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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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Greijdanus NG, van Erning FN, van Workum F, Tanis PJ, de Wilt JHW, Vissers PAJ. Variation in hospital performances after colorectal cancer surgery: A case-mix adjusted Dutch population based study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107296. [PMID: 38219695 DOI: 10.1016/j.ejso.2023.107296] [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: 07/19/2023] [Revised: 09/25/2023] [Accepted: 11/18/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND This study aimed to investigate hospital variability in postoperative mortality and anastomotic leakage (AL) after colorectal cancer surgery, as well as the association with hospital volume and teaching status. MATERIALS AND METHODS This nationwide population based study derived data from CRC patients who underwent a surgical resection with primary anastomosis from the Netherlands Cancer Registry between 2015 and 2020. Primary outcomes were 90-day mortality and AL for colon cancer (CC) patients, and AL for rectal cancer (RC) patients. Logistic regression modelling was used to evaluate the association between case-mix factors and hospital volume. Variability in outcomes between hospitals was analysed with Poisson regression. RESULTS This study included 44,101 CRC patients, comprising 35,164 CC patients, and 8937 RC patients. In the CC cohort, the unadjusted rates of AL ranged from 2.6 % to 14.4 %, and the unadjusted 90-day mortality rates ranged from 0.0 % to 6.7 %. In the RC cohort, the unadjusted rates of AL ranged from 0.0 % to 28.6 %. After case-mix adjustment, two hospitals performed significantly worse than expected regarding 90-day mortality in the CC cohort, and in both CC and RC cohorts, significant outliers were observed concerning AL. Amongst CC patients, low case volume (OR 1.26 95%CI 1.08-1.46) was significantly associated with AL. CONCLUSION Statistically significant variations in hospital performance were observed among Dutch hospitals after CRC surgery, but this effect could not be entirely attributed to hospitals' teaching status. Nevertheless, concentrating care has the potential to improve outcomes by enhancing individual surgical performance and optimizing care pathways.
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Affiliation(s)
- Nynke G Greijdanus
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Felice N van Erning
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands; Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Pauline A J Vissers
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands; Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
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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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de Jong EJM, van der Geest LG, Besselink MG, Bouwense SAW, Buijsen J, Dejong CHC, Koerkamp BG, Heij LR, de Hingh IHJT, Hoge C, Kazemier G, van Laarhoven HWM, de Meijer VE, Stommel MWJ, Tjan-Heijnen VCG, Valkenburg-van Iersel LBJ, Wilmink JW, Geurts SME, de Vos-Geelen J. Treatment and overall survival of four types of non-metastatic periampullary cancer: nationwide population-based cohort study. HPB (Oxford) 2022; 24:1433-1442. [PMID: 35135724 DOI: 10.1016/j.hpb.2022.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/29/2021] [Accepted: 01/17/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Periampullary adenocarcinoma consists of pancreatic adenocarcinoma (PDAC), distal cholangiocarcinoma (DC), ampullary cancer (AC), and duodenal adenocarcinoma (DA). The aim of this study was to assess treatment modalities and overall survival by tumor origin. METHODS Patients diagnosed with non-metastatic periampullary cancer in 2012-2018 were identified from the Netherlands Cancer Registry. OS was studied with Kaplan-Meier analysis and multivariable Cox regression analyses, stratified by origin. RESULTS Among the 8758 patients included, 68% had PDAC, 13% DC, 12% AC, and 7% DA. Resection was performed in 35% of PDAC, 56% of DC, 70% of AC, and 59% of DA. Neoadjuvant and/or adjuvant therapy was administered in 22% of PDAC, 7% of DC, 7% of AC, and 12% of DA. Three-year OS was highest for AC (37%) and DA (34%), followed by DC (21%) and PDAC (11%). Adjuvant therapy was associated with improved OS among PDAC (HR = 0.62; 95% CI 0.55-0.69) and DC (HR = 0.69; 95% CI 0.48-0.98), but not AC (HR = 0.87; 95% CI 0.62-1.22) and DA (HR = 0.85; 95% CI 0.48-1.50). CONCLUSION This retrospective study identified considerable differences in treatment modalities and OS between the four periampullary cancer origins in daily clinical practice. An improved OS after adjuvant chemotherapy could not be demonstrated in patients with AC and DA.
