teknos
- UH Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, United States
| | - James W Rocco
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W 10(th) Avenue, 5(th) floor, Columbus, OH 43210, United States
| | - Sidharth V Puram
- Department of Otolaryngology-Head & Neck Surgery, Washington University School of Medicine, 4921 Parkway Place, 11(th) Floor, St. Louis, MO 63110, United States
| | - Nolan B Seim
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W 10(th) Avenue, 5(th) floor, Columbus, OH 43210, United States
| | - Brian Swendseid
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W 10(th) Avenue, 5(th) floor, Columbus, OH 43210, United States
| | - Catherine T Haring
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W 10(th) Avenue, 5(th) floor, Columbus, OH 43210, United States
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Suite M1-102, Toronto, ON M4N 3M5, Canada
| | - Stephen Y Kang
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W 10(th) Avenue, 5(th) floor, Columbus, OH 43210, United States.
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10
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Disparities in Access to Thoracic Surgeons among Patients Receiving Lung Lobectomy in the United States. Curr Oncol 2023; 30:2801-2811. [PMID: 36975426 PMCID: PMC10047038 DOI: 10.3390/curroncol30030213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Objective: Lung lobectomy is the standard of care for early-stage lung cancer. Studies have suggested improved outcomes associated with lobectomy performed by specialized thoracic surgery providers. We hypothesized that disparities would exist regarding access to thoracic surgeons among patients receiving lung lobectomy for cancer. Methods: The Premier Hospital Database was used to identify adult inpatients receiving lung lobectomy from 2009 to 2019. Patients were categorized as receiving their lobectomy from a thoracic surgeon, cardiovascular surgeon, or general surgeon. Sample-weighted multivariable analysis was performed to identify factors associated with provider type. Results: When adjusted for sampling, 121,711 patients were analyzed, including 71,709 (58.9%) who received lobectomy by a thoracic surgeon, 36,630 (30.1%) by a cardiovascular surgeon, and 13,373 (11.0%) by a general surgeon. Multivariable analysis showed that thoracic surgeon provider type was less likely with Black patients, Medicaid insurance, smaller hospital size, in the western region, and in rural areas. In addition, non-thoracic surgery specialty was less likely to perform minimally-invasive (MIS) lobectomy (cardiovascular OR 0.80, p < 0.001, general surgery OR 0.85, p = 0.003). Conclusions: In this nationally representative analysis, smaller, rural, non-teaching hospitals, and certain regions of the United States are less likely to receive lobectomy from a thoracic surgeon. Thoracic surgeon specialization is also independently associated with utilization of minimally invasive lobectomy. Combined, there are significant disparities in access to guideline-directed surgical care of patients receiving lung lobectomy.
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11
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Blum TG, Morgan RL, Durieux V, Chorostowska-Wynimko J, Baldwin DR, Boyd J, Faivre-Finn C, Galateau-Salle F, Gamarra F, Grigoriu B, Hardavella G, Hauptmann M, Jakobsen E, Jovanovic D, Knaut P, Massard G, McPhelim J, Meert AP, Milroy R, Muhr R, Mutti L, Paesmans M, Powell P, Putora PM, Rawlinson J, Rich AL, Rigau D, de Ruysscher D, Sculier JP, Schepereel A, Subotic D, Van Schil P, Tonia T, Williams C, Berghmans T. European Respiratory Society guideline on various aspects of quality in lung cancer care. Eur Respir J 2023; 61:13993003.03201-2021. [PMID: 36396145 DOI: 10.1183/13993003.03201-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.
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Affiliation(s)
- Torsten Gerriet Blum
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - David R Baldwin
- Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
| | | | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | | | | | - Bogdan Grigoriu
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Georgia Hardavella
- Department of Respiratory Medicine, King's College Hospital London, London, UK
- Department of Respiratory Medicine and Allergy, King's College London, London, UK
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Neuruppin, Germany
| | - Erik Jakobsen
- Department of Thoracic Surgery, Odense University Hospital, Odense, Denmark
| | | | - Paul Knaut
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Gilbert Massard
- Faculty of Science, Technology and Medicine, University of Luxembourg and Department of Thoracic Surgery, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - John McPhelim
- Lung Cancer Nurse Specialist, Hairmyres Hospital, NHS Lanarkshire, East Kilbride, UK
| | - Anne-Pascale Meert
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Robert Milroy
- Scottish Lung Cancer Forum, Glasgow Royal Infirmary, Glasgow, UK
| | - Riccardo Muhr
- Department of Pneumology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Luciano Mutti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- SHRO/Temple University, Philadelphia, PA, USA
| | - Marianne Paesmans
- Data Centre, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Paul Martin Putora
- Departments of Radiation Oncology, Kantonsspital St Gallen, St Gallen and University of Bern, Bern, Switzerland
| | | | - Anna L Rich
- Department of Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | - Dirk de Ruysscher
- Maastricht University Medical Center, Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
- Erasmus Medical Center, Department of Radiation Oncology, Rotterdam, The Netherlands
| | - Jean-Paul Sculier
- Intensive Care and Oncological Emergencies and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Arnaud Schepereel
- Pulmonary and Thoracic Oncology, Université de Lille, Inserm, CHU Lille, Lille, France
| | - Dragan Subotic
- Clinic for Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Thierry Berghmans
- Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Brussels, Belgium
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12
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Effect of Thoracic Surgery Regionalization on 1- and 3-Year Survival after Cancer Esophagectomy. Ann Surg 2023; 277:e305-e312. [PMID: 34261883 DOI: 10.1097/sla.0000000000005076] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to investigate whether our previously reported improvements in short-term cancer esophagectomy outcomes after large-scale regionalization in the United States translated to longer-term survival benefit. BACKGROUND Regionalization is associated with better early postoperative outcomes following cancer esophagectomy; however, data regarding its effect on long-term survival are mixed. METHODS We retrospectively reviewed 461 patients undergoing cancer esophagectomy before (2009-2013, N = 272) and after (2014-2016, N = 189) regionalization. Kaplan-Meier curves and chi-square tests were used to describe 1- and 3-year survival in each era. Hierarchical logistic regression models examined the adjusted effect of regionalization on mortality. RESULTS Compared to pre-regionalization patients, post-regionalization patients had significantly higher 1-year survival (83.1% vs 73.9%, P = 0.02) but not 3-year survival (52.9% vs 58.2%, P = 0.26).Subgroup analysis by cancer stage revealed that 1-year survival benefit was only significant among mid-stage (IIB-IIIB) patients, whereas differences in 3-year survival only approached significance among early-stage (IA-IIA) patients.In multivariable analysis, only regionalization was a predictor of lower mortality at 1 year [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.29-1.00], and only thoracic specialty at 3years (OR 0.62, 95% CI 0.38-0.99). Older age, more advanced stage, and complications were associated with higher 1- and 3-year mortality. Comorbidity, minimally invasive approach, surgeon volume, facility volume, and neoadjuvant treatment were not significant in this model. CONCLUSIONS Regionalization was associated with improved 1-year survival after cancer esophagectomy, independent of factors such as morbidity or volume in our adjusted models. This survival benefit did not persist at 3 years, likely due to the aggressive nature of the disease.
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13
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Symptom Assessment Following Surgery for Lung Cancer: A Canadian Population-based Retrospective Cohort Study. Ann Surg 2023; 277:e428-e438. [PMID: 33605583 DOI: 10.1097/sla.0000000000004802] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To conduct a population-level analysis of temporal trends and risk factors for high symptom burden in patients receiving surgery for non-small cell lung cancer (NSCLC). BACKGROUND A population-level overview of symptoms after curative intent surgery is necessary to inform decision making and supportive care for patients with lung cancer. METHODS Retrospective cohort study of patients receiving surgery for stages I to III NSCLC between January 2007 and September 2018. Prospectively collection Edmonton Symptom Assessment System (ESAS) scores, linked to provincial administrative data, were used to describe the prevalence, trajectory, and predictors of moderate-to-severe symptoms in the year following surgery. RESULTS A total of 5350 patients, with 28,490 unique ESAS assessments, were included in the analysis. Moderate-to-severe tiredness (68%), poor wellbeing (63%), and shortness of breath (60%) were the most common symptoms reported. The rise and fall in the proportion of patients experiencing moderate-to-severe symptoms after surgery coincided with the median time to first (58 days, interquartile range: 47-72) and last cycle of chemotherapy (140 days, interquartile range: 118-168), respectively. There was eventual stabilization, albeit above the preoperative baseline, within 6 to 7 months after surgery. Female sex (relative risk [RR] 1.09- 1.26), lower income (RR 1.08-1.23), stage III disease (RR 1.15-1.43), adjuvant therapy (RR 1.09-1.42), chemotherapy within 2 weeks of an ESAS assessment (RR 1.14-1.73), and pneumonectomy (RR 1.05-1.15) were associated with moderate-to-severe symptoms following surgery. CONCLUSIONS Knowledge of population-level prevalence, trajectory, and predictors of moderate-to-severe symptoms after surgery for NSCLC can be used to facilitate shared decision making and improve symptom management throughout the course of illness.
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Hanna NM, Nguyen P, Chung W, Groome PA. Time to Surgery for Patients with Esophageal Cancer Undergoing Trimodal Therapy in Ontario: A Population-Based Cross-Sectional Study. Curr Oncol 2022; 29:5901-5918. [PMID: 36005204 PMCID: PMC9406364 DOI: 10.3390/curroncol29080466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/14/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
Patients with resectable esophageal cancer are recommended to undergo chemoradiotherapy before esophagectomy. A longer time to surgery (TTS) and/or time to consultation (TTC) may be associated with inferior cancer-related outcomes and heightened anxiety. Thoracic cancer surgery centers (TCSCs) oversee esophageal cancer management, but differences in TTC/TTS between centers have not yet been examined. This Ontario population-level study used linked administrative healthcare databases to investigate patients with esophageal cancer between 2013–2018, who underwent neoadjuvant chemoradiotherapy and then surgery. TTC and TTS were time from diagnosis to the first surgical consultation and then to surgery, respectively. Patients were assigned a TCSC based on the location of the surgery. Patient, disease, and diagnosing physician characteristics were investigated. Quantile regression was used to model TTS/TTC at the 50th and 90th percentiles and identify associated factors. The median TTS and TTC were 130 and 29 days, respectively. The adjusted differences between the TCSCs with the longest and shortest median TTS and TTC were 32 and 18 days, respectively. Increasing age was associated with a 16-day longer median TTS. Increasing material deprivation was associated with a 6-day longer median TTC. Significant geographic variability exists in TTS and TTC. Therefore, the investigation of TCSC characteristics is warranted. Shortening wait times may reduce patient anxiety and improve the control of esophageal cancer.
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Affiliation(s)
- Nader M. Hanna
- Department of Surgery, Division of General Surgery, Queen’s University, 76 Stuart Street, Kingston, ON K7L 2V7, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 2V7, Canada
- Correspondence:
| | - Paul Nguyen
- ICES Queen’s, Queen’s University, Kingston, ON K7L 2V7, Canada
| | - Wiley Chung
- Department of Surgery, Division of Thoracic Surgery, Queen’s University, Kingston, ON K7L 2V7, Canada
| | - Patti A. Groome
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 2V7, Canada
- ICES Queen’s, Queen’s University, Kingston, ON K7L 2V7, Canada
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, ON K7L 2V7, Canada
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15
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Aggarwal A, Han L, van der Geest S, Lewis D, Lievens Y, Borras J, Jayne D, Sullivan R, Varkevisser M, van der Meulen J. Health service planning to assess the expected impact of centralising specialist cancer services on travel times, equity, and outcomes: a national population-based modelling study. Lancet Oncol 2022; 23:1211-1220. [DOI: 10.1016/s1470-2045(22)00398-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/29/2022] [Accepted: 07/01/2022] [Indexed: 10/16/2022]
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16
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Manchon-Walsh P, Aliste L, Borràs JM, Coll-Ortega C, Casacuberta J, Casanovas-Guitart C, Clèries M, Cruz S, Guarga À, Mompart A, Planella A, Pozuelo A, Ticó I, Vela E, Prades J. Socioeconomic Status and Distance to Reference Centers for Complex Cancer Diseases: A Source of Health Inequalities? A Population Cohort Study Based on Catalonia (Spain). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148814. [PMID: 35886665 PMCID: PMC9322195 DOI: 10.3390/ijerph19148814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 12/10/2022]
Abstract
The centralization of complex surgical procedures for cancer in Catalonia may have led to geographical and socioeconomic inequities. In this population-based cohort study, we assessed the impacts of these two factors on 5-year survival and quality of care in patients undergoing surgery for rectal cancer (2011–12) and pancreatic cancer (2012–15) in public centers, adjusting for age, comorbidity, and tumor stage. We used data on the geographical distance between the patients’ homes and their reference centers, clinical patient and treatment data, income category, and data from the patients’ district hospitals. A composite ‘textbook outcome’ was created from five subindicators of hospitalization. We included 646 cases of pancreatic cancer (12 centers) and 1416 of rectal cancer (26 centers). Distance had no impact on survival for pancreatic cancer patients and was not related to worse survival in rectal cancer. Compared to patients with medium–high income, the risk of death was higher in low-income patients with pancreatic cancer (hazard ratio (HR) 1.46, 95% confidence interval (CI) 1.15–1.86) and very-low-income patients with rectal cancer (HR 5.14, 95% CI 3.51–7.52). Centralization was not associated with worse health outcomes in geographically dispersed patients, including for survival. However, income level remained a significant determinant of survival.
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Affiliation(s)
- Paula Manchon-Walsh
- Catalonian Cancer Strategy, Department of Health, Government of Catalonia, Avenida Gran Via de l’Hospitalet, 199-203, 08908 L’Hospitalet de Llobregat, Spain; (L.A.); (J.M.B.); (C.C.-O.); (J.P.)
- Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona, C/Feixa Llarga, s/n, 08907 L’Hospitalet de Llobregat, Spain
- Correspondence:
| | - Luisa Aliste
- Catalonian Cancer Strategy, Department of Health, Government of Catalonia, Avenida Gran Via de l’Hospitalet, 199-203, 08908 L’Hospitalet de Llobregat, Spain; (L.A.); (J.M.B.); (C.C.-O.); (J.P.)
- Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona, C/Feixa Llarga, s/n, 08907 L’Hospitalet de Llobregat, Spain
| | - Josep M. Borràs
- Catalonian Cancer Strategy, Department of Health, Government of Catalonia, Avenida Gran Via de l’Hospitalet, 199-203, 08908 L’Hospitalet de Llobregat, Spain; (L.A.); (J.M.B.); (C.C.-O.); (J.P.)
- Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona, C/Feixa Llarga, s/n, 08907 L’Hospitalet de Llobregat, Spain
| | - Cristina Coll-Ortega
- Catalonian Cancer Strategy, Department of Health, Government of Catalonia, Avenida Gran Via de l’Hospitalet, 199-203, 08908 L’Hospitalet de Llobregat, Spain; (L.A.); (J.M.B.); (C.C.-O.); (J.P.)
| | - Joan Casacuberta
- Cartographic and Geological Institute of Catalonia, Parc de Montjuïc, 08038 Barcelona, Spain; (J.C.); (I.T.)
| | - Cristina Casanovas-Guitart
- Health Service Procurement and Assessment, Catalonian Health Service (CatSalut), Government of Catalonia, Travessera de les Corts, 131-159, 08028 Barcelona, Spain; (C.C.-G.); (À.G.); (A.P.)
| | - Montse Clèries
- Healthcare Information and Knowledge Unit, Department of Health, Government of Catalonia, Gran Via de les Corts Catalanes, 591, 08007 Barcelona, Spain; (M.C.); (E.V.)