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Affiliation(s)
- Evelien J M de Jong
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Lydia G van der Geest
- Department of Research and Innovation, Netherlands Comprehensive Cancer Organization (IKNL), 3501 DB, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, 1081 HV, Amsterdam, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Jeroen Buijsen
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - C H C Dejong
- Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Bas G Koerkamp
- Department of Surgery, Division of Oncology, Erasmus Medical Center, 3015 GD, Rotterdam, the Netherlands
| | - Lara R Heij
- Department of Surgery, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands; Surgery Aachen: Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, RWTH Aachen University Hospital, Aachen, 52062, Germany; Institute of Pathology, RWTH Aachen University, Aachen, 52062, Germany
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Cancer Institute, 5623 EJ, Eindhoven, the Netherlands; GROW - School for Oncology and Developmental Biology, Maastricht University, PO Box 616, 6200 MD, Maastricht, Netherlands
| | - Chantal Hoge
- Department of Internal Medicine, Division of Gastroenterology, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, 1081 HV, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ, Amsterdam, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, 9713 GZ, Groningen, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Nijmegen Medical Center, 6500 HB, Nijmegen, the Netherlands
| | - Vivianne C G Tjan-Heijnen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Liselot B J Valkenburg-van Iersel
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ, Amsterdam, the Netherlands
| | - Sandra M E Geurts
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands.
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Saraswathula A, Austin JM, Fakhry C, Eisele DW, Kachalia A, Gourin CG. Volume-Based Versus Mortality-Based Standards for Surgical Quality: Both Risk Adjustment and Volume Matter. J Clin Oncol 2022; 40:2996-2997. [PMID: 35671418 DOI: 10.1200/jco.22.00407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - J Matthew Austin
- Anirudh Saraswathula, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; J. Matthew Austin, PhD, MS, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD; Carole Fakhry, MD, MPH, David W. Eisele, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Allen Kachalia, MD, JD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Christine G. Gourin, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
| | - Carole Fakhry
- Anirudh Saraswathula, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; J. Matthew Austin, PhD, MS, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD; Carole Fakhry, MD, MPH, David W. Eisele, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Allen Kachalia, MD, JD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Christine G. Gourin, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
| | - David W Eisele
- Anirudh Saraswathula, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; J. Matthew Austin, PhD, MS, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD; Carole Fakhry, MD, MPH, David W. Eisele, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Allen Kachalia, MD, JD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Christine G. Gourin, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
| | - Allen Kachalia
- Anirudh Saraswathula, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; J. Matthew Austin, PhD, MS, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD; Carole Fakhry, MD, MPH, David W. Eisele, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Allen Kachalia, MD, JD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Christine G. Gourin, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
| | - Christine G Gourin
- Anirudh Saraswathula, MD, MS, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; J. Matthew Austin, PhD, MS, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD; Carole Fakhry, MD, MPH, David W. Eisele, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Allen Kachalia, MD, JD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and Christine G. Gourin, MD, MPH, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
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6
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Coll-Ortega C, Prades J, Manchón-Walsh P, Borras JM. Centralisation of surgery for complex cancer diseases: A scoping review of the evidence base on pancreatic cancer. J Cancer Policy 2022; 32:100334. [PMID: 35594645 DOI: 10.1016/j.jcpo.2022.100334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 04/09/2022] [Accepted: 04/18/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Centralisation of cancer surgery is a commonly applied healthcare strategy worldwide. This study aimed to detail the design of centralisation policies, to shed light on the implications of such policies in real practice and to describe the different perspectives taken to deal with difficulties that emerged, taking pancreatic cancer as an example of a complex cancer disease requiring surgery. METHODOLOGY A scoping review was conducted using the MEDLINE database. We systematically searched for eligible studies published between January 2000 and December 2018. RESULTS In the 33 included studies, centralisation of pancreatic cancer surgery was implemented through three different models: designated hospitals, definition of minimum volumes per provider, and/or recommendations included in protocols and national guidelines. The presence of highly advanced technology and infrastructures, the availability of extensive service coverage and advanced care processes based on expert multidisciplinary teams, and higher caseloads were identified as key components of centralisation policy. CONCLUSIONS Centralisation models for pancreatic cancer surgery showed that having expert centres where the care process is comprehensively guided is a foundational policy approach. External quality assessment and the accreditation of centres and professionals performing complex surgical procedures are levers that may positively impact the effectiveness of the measure. POLICY SUMMARY: while we found different experiences and three models of centralisation, all of them were guided by the will to positively impact on pancreatic cancer patients' access to expert care. Clinical research might be able to make progress in the coming years and perhaps contribute to reversing a critical situation of high mortality and growing incidence. However, policymakers must optimise health system responses considering current resources, as suggested by the recommendations proposed in the framework of the EU initiative Bratislava Statement for pancreatic cancer care.
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Affiliation(s)
| | - Joan Prades
- Catalonian Cancer Strategy, Department of Health, Barcelona, Spain & University of Barcelona (IDIBELL)| Catalonian Cancer Strategy, Spain
| | - Paula Manchón-Walsh
- Catalonian Cancer Strategy, Department of Health, Barcelona, Spain & University of Barcelona (IDIBELL)| Catalonian Cancer Strategy, Spain
| | - Josep M Borras
- Catalonian Cancer Strategy, Department of Health, Barclona, Spain & University of Barcelona (Department of Clinical Sciences, IDIBELL)| Catalonian Cancer Strategy, Spain
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Baum P, Lenzi J, Diers J, Rust C, Eichhorn ME, Taber S, Germer CT, Winter H, Wiegering A. Risk-Adjusted Mortality Rates as a Quality Proxy Outperform Volume in Surgical Oncology-A New Perspective on Hospital Centralization Using National Population-Based Data. J Clin Oncol 2022; 40:1041-1050. [PMID: 35015575 DOI: 10.1200/jco.21.01488] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery to safer hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume. METHODS We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for any of five major cancer types, splitting the data into training (2010-2015) and validation sets (2016-2018). For each surgical group, we calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modeled a market exit of low-performing hospitals, and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance or time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure. RESULTS Between 2016 and 2018, 158,079 patients were treated in 974 hospitals. At least 50% of high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In an RSMR centralization model, an average of 32 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, whereas 47 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery ranged from 10 minutes for colorectal cancer to 24 minutes for pancreatic cancer. Centralization on the basis of RSMR compared with volume would ensure lower median travel times for all cancer types, and these times would be lower than those observed. CONCLUSION RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.
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Affiliation(s)
- Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph Rust
- Department of Econometrics, University of Regensburg, Regensburg, Germany.,Department of Finance, Accounting and Statistics, Vienna University of Economics and Business, Vienna, Austria
| | - Martin E Eichhorn
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Samantha Taber
- Department of Thoracic Surgery, Heckeshorn Lung Clinic, HELIOS Klinikum Emil von Behring, Berlin, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.,Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.,Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany.,Theodor Boveri Institute, Biocenter, University of Wuerzburg, Am Hubland, Würzburg, Germany
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8
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Luijten JCHBM, Nieuwenhuijzen GAP, Sosef MN, de Hingh IHJT, Rosman C, Ruurda JP, van Duijvendijk P, Heisterkamp J, de Steur WO, van Laarhoven HWM, Besselink MG, Groot Koerkamp B, van Santvoort HC, Lemmens VEP, Vissers PAJ. Impact of nationwide centralization of oesophageal, gastric, and pancreatic surgery on travel distance and experienced burden in the Netherlands. Eur J Surg Oncol 2021; 48:348-355. [PMID: 34366174 DOI: 10.1016/j.ejso.2021.07.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study aims to assess the impact of nationwide centralization of surgery on travel distance and travel burden among patients with oesophageal, gastric, and pancreatic cancer according to age in the Netherlands. As centralization of care increases to improve postoperative outcomes, travel distance and experienced burden might increase. MATERIALS AND METHODS All patients who underwent surgery between 2006 and 2017 for oesophageal, gastric and pancreatic cancer in the Netherlands were included. Travel distance between patient's home address and hospital of surgery in kilometres was calculated. Questionnaires were used to assess experienced travel burden in a subpopulation (n = 239). Multivariable ordinal logistic regression models were constructed to identify predictors for longer travel distance. RESULTS Over 23,838 patients were included, in whom median travel distance for surgical care increased for oesophageal cancer (n = 9217) from 18 to 28 km, for gastric cancer (n = 6743) from 9 to 26 km, and for pancreatic cancer (n = 7878) from 18 to 25 km (all p < 0.0001). Multivariable analyses showed an increase in travel distance for all cancer types over time. In general, patients experienced a physical and social burden, and higher financial costs, due to traveling extra kilometres. Patients aged >70 years travelled less often independently (56% versus 68%), as compared to patients aged ≤70 years. CONCLUSION With nationwide centralization, travel distance increased for patients undergoing oesophageal, gastric, and pancreatic cancer surgery. Younger patients travelled longer distances and experienced a lower travel burden, as compared to elderly patients. Nevertheless, on a global scale, travel distances in the Netherlands remain limited.