- Digitalization for the Sustainability of the Healthcare System (DS3), Sistema de Salut de Catalunya, Government of Catalonia, Gran Via de les Corts Catalanes, 591, 08007 Barcelona, Spain
| | - Sergi Cruz
- Subdirectorate-General for the Service Portfolio and Health Map, Directorate-General for Health Planning, Department of Health, Government of Catalonia, Travessera de les Corts, 131-159, 08028 Barcelona, Spain; (S.C.); (A.M.); (A.P.)
| | - Àlex Guarga
- Health Service Procurement and Assessment, Catalonian Health Service (CatSalut), Government of Catalonia, Travessera de les Corts, 131-159, 08028 Barcelona, Spain; (C.C.-G.); (À.G.); (A.P.)
| | - Anna Mompart
- Subdirectorate-General for the Service Portfolio and Health Map, Directorate-General for Health Planning, Department of Health, Government of Catalonia, Travessera de les Corts, 131-159, 08028 Barcelona, Spain; (S.C.); (A.M.); (A.P.)
| | - Antoni Planella
- Subdirectorate-General for the Service Portfolio and Health Map, Directorate-General for Health Planning, Department of Health, Government of Catalonia, Travessera de les Corts, 131-159, 08028 Barcelona, Spain; (S.C.); (A.M.); (A.P.)
| | - Alfonso Pozuelo
- Health Service Procurement and Assessment, Catalonian Health Service (CatSalut), Government of Catalonia, Travessera de les Corts, 131-159, 08028 Barcelona, Spain; (C.C.-G.); (À.G.); (A.P.)
| | - Isabel Ticó
- Cartographic and Geological Institute of Catalonia, Parc de Montjuïc, 08038 Barcelona, Spain; (J.C.); (I.T.)
| | - Emili Vela
- Healthcare Information and Knowledge Unit, Department of Health, Government of Catalonia, Gran Via de les Corts Catalanes, 591, 08007 Barcelona, Spain; (M.C.); (E.V.)
- Digitalization for the Sustainability of the Healthcare System (DS3), Sistema de Salut de Catalunya, Government of Catalonia, Gran Via de les Corts Catalanes, 591, 08007 Barcelona, Spain
| | - Joan Prades
- Catalonian Cancer Strategy, Department of Health, Government of Catalonia, Avenida Gran Via de l’Hospitalet, 199-203, 08908 L’Hospitalet de Llobregat, Spain; (L.A.); (J.M.B.); (C.C.-O.); (J.P.)
- Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona, C/Feixa Llarga, s/n, 08907 L’Hospitalet de Llobregat, Spain
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Okawa S, Tabuchi T, Morishima T, Nakata K, Koyama S, Odani S, Miyashiro I. Minimum surgical volume to ensure 5-year survival probability for six cancer sites in Japan. Cancer Med 2022; 12:1293-1304. [PMID: 35796145 PMCID: PMC9883575 DOI: 10.1002/cam4.4999] [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: 04/20/2022] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In Japan, the government designates hospitals specialized in cancer care, requiring them to perform 400 surgeries annually without requiring surgical volume per cancer site. This study aimed to estimate the site-specific minimum surgical volume per year based on its associations with 5-year survival probability. METHODS The data of 64,402 patients who had undergone surgery for six types of cancers (including esophageal, stomach, colorectal, pancreatic, lung, and breast cancers) at designated cancer care hospitals in Osaka between 2007 and 2011 were analyzed. The hospitals were categorized by the average annual surgical volume per cancer type (e.g., 0-4, 5-9, 10-14…). We estimated the adjusted 5-year survival probability per surgical volume category using multivariable Cox proportional hazard regression. Furthermore, we identified inflection points for the trend of adjusted survival probability per increase of five surgical volumes using the joinpoint regression model and considered them as the suggested minimum surgical volume. RESULTS The estimated minimum surgical volumes were 35-39, 20-25, 25-29, 10-14, 10-14, and 25-29 for esophageal, stomach, colorectal, pancreatic, lung, and breast cancers, respectively. The percentage change in the adjusted 5-year survival probability per increase of five surgical volumes before and after the suggested surgical volume were +2.23 and +0.39 for the esophagus, +9.68 and +0.34 for the stomach, +8.11 and +0.05 for the colorectum, +3.82 and +0.87 for the pancreas, +9.46 and +0.23 for the lung, and +1.27 and +0.03 for the breast. CONCLUSIONS The suggested surgical volume based on the association with survival probability varies with cancer sites, some of which are close to the existing surgical volume standards used in Japan. These evidence-based minimum surgical volumes may help improve the quality of cancer surgeries.
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Affiliation(s)
- Sumiyo Okawa
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan,Institute for Global Health Policy ResearchBureau of International Health Cooperation, National Center for Global Health and MedicineTokyoJapan
| | - Takahiro Tabuchi
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan
| | | | - Kayo Nakata
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan
| | - Shihoko Koyama
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan
| | - Satomi Odani
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan
| | - Isao Miyashiro
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan
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18
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Eskander A, Noel CW, Griffiths R, Pasternak JD, Higgins K, Urbach D, Goldstein DP, Irish JC, Fu R. Surgeon Thyroidectomy Case Volume Impacts Disease-free Survival in the Management of Thyroid Cancer. Laryngoscope 2022; 133 Suppl 4:S1-S15. [PMID: 35796293 DOI: 10.1002/lary.30276] [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: 04/04/2022] [Revised: 05/23/2022] [Accepted: 06/17/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To assess the association between surgeons thyroidectomy case volume and disease-free survival (DFS) for patients with well-differentiated thyroid cancer (WDTC). A secondary objective was to assess a surgeon volume cutoff to optimize outcomes in those with WDTC. We hypothesized that surgeon volume will be an important predictor of DFS in patients with WDTC after adjusting for hospital volume and sociodemographic and clinical factors. METHODS In this retrospective population-based cohort study, we identified WDTC patients in Ontario, Canada, who underwent thyroidectomy confirmed by both hospital-level and surgeon-level administrative data between 1993 and 2017 (N = 37,233). Surgeon and hospital volumes were calculated based on number of cases performed in the year prior by the physician and at an institution performing each case, respectively and divided into quartiles. A multilevel hierarchical Cox regression model was used to estimate the effect of volume on DFS. RESULTS A crude model without patient or treatment characteristics demonstrated that both higher surgeon volume quartiles (p < 0.001) and higher hospital volume quartiles (p < 0.001) were associated with DFS. After controlling for clustering and patient/treatment covariates and hospital volume, moderately low (18-39/year) and low (0-17/year) volume surgeons (hazard ratios [HR]: 1.23, 95% confidence interval [CI]: 1.09-1.39 and HR: 1.34, 95% CI: 1.17-1.53 respectively) remained an independent statistically significant negative predictor of DFS. CONCLUSION Both high-volume surgeons and hospitals are predictors of better DFS in patients with WDTC. DFS is higher among surgeons performing more than 40 thyroidectomies a year. LEVEL OF EVIDENCE 3 Laryngoscope, 2022.
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Affiliation(s)
- Antoine Eskander
- Department of Otolaryngology - Head & Neck Surgery, Michael Garron Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - Christopher W Noel
- Department of Otolaryngology - Head & Neck Surgery, Michael Garron Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Griffiths
- ICES, Toronto, Ontario, Canada.,Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada
| | - Jesse D Pasternak
- Section of Endocrine Surgery, Division of General Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kevin Higgins
- Department of Otolaryngology - Head & Neck Surgery, Michael Garron Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - David Urbach
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital and Departments of Surgery, Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology - Head & Neck Surgery, Michael Garron Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery/Surgical Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Department of Otolaryngology - Head & Neck Surgery, Michael Garron Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology - Head & Neck Surgery/Surgical Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Rui Fu
- Department of Otolaryngology - Head & Neck Surgery, Michael Garron Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
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19
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Finley C, Begum H, Akhtar-Danesh GG, Akhtar-Danesh N. Survival effects of time to surgery for Stage I lung cancer: A population-based study. Surg Oncol 2022; 42:101744. [DOI: 10.1016/j.suronc.2022.101744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/25/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
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20
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Yang Z, Subramanian MP, Yan Y, Meyers BF, Kozower BD, Patterson GA, Nava RG, Hachem RR, Witt CA, Pasque MK, Byers DE, Kulkarni HS, Kreisel D, Itoh A, Puri V. The Impact of Center Volume on Outcomes in Lung Transplantation. Ann Thorac Surg 2022; 113:911-917. [PMID: 33857492 PMCID: PMC8505551 DOI: 10.1016/j.athoracsur.2021.03.092] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/13/2021] [Accepted: 03/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Studies in lung transplantation have shown variable association between hospital volume and clinical outcomes. We aimed to identify the pattern of effect of hospital volume on individual patient survival after lung transplantation. METHODS We performed a retrospective analysis using the United Network for Organ Sharing national thoracic organ transplantation database. Adult patients who underwent lung transplantation between January 2013 and December 2017 were included. The association between mean annual center volume and 1-year overall survival was examined using restricted cubic splines in a random effects multivariable Cox model. The volume threshold for optimal 1-year overall survival was subsequently approximated by the maximum likelihood approach using segmented linear splines in the same model. RESULTS The study included 10,007 patients at 71 transplant centers. Median annual center volume was 22 cases (interquartile range, 10.6 to 38). A center volume threshold was identified at 33 cases per year (95% confidence interval, 28 to 37). Higher center volume, to 33 cases per year, was associated with better 1-year survival (hazard ratio 0.989, 95% confidence interval, 0.980 to 0.999 every additional case). Further increase in center volume above 33 cases per year showed no additional benefit (hazard ratio 1.000, 95% confidence interval, 0.996 to 1.003 every additional case). Twenty-three centers (32.4%) reached the volume threshold of 33 cases per year. CONCLUSIONS One-year survival after lung transplantation improved with increasing center volume to as many as 33 cases per year. Low volume centers below the 33 cases per year threshold had large variations in their outcomes and had a higher risk of performing poorly, although many of them maintained good performance.