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Affiliation(s)
- J C H B M Luijten
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | | | - M N Sosef
- Department of Surgery, Zuyderland Hospital, Heerlen, the Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - C Rosman
- Department of Surgery, Radboudumc, Nijmegen, the Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - J Heisterkamp
- Department of Surgery, Elisabeth Tweesteden Hospital, Tilburg, Embraze Regional Cancer Network, the Netherlands
| | - W O de Steur
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - H W M van Laarhoven
- Department of Medical Oncology, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - H C van Santvoort
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Surgery, Sint. Antonius, Nieuwegein, the Netherlands
| | - V E P Lemmens
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands; Department of Public Health, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - P A J Vissers
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands.
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9
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Goel S, Symer MM, Alzghari T, Baltich Nelson B, Yeo HL. Systematic review of prospective studies focused on regionalization of care in surgical oncology. Updates Surg 2021; 73:1699-1707. [PMID: 34028698 DOI: 10.1007/s13304-021-01073-9] [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: 12/16/2020] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
To perform a systematic review of studies prospectively analyzing the impact of regionalization of complex surgical oncology care on patient outcomes. High volume care of complex surgical oncology patients has been repeatedly associated with improved outcomes. Most studies, however, are retrospective and have not prospectively accounted for confounders such as financial ability and social support. Four electronic databases (Ovid MEDLINE®, Ovid EMBASE, Cochrane Library (Wiley), and EBSCHOHost) were searched from inception until August 25, 2018. Two authors independently reviewed 5887 references, with a third independent reviewer acting as arbitrator when needed. Data extracted from 11 articles that met inclusion criteria. Risk of bias assessments conducted using MINORS criteria for the non-randomized, observational studies, and the Cochrane tool for the randomized-controlled trial. Of the 11 studies selected, we found 7 historically-controlled trials, two retrospective cohort studies with prospective data collection, one prospective study, and one randomized-controlled trial. 73% of studies were from Northern Europe, 18% from Ontario, Canada, and 9% from England. Pancreatic surgery accounted for 36% of studies, followed by gynecologic oncology (27%), thoracic surgery (18%), and dermatologic surgery (9%). The studies reported varying outcome parameters, but all showed improvement post-regionalization. Included studies featured poor-to-fair risk of bias. 11 studies indicated improved outcomes following regionalization of surgical oncology, but most exhibit poor methodological rigor. Prospective evidence for the regionalization of surgical oncology is lacking. More research addressing patient access to care and specialist availability is needed to understand the shortcomings of centralization.
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Affiliation(s)
- Shokhi Goel
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA. .,Department of Surgical Oncology, Department of Healthcare Policy, Weill Cornell Medicine, 525 E 68th St, New York, NY, 10065, USA.
| | - Matthew M Symer
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Talal Alzghari
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Becky Baltich Nelson
- Clinical and Systems Librarian, Weill Cornell Medical College, New York, NY, USA
| | - Heather L Yeo
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA.,Department of Surgical Oncology, Department of Healthcare Policy, Weill Cornell Medicine, 525 E 68th St, New York, NY, 10065, USA
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10
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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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11
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Bernard A, Cottenet J, Aho S, Doussot A, Mariet AS, Facy O, Quantin C. Detecting Hospital Outliers in Post-Pancreatectomy Care Using Funnel Plots from 2009-2018 Based on Nationwide Medico-Administrative Data. World J Surg 2021; 45:2210-2217. [PMID: 33821349 PMCID: PMC8154844 DOI: 10.1007/s00268-021-06078-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 11/28/2022]
Abstract
Objectives Our objective was to identify hospitals with unusual mortality rates for major pancreatectomies over a period of ten years using 30-day mortality data from the French national database. Methods Data for all patients who underwent pancreatectomy were extracted from the national medico-economic database (Programme de Médicalisation des Systèmes d'Information). To identify quality outliers for each hospital, the observed-to-expected 30-day mortality rates were used as a quality indicator. Results A total of 19 494 patients underwent a major pancreatectomy in France between January 2009 and December 2018. The overall 30-day mortality rate was 4.8% (n = 944). For the 2009–2014 period, the funnel plot showed that 10 of the 176 hospitals lie outside the central 95% region and 7 lie outside the central 99.8% region. For the 2015–2018 period, out of 176 hospitals, 6 lie outside the central 95% region and 2 lie outside the central 99.8% region. The change in standardized mortality ratios between 2009–2014 and 2015–2018 testing for differences from the overall change, they were there 4 hospitals lie outside the central 95% region and 0 lie outside the central 99.8% region. Conclusion Over time, the improvement in hospital quality was weak. This study suggests that there is a pressing need to reorganize the supply of care for pancreatic surgery in France.
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Affiliation(s)
- Alain Bernard
- Department of Thoracic and Cardiovascular Surgery, Dijon University Hospital, CHU Dijon, Hôpital du Bocage, 14 rue Gaffarel, BP 77908, 21079, Dijon, France.
| | - Jonathan Cottenet
- Department of Biostatistics, Dijon University Hospital, University of Burgundy, Dijon, France
| | - Serge Aho
- Bacteriology and Hospital Hygiene Department, Nantes University Hospital, Nantes, France
| | - Alexandre Doussot
- Department of Digestive Surgery, Dijon University Hospital, Dijon, France
| | - Anne-Sophie Mariet
- Department of Biostatistics, Dijon University Hospital, University of Burgundy, Dijon, France
| | - Olivier Facy
- Department of Digestive Surgery, Dijon University Hospital, Dijon, France
| | - Catherine Quantin
- Department of Biostatistics, Dijon University Hospital, University of Burgundy, Dijon, France.,INSERM, CIC 1432, Clinical Investigation Centre, Dijon University Hospital, University of Burgundy, Dijon, France.,INSERM, UVSQ, Pasteur Institute, Paris-Saclay University, Paris, France
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12
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Moriarty P, Chang J, Kayani B, Roberts L, Bourke N, Dann C, MacArthur E, Haddad FS. The Development of a Surgical Oncology Center During the COVID-19 Pandemic. J Patient Saf 2021; 17:81-86. [PMID: 33635842 DOI: 10.1097/pts.0000000000000821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organization on March 11, 2020. By mid-March, London had emerged as the epicenter in the United Kingdom, accounting for 45% of the COVID-19-related mortality. A cancer COVID-19-free "cold hub," through National Health Service partnership with independent institutions, was established to maintain a throughput of surgical oncology patients with an accessible triage system for oncologic specialties. The high population density, commuter volume, and rising COVID-19 incidence heightened the challenge of segregating a vulnerable population that was already at high risk for surgical morbidity and mortality.The aim of this review is to report the experience of developing a multicenter COVID-19-free cold hub with the aim of providing safe surgery for surgical oncology patients. We discuss the timeline, structure, and infection control policy and suggest practical points that may guide other health care systems.The surgical oncology hub treated 1542 patients between March 1 and July 1, 2020. There were no cases of COVID-19-related mortality in a 30-day follow-up. Key strategies for the restructuring of the cancer service included the following: (1) formation of an accessible referral pathway, (2) creation and structuring of cold hub hospitals, (3) development of protocols for infection control and preoperative testing, (4) rapid reorganization of services based on initial feedback, and (5) clear communication and leadership.It has been shown that a surgical oncology cold hub with an accessible referral system and an effective system of preoperative screening system can minimize COVID-19 transmission, morbidity, and mortality, in a region with heavy disease prevalence. This structure represents a safe, ethical, and viable system that can be replicated in other health care systems.