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Affiliation(s)
- Zhizhou Yang
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | | | - Yan Yan
- Washington University School of Medicine, Division of Public Health Sciences
| | - Bryan F. Meyers
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Benjamin D. Kozower
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | | | - Ruben G. Nava
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Ramsey R. Hachem
- Washington University School of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Chad A. Witt
- Washington University School of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Michael K. Pasque
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Derek E. Byers
- Washington University School of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Hrishikesh S. Kulkarni
- Washington University School of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Daniel Kreisel
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Akinobu Itoh
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri.
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21
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Pollock C, Soder S, Ezer N, Ferraro P, Lafontaine E, Martin J, Nasir B, Liberman M. Impact of Volume on Mortality and Hospital Stay After Lung Cancer Surgery in a Single-Payer System. Ann Thorac Surg 2021; 114:1834-1841. [PMID: 34736929 DOI: 10.1016/j.athoracsur.2021.09.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 09/12/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is a literature gap for hospitals in single-payer healthcare systems quantifying the influence of hospital volume on outcomes following major lung cancer resection. We aimed to determine the effect of hospital volume on mortality, and length of stay (LOS). METHODS A retrospective cohort study using administrative, population-based data from a single-payer universal healthcare system was performed in adults with non-small cell lung cancer who underwent lobectomy or pneumonectomy between 2008 and 2017. Hospital volume was defined as the average annual number of major lung resections performed at each institution. Length of stay and post-operative mortality was compared using multivariable linear and non-linear regression between hospital volume categories and continuously. Adjusted association between hospital volume and post-operative mortality was determined by multivariable logistic regression. RESULTS 10,831 lung resections were performed: 1237 pneumonectomies; 9594 lobectomies. Patients undergoing lobectomy at high-volume hospitals had shorter median LOS (6 vs 8 days, p = 0.001) compared with low-volume hospitals. After adjusting for confounders, surgery at a high-volume center was significantly associated with shorter LOS after lobectomy and overall resections (p=<0.001), but not after pneumonectomy (p=0.787). Surgery at a high-volume center was positively associated with improved 90-day mortality in lobectomy and overall procedures (OR 0.607; [0.399-0.925]; and 0.632 [0.441-0.904], respectively). Volume was not a predictor of 90-day mortality after pneumonectomy (OR 0.533 [0.257-1.104], p=0.090). CONCLUSIONS Surgery at a high-volume center was positively correlated with improved 90-day survival and shorter hospital LOS. The results support regionalized lung cancer care in a single-payer healthcare system.
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Affiliation(s)
- Clare Pollock
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Stephan Soder
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Nicole Ezer
- Division of Respirology, Department of Medicine, McGill University Health Center, Center for Outcomes Research and Evaluation, Research Institute, Montreal, Quebec, Canada
| | - Pasquale Ferraro
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Edwin Lafontaine
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Jocelyne Martin
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Basil Nasir
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada
| | - Moishe Liberman
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center, University of Montreal, Montreal, Quebec, Canada.
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22
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Siu J, Griffiths R, Noel CW, Austin PC, Pasternak J, Urbach D, Monteiro E, Goldstein DP, Irish JC, Sawka AM, Eskander A. Surgical Case Volume has an Impact on Outcomes for Patients with Lateral Neck Disease in Thyroid Cancer. Ann Surg Oncol 2021; 29:1141-1150. [PMID: 34705145 DOI: 10.1245/s10434-021-10923-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 09/27/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study aimed to assess whether surgical case volume for lateral neck dissection has an impact on the survival of patients who have well-differentiated thyroid cancer (WDTC) with lateral cervical node metastases. The authors used a population-based cohort study design. METHODS The study cohort consisted of WDTC patients in Ontario Canada who underwent thyroidectomy and lateral neck dissection. These patients were identified using both hospital- and surgeon-level administrative data between 1993 and 2017 (n = 1832). Surgeon and hospital volumes were calculated based on the number of cases managed in the year before the procedure by the physician and at the institution managing each case, respectively, and divided into tertiles. Multilevel Cox regression models were used to estimate the effect of volume on disease-free survival (DFS). RESULTS A crude model without patient or treatment characteristics demonstrated that DFS was associated with both higher surgeon volume tertiles (p < 0.01) and higher hospital volume tertiles (p < 0.01). After control for clustering, patient/treatment covariates, and hospital volume, the lowest surgeon volume tertile (range, 0-20/year; mean, 6.5/year) remained an independent statistically significant negative predictor of DFS (hazard ratio, 1.71; 95 % confidence interval, 1.22-2.4; p < 0.01). CONCLUSION Surgeon lateral neck dissection case volume is a predictor of better DFS for thyroid cancer patients, with the lowest surgeon volume tertile (<20 neck dissections per year) demonstrating poorer DFS.
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Affiliation(s)
- Jennifer Siu
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Rebecca Griffiths
- ICES, Toronto, ON, Canada.,Cancer Care and Epidemiology, Queens University, Kingston, ON, Canada
| | - Christopher W Noel
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
| | - Peter C Austin
- ICES, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
| | - Jesse Pasternak
- Department of Surgery, Division of General Surgery/Surgical Oncology, University of Toronto, University Health Network, Toronto, ON, Canada
| | - David Urbach
- Womens College Hospital and Departments of Surgery and Health Policy, Management and Evaluation, Womens College Research Institute, University of Toronto, Toronto, ON, Canada
| | - Eric Monteiro
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jonathan C Irish
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Anna M Sawka
- Division of Endocrinology, Department of Medicine, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada. .,ICES, Toronto, ON, Canada. .,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada. .,Department of Otolaryngology-Head and Neck Surgery, Surgical Oncology, Sunnybrook Health Sciences Centre and Michael Garron Hospital, University of Toronto, Toronto, ON, Canada.
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23
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Stenger M, Jakobsen E, Wright G, Zalcberg J, Stirling RG. A comparison of outcomes and survival between Victoria and Denmark in lung cancer surgery: opportunities for international benchmarking. ANZ J Surg 2021; 92:1050-1055. [PMID: 34676962 DOI: 10.1111/ans.17302] [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: 04/28/2021] [Revised: 08/25/2021] [Accepted: 09/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUNDS Victoria (Australia) and Denmark have comparable population sizes and high-quality healthcare systems. Lung cancer surgery, however, is performed in more than 20 Victorian hospitals compared to four in Denmark. Such differences in centralization may influence outcomes. We engaged clinical quality registries to enable international benchmarking by exploring patterns of lung cancer surgery including mortality and survival. METHODS All patients undergoing lung cancer surgery between 2015 and 2018 registered in the Victorian Lung Cancer Registry and the Danish Lung Cancer Registry were included. Analyses on stage concordance, 30 and 90-day mortality, and overall survival were restricted to a selected subgroup with NSCLC and no neo-adjuvant therapy or metastatic disease and only one operation. RESULTS We included 1554 Victorian and 4319 Danish patients. The resection rate was 26.3% in Victoria and 28% in Denmark, but a higher proportion of Victorian patients underwent wedge resection (19.1% versus 8.8%). Stage concordance was 59.6% and 54.9% in Victoria and Denmark, respectively. The 30- and 90-day mortality was 1.3% and 2.6% in Victoria, compared to 1.4% and 2.8% in Denmark with no difference in overall survival (p = 0.28) or risk-adjusted survival (HR: 1.10 (95% CI: 0.89-1.37); p = 0.38). CONCLUSION High-quality surgical lung cancer care was confirmed by similar high resection and low mortality rates including no overall survival difference. The drivers and consequences of stage discordance and differences in patterns of resection deserve further exploration. This study provides a model for international benchmarking using clinical quality registries, although caution remains in the interpretation given disparities in data completeness.
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Affiliation(s)
- Michael Stenger
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Erik Jakobsen
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Gavin Wright
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - John Zalcberg
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robert G Stirling
- Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
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24
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Grilli R, Violi F, Bassi MC, Marino M. The effects of centralizing cancer surgery on postoperative mortality: A systematic review and meta-analysis. J Health Serv Res Policy 2021; 26:289-301. [PMID: 33944635 DOI: 10.1177/13558196211008942] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To review the evidence of the effects of centralization of cancer surgery on postoperative mortality. METHODS We searched Medline, Embase, Cinahl, Cochrane and Scopus (up to November 2019) for studies that (i) assessed the effects of centralization of cancer surgery policies on in-hospital or 30-day mortality, or (ii) described changes in both postoperative mortality for a surgical intervention and degree of centralization using reduction in the number of hospitals or increases in the proportion of patients undergoing cancer surgery at high volume hospitals as proxy. PRISMA guidelines were followed. We estimated pooled odds ratios (OR) and conducted meta-regression to assess the relationship between degree of centralization and mortality. RESULTS A total of 41 studies met our inclusion criteria of which 15 evaluated the effect of centralization policies on postoperative mortality after cancer surgery and 26 described concurrent changes in the degree of centralization and postoperative mortality. Policy evaluation studies mainly used before-after designs (n = 13) or interrupted time series analysis (n = 2), mainly focusing on pancreatic, oesophageal and gastric cancer. All but one showed some degree of reduction in postoperative mortality, with statistically significant effects demonstrated by six studies. The pooled odds ratio for centralization policy effect was 0.68 (95% Confidence interval: 0.54-0.85; I2 = 80%). Meta-regression analysis of the 26 descriptive studies found that an increase of the proportion of patients treated at high volume hospitals was associated with greater reduction in postoperative mortality. CONCLUSIONS Centralization of cancer surgery is associated with reduced postoperative mortality. However, existing evidence tends to be of low quality and estimates of the effect size are likely inflated. There is a need for prospective studies using more robust approaches, and for centralization efforts to be accompanied by well-designed evaluations of their effectiveness.
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Affiliation(s)
- Roberto Grilli
- Head, Department of Clinical Governance, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
| | - Federica Violi
- Researcher, Department of Clinical Governance, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy.,Researcher, Clinical and Experimental Medicine PhD program, University of Modena and Reggio Emilia, Italy
| | - Maria Chiara Bassi
- Information Specialist, Medical Library, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
| | - Massimiliano Marino
- Biostatistician, Department of Clinical Governance, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Italy
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25
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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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26
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Shakeel S, Dhanoa M, Khan O, Dibajnia P, Akhtar-Danesh N, Behzadi A. Wait times in the management of non-small cell lung carcinoma before, during and after regionalization of lung cancer care: a high-resolution analysis. Can J Surg 2021; 64:E218-E227. [PMID: 33769006 PMCID: PMC8064257 DOI: 10.1503/cjs.013319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Timeliness can have a substantial effect on treatment outcomes, prognosis and quality of life for patients with lung cancer. We sought to evaluate changes in wait times for patients with non–small cell lung carcinoma (NSCLC) and to identify bottlenecks in cancer care. Methods We included patients who received treatment with curative intent or palliative treatment for NSCLC, diagnosed through mediastinal staging by a thoracic surgeon. Data were collected from 3 cohorts over 3 time periods: before the regionalization of lung cancer care (2005–2007, C1), immediately postregionalization (2011–2013, C2) and 5 years after regionalization (2016–2017, C3). Total wait time and delays along treatment pathways were compared across cohorts using multivariate Cox proportionality models. Results Our total sample size was 299 patients. Overall, there was no significant difference in total wait time among the 3 cohorts. However, wait time from symptom onset to first physician visit significantly increased in C3 compared with C2 (hazard ratio [HR] 0.41, p < 0.01) and C1 (HR 0.43, p < 0.01). Time from first physician visit to computed tomography (CT) scan significantly decreased in C3 compared with C2 (HR 1.54, p < 0.01). Time from abnormal CT scan to first surgeon visit also significantly decreased in C2 (HR 1.43, p < 0.01) and C3 (HR 4.47, p < 0.01) compared with C1, and between C3 and C2 (HR 2.67, p < 0.01). In contrast, time from first surgeon visit to completion of staging significantly increased in C2 (HR 0.36, p < 0.01) and C3 (HR 0.24, p < 0.01) compared with C1, as well as between C3 and C2 (HR 0.60, p < 0.01). Time to first treatment after completion of staging was significantly shorter for C3 than C1 (HR 1.58, p < 0.01). Conclusion Trends toward a reduction in wait time are evident 5 years after the regionalization of lung cancer care, primarily led by shorter wait times for CT scans and thoracic surgeon consults. However, wait times can further be reduced by addressing delays in staging completion and patient and provider education to identify the early signs of NSCLC.
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Affiliation(s)
- Saad Shakeel
- From the School of Medicine, University of Toronto, Toronto, Ont. (Shakeel, Dhanoa, Khan, Dibajnia, Behzadi); the Department of Oncology, Trillium Health Partners, Mississauga, Ont. (Dibajnia, Behzadi); the Department of Medicine, Health Sciences North, Sudbury, Ont. (Dibajnia); the Northern Ontario School of Medicine, Laurentian University, Sudbury, Ont. (Dibajnia); the School of Nursing, McMaster University, Hamilton, Ont. (Akhtar-Danesh); and the Department of Surgery, University of Toronto, Toronto, Ont. (Behzadi)
| | - Mankeeran Dhanoa
- From the School of Medicine, University of Toronto, Toronto, Ont. (Shakeel, Dhanoa, Khan, Dibajnia, Behzadi); the Department of Oncology, Trillium Health Partners, Mississauga, Ont. (Dibajnia, Behzadi); the Department of Medicine, Health Sciences North, Sudbury, Ont. (Dibajnia); the Northern Ontario School of Medicine, Laurentian University, Sudbury, Ont. (Dibajnia); the School of Nursing, McMaster University, Hamilton, Ont. (Akhtar-Danesh); and the Department of Surgery, University of Toronto, Toronto, Ont. (Behzadi)
| | - Omar Khan
- From the School of Medicine, University of Toronto, Toronto, Ont. (Shakeel, Dhanoa, Khan, Dibajnia, Behzadi); the Department of Oncology, Trillium Health Partners, Mississauga, Ont. (Dibajnia, Behzadi); the Department of Medicine, Health Sciences North, Sudbury, Ont. (Dibajnia); the Northern Ontario School of Medicine, Laurentian University, Sudbury, Ont. (Dibajnia); the School of Nursing, McMaster University, Hamilton, Ont. (Akhtar-Danesh); and the Department of Surgery, University of Toronto, Toronto, Ont. (Behzadi)
| | - Pooya Dibajnia
- From the School of Medicine, University of Toronto, Toronto, Ont. (Shakeel, Dhanoa, Khan, Dibajnia, Behzadi); the Department of Oncology, Trillium Health Partners, Mississauga, Ont. (Dibajnia, Behzadi); the Department of Medicine, Health Sciences North, Sudbury, Ont. (Dibajnia); the Northern Ontario School of Medicine, Laurentian University, Sudbury, Ont. (Dibajnia); the School of Nursing, McMaster University, Hamilton, Ont. (Akhtar-Danesh); and the Department of Surgery, University of Toronto, Toronto, Ont. (Behzadi)
| | - Noori Akhtar-Danesh
- From the School of Medicine, University of Toronto, Toronto, Ont. (Shakeel, Dhanoa, Khan, Dibajnia, Behzadi); the Department of Oncology, Trillium Health Partners, Mississauga, Ont. (Dibajnia, Behzadi); the Department of Medicine, Health Sciences North, Sudbury, Ont. (Dibajnia); the Northern Ontario School of Medicine, Laurentian University, Sudbury, Ont. (Dibajnia); the School of Nursing, McMaster University, Hamilton, Ont. (Akhtar-Danesh); and the Department of Surgery, University of Toronto, Toronto, Ont. (Behzadi)