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Affiliation(s)
- Peter Moriarty
- From the University College London Hospitals NHS Foundation Trust, London, United Kingdom
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13
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Ou C, Rektorysova M, Othman B, Windsor JA, Pandanaboyana S, Loveday BPT. Benchmarking Performance in Pancreatic Surgery: a Systematic Review of Published Quality Metrics. J Gastrointest Surg 2021; 25:834-842. [PMID: 33159243 DOI: 10.1007/s11605-020-04827-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/08/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic surgery is performed in relatively few centres. There are validated quality benchmarks for pancreatic surgery, although it remains unclear how published benchmarks compare with each other. This study aimed to systematically review published literature to summarise metrics that define quality benchmarks for pancreatic surgery. METHOD A search of MEDLINE, EMBASE and CENTRAL was undertaken until June 2019. Articles that developed or validated published quality benchmarks for pancreatic surgery were included. Benchmarks were classified into three domains using the Donabedian framework, and their quality assessed using the AIRE Instrument. RESULTS Nineteen studies included 55 quality metrics, of which 8 developed new metrics, and 11 studies validated previously published metrics. The methodology of metric development was either expert opinion-driven or data-driven. All metrics demonstrated moderate quality scores. There was partial agreement in some metrics (e.g. < 10 h total operative duration), but lack of consensus for most others (e.g. lymph node yield ≥ 10, ≥ 12, ≥ 15, ≥ 16). No metrics related to patient reported outcomes. CONCLUSIONS Published quality benchmarks for pancreatic surgery predominantly arise from eight studies, with heterogeneity in how the metrics were developed. There was not consensus for all metrics. Metrics need to be reviewed as new data emerge, technologies develop and opinions change.
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Affiliation(s)
- Cindy Ou
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Bushra Othman
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - John A Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland District Health Board, Auckland, New Zealand
| | | | - Benjamin P T Loveday
- Department of Surgery, University of Auckland, Auckland, New Zealand.
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Australia.
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14
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de Cruppé W, Ortwein A, Kraska RA, Geraedts M. Impact of suspending minimum volume requirements for knee arthroplasty on hospitals in Germany: an uncontrolled before-after study. BMC Health Serv Res 2020; 20:1109. [PMID: 33261615 PMCID: PMC7709412 DOI: 10.1186/s12913-020-05957-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/23/2020] [Indexed: 11/20/2022] Open
Abstract
Background In 2004, the Federal Joint Committee, supreme decision-making body in German healthcare, introduced minimum volume requirements (MVRQs) as a quality instrument. Since then, MVRQs were implemented for seven hospital procedures. This study evaluates the effect of a system-wide intermission of MVRQ for total knee arthroplasty (TKA), demanding 50 annual cases per hospital. Methods An uncontrolled before–after study based on federal-level data including the number of hospitals performing TKA, and TKA cases from the external hospital quality assurance programme in Germany (2004–2017). Bi- and multivariate analyses based on hospital-level secondary data of TKA cases and TKA quality indicators extracted from hospital quality reports in Germany (2006–2014). Results The number of TKAs performed in Germany decreased by 11% after suspending the TKA-MVRQ in 2011, and rose by 13% after its reintroduction in 2015. The number of hospitals with less than 50 cases rose from 10 to 25% and their case share from 2 to 5.5% during suspension. Change in hospital volume after the suspension of TKA-MVRQ was not associated with hospital size, ownership, or region. All four evaluable quality indicators increased significantly in the year after their first public reporting. Compared to hospitals meeting the TKA-MVRQ, three indicators show slight but statistically significant better quality in hospitals below the TKA-MVRQ. Conclusions In Germany, TKA-MVRQs seem to induce in-hospital caseload adjustments rather than foster regional inter-hospital case transfers as intended.