| | - Abdollah Behzadi
- From the School of Medicine, University of Toronto, Toronto, Ont. (Shakeel, Dhanoa, Khan, Dibajnia, Behzadi); the Department of Oncology, Trillium Health Partners, Mississauga, Ont. (Dibajnia, Behzadi); the Department of Medicine, Health Sciences North, Sudbury, Ont. (Dibajnia); the Northern Ontario School of Medicine, Laurentian University, Sudbury, Ont. (Dibajnia); the School of Nursing, McMaster University, Hamilton, Ont. (Akhtar-Danesh); and the Department of Surgery, University of Toronto, Toronto, Ont. (Behzadi)
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27
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Ely S, Jiang SF, Dominguez DA, Patel AR, Ashiku SK, Velotta JB. Effect of thoracic surgery regionalization on long-term survival after lung cancer resection. J Thorac Cardiovasc Surg 2021; 163:769-777. [PMID: 33934900 DOI: 10.1016/j.jtcvs.2021.03.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Existing evidence demonstrates some benefit of regionalization on early postoperative outcomes following lung cancer resection, but data regarding the persistence of this effect in long-term mortality are lacking. We investigated whether previously reported improvements in short-term outcomes translated to long-term survival benefit. METHODS We retrospectively reviewed patients undergoing major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) for cancer within our integrated health care system before (2011-2013; n = 782) and after (2015-2017; n = 845) thoracic surgery regionalization. Overall survival was compared by Kaplan-Meier analysis, and 1- and 3-year mortality was compared by the by χ2 or Fisher exact test. Multivariable Cox regression models evaluated the effect of regionalization on mortality adjusted for relevant factors. RESULTS Kaplan-Meier curves showed that overall survival was better among patients undergoing surgery postregionalization (log-rank test, P < .0001). Both 1- and 3-year mortality were decreased after regionalization: to 5.7% from 11.1% (P < .0001) for 1 year and to 17.0% from 25.5% (P = .0002) for 3 years. The multivariable adjusted Cox regression analysis revealed that only regionalization (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.42-0.76), age (HR, 1.03; 95% CI, 1.02-1.04), cancer stage (HR, 1.72, 1.83, and 2.56 for stages II, III, and IV, respectively), and Charlson comorbidity index (HR, 1.80 for 1-2; 2.05 for ≥3) were independent predictors of mortality. CONCLUSIONS We found that overall mortality as well as 1- and 3-year mortality for lung cancer resection were lower after thoracic surgery regionalization. The association between regionalization and reduced mortality was significant even after adjusting for other related factors in a multivariable Cox analysis. Notably, surgeon volume, facility volume, surgeon specialty, neoadjuvant treatment, and video-assisted thoracoscopic surgery approach did not significantly affect mortality in the adjusted model.
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Affiliation(s)
- Sora Ely
- Department of Surgery, UCSF East Bay, Highland Hospital, Oakland, Calif; Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif.
| | - Sheng-Fang Jiang
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| | - Dana A Dominguez
- Department of Surgery, UCSF East Bay, Highland Hospital, Oakland, Calif; Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif
| | - Ashish R Patel
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif
| | - Simon K Ashiku
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif
| | - Jeffrey B Velotta
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif
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Nica A, Sutradhar R, Kupets R, Covens A, Vicus D, Li Q, Ferguson SE, Gien LT. Outcomes after the regionalization of care for high-grade endometrial cancers: a population-based study. Am J Obstet Gynecol 2021; 224:274.e1-274.e10. [PMID: 32931769 DOI: 10.1016/j.ajog.2020.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/29/2020] [Accepted: 09/08/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND In June 2013, Ontario Health (Cancer Care Ontario), the agency responsible for advancing cancer care in Ontario, Canada, published practice guidelines recommending that gynecologic oncologists at tertiary care centers manage the treatment of patients with high-grade endometrial cancers. This study examines the effects of this regionalization of care on patient outcomes. OBJECTIVE This study aimed to evaluate the impact of the regionalization of surgery for high-grade endometrial cancer on patient and treatment outcomes. STUDY DESIGN In this retrospective cohort study, patients diagnosed with nonendometrioid high-grade endometrial cancer from 2003 to 2017 were identified using province-wide administrative databases. To allow 6 months for knowledge translation, 2 periods were defined, with January 1, 2014, as the cutoff. Methods for segmented regression were used to test the effect of the guidelines. Multivariable Cox proportional hazards regression was used to evaluate whether regionalization of care had an impact on patient survival. RESULTS There were 3518 patients with nonendometrioid high-grade endometrial cancer identified. The case mix as represented by patient comorbidities and the disease stage distribution did not differ significantly between the 2 regionalization periods. There was a significant increase (69%-85%; P<.001) in the proportion of primary surgeries performed by gynecologic oncologists after regionalization, which was not explained by secular trends. After regionalization, the proportion of patients who had surgical staging (50%-63%; P<.001) and the proportion of patients who received adjuvant treatment (65%-71%; P<.001) increased significantly. After adjusting for age, stage, and comorbidities, there was a decrease in the hazard of mortality (hazard ratio, 0.85 [95% confidence interval, 0.73-0.99]; P=.04) after regionalization. CONCLUSION The publication of a regionalization policy for the treatment of high-grade endometrial cancers in Ontario led to an increase in the proportion of surgeries performed by gynecologic oncologists. This also translated into a significant improvement in patient survival.
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Affiliation(s)
- Andra Nica
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Kupets
- Division of Gynecologic Oncology, Odette Cancer Center, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Odette Cancer Center, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Danielle Vicus
- Division of Gynecologic Oncology, Odette Cancer Center, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Sarah E Ferguson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynaecology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Lilian T Gien
- Division of Gynecologic Oncology, Odette Cancer Center, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Uptake and survival effects of minimally invasive surgery for lung cancer: A population-based study. Eur J Surg Oncol 2021; 47:1791-1796. [PMID: 33468371 DOI: 10.1016/j.ejso.2021.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/03/2020] [Accepted: 01/06/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Despite growing evidence supporting the safety of minimally invasive surgery (MIS) in the treatment of lung cancer, its uptake is still variable and its outcomes debated. This study examines the factors associated with MIS uptake and its effects on survival in patients with non-small cell lung cancer (NSCLC). METHODS All patients in the Canadian province of Ontario with early stage NSCLC (stage I/II) from 2007 to 2017 were included. A logistic regression identified the predictors of MIS uptake, and a flexible parametric model was used to estimate survival rates based on MIS versus open resection. RESULTS In total, 8,988 patients underwent surgical resection; 53.6% had MIS. Year of diagnosis was associated with MIS uptake (OR = 1.33, p < 0.001); patients in later years were more likely to receive MIS. Rurality was a significant predictor of MIS, though distance from nearest regional cancer center did not predict MIS utilization. Patients with stage II disease were less likely to receive MIS compared to those with stage I disease (OR = 0.44, p < 0.001). MIS had a significantly higher 5-year survival compared to open resection for stage I and II disease. Patients >70 years had the greatest 5-year survival benefit from MIS. CONCLUSIONS We observed a substantial long-term survival benefit in patients undergoing MIS for early stage NSCLC. This difference was most pronounced in the oldest age group. These findings support the use of MIS in the treatment of lung cancer and challenge the notion that MIS compromises oncologic outcomes.
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Regionalization for thoracic surgery: Economic implications of regionalization in the United States. J Thorac Cardiovasc Surg 2020; 161:1705-1709. [PMID: 33323196 DOI: 10.1016/j.jtcvs.2020.10.132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 08/01/2020] [Accepted: 10/09/2020] [Indexed: 12/23/2022]
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Nason GJ, Wood LA, Huddart RA, Albers P, Rendon RA, Einhorn LH, Nichols CR, Kollmannsberger C, Anson-Cartwright L, Sweet J, Warde P, Jewett MA, Chung P, Bedard PL, Hansen AR, Hamilton RJ. A Canadian approach to the regionalization of testis cancer: A review. Can Urol Assoc J 2020; 14:346-351. [PMID: 32432537 PMCID: PMC7716843 DOI: 10.5489/cuaj.6268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
At the Canadian Testis Cancer Workshop, the rationale and feasibility of regionalization of testis cancer care were discussed. The two-day workshop involved urologists, medical and radiation oncologists, pathologists, radiologists, physician's assistants, residents and fellows, and nurses, as well as patients and patient advocacy groups.This review summarizes the discussion and recommendations of one of the central topics of the workshop - the centralization of testis cancer in Canada. It was acknowledged that non-guideline-concordant care in testis cancer occurs frequently, in the range of 18-30%. The National Health Service in the U.K. stipulates various testis cancer care modalities be delivered through supra-regional network. All cases are reviewed at a multidisciplinary team meeting and aspects of care can be delivered locally through the network. In Germany, no such network exists, but an insurance-supported online second opinion network was developed that currently achieves expert case review in over 30% of cases. There are clear benefits to regionalization in terms of survival, treatment morbidity, and cost. There was agreement at the workshop that a structured pathway for diagnosis and treatment of testis cancer patients is required.Regionalization may be challenging in Canada because of geography; independent administration of healthcare by each province; physicians fearing loss of autonomy and revenue; patient unwillingness to travel long distances from home; and the inability of the larger centers to handle the ensuing increase in volume. We feel the first step is to identify the key performance indicators and quality metrics to track the quality of care received. After identifying these metrics, implementation of a "networks of excellence" model, similar to that seen in sarcoma care in Ontario, could be effective, coupled with increased use of health technology, such as virtual clinics and telemedicine.
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Affiliation(s)
- Gregory J. Nason
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Lori A. Wood
- Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Robert A. Huddart
- The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Peter Albers
- Department of Urology, Heinrich-Heine University, Medical Faculty, Düsseldorf, Germany
| | | | - Lawrence H. Einhorn
- Department of Oncology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Craig R. Nichols
- Testicular Cancer Multidisciplinary Clinic, Virginia Mason Medical Center, Seattle, WA, United States
| | - Christian Kollmannsberger
- British Columbia Cancer Agency Vancouver Cancer Center, University of British Columbia, Vancouver, BC, Canada
| | - Lynn Anson-Cartwright
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Joan Sweet
- Department of Pathology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Padraig Warde
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
| | - Michael A.S. Jewett
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Peter Chung
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
| | - Philippe L. Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Aaron R. Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Robert J. Hamilton
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Hategeka C, Ruton H, Karamouzian M, Lynd LD, Law MR. Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review. BMJ Glob Health 2020; 5:e003567. [PMID: 33055094 PMCID: PMC7559052 DOI: 10.1136/bmjgh-2020-003567] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions. METHODS We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427). RESULTS Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time. CONCLUSIONS The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.
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Affiliation(s)
- Celestin Hategeka
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Hinda Ruton
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Mohammad Karamouzian
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- HIV/STI Surveillance Research Centre, and WHO Collaborating Centre for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Center for Health Evaluation and Outcome Sciences, Providence Health Research Institute, Vancouver, British Columbia, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
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Vossler JD, Abdul-Ghani A, Tsai PI, Morris PT. Outcomes of Anatomic Lung Resection for Cancer Are Better When Performed by Cardiothoracic Surgeons. Ann Thorac Surg 2020; 111:1004-1011. [PMID: 32800788 DOI: 10.1016/j.athoracsur.2020.06.022] [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: 01/05/2020] [Revised: 05/01/2020] [Accepted: 06/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Anatomic lung resection (ALR) outcomes are superior for cardiothoracic surgeons (CTSs) by analysis of Medicare; National Inpatient Sample; South Carolina Office of Research and Statistics; and Surveillance, Epidemiology, and End Results databases. Similar findings have been reported for all noncardiac thoracic procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Our aim was to further delineate outcome differences between CTSs and general surgeons (GSs) specifically for ALR. METHODS A retrospective analysis of 15,574 nonemergent, nonpediatric ALR for lung cancer was conducted using the ACS-NSQIP 2013 to 2017 database. Included procedures were all ALR for lung cancer. Surgeons were classified as CTSs or GSs. Other specialties were excluded. Preoperative characteristics and 30-day outcomes were compared by bivariate (chi-square test) and multivariate analysis. Multivariate analysis was conducted by multiple logistic regression. RESULTS CTSs performed 14,172 (91.0%) of included procedures, and GSs performed 1402 (9.0%). A thoracoscopic approach was utilized at a similar rate (49.08% for CTSs vs 49.71% for GSs; P = .747). The extent of resection differed in a statistically, but not clinically, significant fashion. CTS patients had a higher rate of preoperative dyspnea (22.66% for CTSs vs 17.62% for GSs; P < .001). Procedures performed by CTSs had a lower risk-adjusted odds ratio of overall morbidity, pulmonary morbidity, sepsis or septic shock, bleeding requiring transfusion, and length of stay greater than the median (5 days). CONCLUSIONS ALR outcomes are superior for CTSs when compared with GSs. This is consistent with prior studies looking at this specific subset of patients and studies looking at a different subset of patients using the ACS-NSQIP database.
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Affiliation(s)
- John D Vossler
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Ayman Abdul-Ghani
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Peter I Tsai
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Paul T Morris
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii.
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Nieß H, Gensichen J, Werner J. [Finding the ideal hospital for surgery]. MMW Fortschr Med 2020; 162:55-58. [PMID: 32780375 DOI: 10.1007/s15006-020-0751-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Hanno Nieß
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Jochen Gensichen
- Institut für Allgemeinmedizin, Ludwig-Maximilians-Universität München, Deutschland
| | - Jens Werner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, D-81377, München, Deutschland.
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Farjah F, Grau-Sepulveda MV, Gaissert H, Block M, Grogan E, Brown LM, Kosinski AS, Kozower BD. Volume Pledge is Not Associated with Better Short-Term Outcomes After Lung Cancer Resection. J Clin Oncol 2020; 38:3518-3527. [PMID: 32762615 DOI: 10.1200/jco.20.00329] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE We examined the relationship between short-term outcomes and hospitals and surgeons who met minimum volume thresholds for lung cancer resection based on definitions provided by the Volume Pledge. A secondary aim was to evaluate the volume-outcome relationship to determine alternative thresholds in the event the Volume Pledge was not associated with outcomes. PATIENTS AND METHODS We conducted a retrospective study (2015-2017) using the Society of Thoracic Surgeons General Thoracic Surgery Database. We used generalized estimating equations that accounted for confounding and clustering to compare outcomes across hospitals and surgeons who did and did not meet the Volume Pledge criteria: ≥ 40 patients per year for hospitals and ≥ 20 patients per year for surgeons. Our secondary aim was to model volume by using restricted cubic splines to determine the association between volume and short-term outcomes. RESULTS Among 32,183 patients, 465 surgeons, and 209 hospitals, 16,630 patients (52%) received care from both a hospital and surgeon meeting the Volume Pledge criteria. After adjustment, there was no relationship with operative mortality, complications, major morbidity, a major morbidity-mortality composite end point, or failure to rescue. The Volume Pledge group had a 0.5 day (95% CI, 0.2 to 0.7 day) shorter length of stay. Our secondary aim revealed a nonlinear relationship between hospital volume and complications in which intermediate-volume hospitals had the highest risk of complications. Surgeon volume was associated with major morbidity, a major morbidity-mortality composite end point, and length of stay in an inverse linear fashion. Only 8% of surgeons had volumes associated with better outcomes. CONCLUSION The Volume Pledge was not associated with better outcomes except for a marginally shorter length of stay. A re-examination of volume-outcome relationships for hospitals and surgeons yielded mixed results that did not reveal a practical alternative for volume-based quality improvement efforts.
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Affiliation(s)
- Farhood Farjah
- Department of Surgery, University of Washington, Seattle, WA
| | | | - Henning Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mark Block
- Division of Thoracic Surgery, Memorial Healthcare System, Hollywood, FL
| | - Eric Grogan
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Lisa M Brown
- Section of General Thoracic Surgery, Department of Surgery, University of California Davis Health, Sacramento, CA
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Durham, NC.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Benjamin D Kozower
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
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Sheetz KH, Massarweh NN. Centralization of High-risk Surgery in the US: Feasible Solution or More Trouble Than It Is Worth? JAMA 2020; 324:339-340. [PMID: 32597965 DOI: 10.1001/jama.2020.2953] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes & Policy, Ann Arbor, Michigan
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Darling GE. Regionalization in thoracic surgery: The importance of the team. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)32193-0. [PMID: 32800567 DOI: 10.1016/j.jtcvs.2020.06.138] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/27/2020] [Accepted: 06/07/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Gail E Darling
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Clinical Lead Thoracic Cancers and High Risk Lung Cancer Screening, Ontario Health, Cancer Care Ontario, Toronto, Ontario, Canada; Thoracic Cancers and High Risk Lung Cancer Screening and Toronto General Research Institute, Toronto General Hospital, Toronto, Ontario, Canada.
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Ely S, Jiang SF, Patel AR, Ashiku SK, Velotta JB. Regionalization of Lung Cancer Surgery Improves Outcomes in an Integrated Health Care System. Ann Thorac Surg 2020; 110:276-283. [DOI: 10.1016/j.athoracsur.2020.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 01/10/2020] [Accepted: 02/06/2020] [Indexed: 11/16/2022]
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Liberman M. Commentary: There is no "I" in team. Regionalization in thoracic surgery, the interdependence of the team, and surgical volume. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)31775-X. [PMID: 32711999 DOI: 10.1016/j.jtcvs.2020.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Moishe Liberman
- Division of Thoracic Surgery, Department of Surgery, University of Montréal, Montréal, Québec, Canada.
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Hadaya J, Dobaria V, Aguayo E, Mandelbaum A, Sanaiha Y, Revels SL, Benharash P. Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States. Ann Thorac Surg 2020; 110:1874-1881. [PMID: 32553767 DOI: 10.1016/j.athoracsur.2020.04.115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 04/06/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual institutional volume of anatomic lung resections on outcomes after elective pneumonectomy. METHODS We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Patients less than 18 years of age, or with trauma-related diagnoses, mesothelioma, or a nonelective admission were excluded. Hospitals were divided into volume quartiles based on annual institutional anatomic lung resection caseload. We studied the effect of institutional volume on inhospital mortality, complications, and failure to rescue, as well as costs and length of stay. RESULTS During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P trend = .045). Compared with the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% confidence interval, 1.14 to 2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure to rescue rates (18.3% vs 12.7%, P = .024) and adjusted odds of mortality (1.70; 95% confidence interval, 1.09 to 2.64) after any complication. CONCLUSIONS High volume hospital status is strongly associated with reduced mortality and failure to rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.
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Affiliation(s)
- Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Esteban Aguayo
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Sha'Shonda L Revels
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California.
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Raphael MJ, Siemens R, Peng Y, Vera-Badillo FE, Booth CM. Volume of systemic cancer therapy delivery and outcomes of patients with solid tumors: A systematic review and methodologic evaluation of the literature. J Cancer Policy 2020. [DOI: 10.1016/j.jcpo.2020.100215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Knisely A, Huang Y, Melamed A, Tergas AI, St. Clair CM, Hou JY, Khoury-Collado F, Ananth CV, Neugut AI, Hershman DL, Wright JD. Effect of regionalization of endometrial cancer care on site of care and patient travel. Am J Obstet Gynecol 2020; 222:58.e1-58.e10. [PMID: 31344350 DOI: 10.1016/j.ajog.2019.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/10/2019] [Accepted: 07/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations. OBJECTIVE To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time. STUDY DESIGN We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed. RESULTS We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P<.0001 for both). CONCLUSION The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.
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Potential Impact of “Take the Volume Pledge” on Access and Outcomes for Gastrointestinal Cancer Surgery. Ann Surg 2019; 270:1079-1089. [DOI: 10.1097/sla.0000000000002796] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Gupta V, Bubis L, Kidane B, Mahar AL, Ringash J, Sutradhar R, Darling GE, Coburn NG. Readmission rates following esophageal cancer resection are similar at regionalized and non-regionalized centers: A population-based cohort study. J Thorac Cardiovasc Surg 2019; 158:934-942.e2. [DOI: 10.1016/j.jtcvs.2019.04.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/28/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
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Regionalization of care for women with ovarian cancer. Gynecol Oncol 2019; 154:394-400. [DOI: 10.1016/j.ygyno.2019.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/10/2019] [Accepted: 05/28/2019] [Indexed: 11/24/2022]
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Abstract
The use of data from the real world to address clinical and policy-relevant questions that cannot be answered using data from clinical trials is garnering increased interest. Indeed, data from cancer registries and linked treatment records can provide unique insights into patients, treatments and outcomes in routine oncology practice. In this Review, we explore the quality of real-world data (RWD), provide a framework for the use of RWD and draw attention to the methodological pitfalls inherent to using RWD in studies of comparative effectiveness. Randomized controlled trials and RWD remain complementary forms of medical evidence; studies using RWD should not be used as substitutes for clinical trials. The comparison of outcomes between nonrandomized groups of patients who have received different treatments in routine practice remains problematic. Accordingly, comparative effectiveness studies need to be designed and interpreted very carefully. With due diligence, RWD can be used to identify and close gaps in health care, offering the potential for short-term improvement in health-care systems by enabling them to achieve the achievable.
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Sheetz KH, Dimick JB, Nathan H. Centralization of High-Risk Cancer Surgery Within Existing Hospital Systems. J Clin Oncol 2019; 37:3234-3242. [PMID: 31251691 DOI: 10.1200/jco.18.02035] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Centralization is often proposed as a strategy to improve the quality of certain high-risk health care services. We evaluated the extent to which existing hospital systems centralize high-risk cancer surgery and whether centralization is associated with short-term clinical outcomes. PATIENTS AND METHODS We merged data from the American Hospital Association's annual survey on hospital system affiliation with Medicare claims to identify patients undergoing surgery for pancreatic, esophageal, colon, lung, or rectal cancer between 2005 and 2014. We calculated the degree to which systems centralized each procedure by calculating the annual proportion of surgeries performed at the highest-volume hospital within each system. We then estimated the independent effect of centralization on the incidence of postoperative complications, death, and readmissions after accounting for patient, hospital, and system characteristics. RESULTS The average degree of centralization varied from 25.2% (range, 6.6% to 100%) for colectomy to 71.2% (range, 8.3% to 100%) for pancreatectomy. Greater centralization was associated with lower rates of postoperative complications and death for lung resection, esophagectomy, and pancreatectomy. For example, there was a 1.1% (95% CI, 0.8% to 1.4%) absolute reduction in 30-day mortality after pancreatectomy for each 20% increase in the degree of centralization within systems. Independent of volume and hospital quality, postoperative mortality for pancreatectomy was two times higher in the least centralized systems than in the most centralized systems (8.9% v 3.7%, P < .01). Centralization was not associated with better outcomes for colectomy or proctectomy. CONCLUSION Greater centralization of complex cancer surgery within existing hospital systems was associated with better outcomes. As hospitals affiliate in response to broader financial and organization pressures, these systems may also present unique opportunities to improve the quality of high-risk cancer care.
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Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, Ann Arbor, MI
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Kozower BD. Commentary: Invasive mediastinal staging for patients with lung cancer-We need to do better! J Thorac Cardiovasc Surg 2019; 158:1230-1231. [PMID: 31235358 DOI: 10.1016/j.jtcvs.2019.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Benjamin D Kozower
- Department of Surgery, Washington University School of Medicine, St Louis, Mo.
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Raphael MJ, Siemens DR, Booth CM. Would Regionalization of Systemic Cancer Therapy Improve the Quality of Cancer Care? J Oncol Pract 2019; 15:349-356. [PMID: 31112481 DOI: 10.1200/jop.18.00671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Michael J Raphael
- 1 Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,2 Queen's University, Kingston, Ontario, Canada
| | - D Robert Siemens
- 1 Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,2 Queen's University, Kingston, Ontario, Canada
| | - Christopher M Booth
- 1 Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,2 Queen's University, Kingston, Ontario, Canada
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