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Affiliation(s)
- Werner de Cruppé
- Institute for Health Services Research and Clinical Epidemiology, Philipps-Universität Marburg, Karl-von-Frisch-Strasse 4, 35043, Marburg, Germany.
| | - Annette Ortwein
- Institute for Health Services Research and Clinical Epidemiology, Philipps-Universität Marburg, Karl-von-Frisch-Strasse 4, 35043, Marburg, Germany
| | - Rike Antje Kraska
- Institute for Health Systems Research, School of Medicin, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Strasse 50, 58448, Witten, Germany
| | - Max Geraedts
- Institute for Health Services Research and Clinical Epidemiology, Philipps-Universität Marburg, Karl-von-Frisch-Strasse 4, 35043, Marburg, Germany
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15
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D'Haese JG, Renz BW, Ilmer M, Werner J. [Surgery for isolated local recurrence and metachronous oligometastasis in pancreatic cancer]. Chirurg 2020; 91:628-635. [PMID: 32424598 DOI: 10.1007/s00104-020-01190-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Most patients with pancreatic cancer suffer a relapse, which occurs either locally or systemically in the sense of liver and the lung metastases. Surgery for pancreatic cancer has become more radical due to the increased use of multimodal treatment concepts; however, the role of surgery in cases of recurrence remains controversial. OBJECTIVE This review summarizes the surgical treatment options for isolated local recurrence and metachronous oligometastatic pancreatic cancer. MATERIAL AND METHODS A selective literature search was carried out and the current evidence for surgical treatment is summarized. RESULTS There are currently no randomized studies on surgery for metastatic pancreatic cancer. Currently available data, however, show that after surgery long-term survival of up to 32-47 months after metastasectomy can be achieved, especially in patients with local recurrence or isolated pulmonary metastases with low morbidity and mortality. Individualized treatment concepts including surgical resection after initial systemic therapy seem promising even for liver metastases. The greatest survival benefits are consistently shown for all localizations in patients with a long as possible disease-free interval after the first operation. CONCLUSION The treatment of isolated local recurrence or metachronous oligometastatic pancreatic cancer is an interdisciplinary challenge that should be performed in specialized pancreatic treatment centers only. Surgical resection embedded in a multimodal treatment concept can be meaningful in selected cases.
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Affiliation(s)
- J G D'Haese
- Klinik für Allgemein, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Standort Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - B W Renz
- Klinik für Allgemein, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Standort Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - M Ilmer
- Klinik für Allgemein, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Standort Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - J Werner
- Klinik für Allgemein, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Standort Großhadern, Marchioninistr. 15, 81377, München, Deutschland
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16
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Narendra A, Baade PD, Aitken JF, Fawcett J, Smithers BM. Pancreaticoduodenectomy in a low-resection volume region: a population-level study examining the impact of hospital-volume on surgical quality and longer-term survival. HPB (Oxford) 2020; 22:1288-1294. [PMID: 31848117 DOI: 10.1016/j.hpb.2019.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/16/2019] [Accepted: 11/24/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND An association between higher hospital-volume and better "quality of surgery" and long-term survival has not been reported following pancreatic cancer surgery in low resection-volume regions such as in Australia. Using a population-level study, we compare "quality of surgery" and two-year survival following pancreaticoduodenectomy between Australian hospitals grouped by resection-volume. METHODS Data on all patients undergoing pancreaticoduodenectomy for adenocarcinoma in the Australian state of Queensland, between 2001 and 2015, were obtained from the Queensland Oncology Repository. Hospitals were grouped into high (≥6 resections annually) and low (<6) volume centres. Following adjustment for case-mix, "quality-of-treatment" indicators were compared between hospital groups using multivariate logistic regression and Poisson regression analysis; and two-year cancer-specific and overall survival were compared using multivariate Cox proportional hazard models. RESULTS Compared with high-volume centres, low-volume centres had worse two-year cancer-specific survival (Adjusted HR = 1.31; 95% CI:1.03-1.68), higher 30-day mortality (Adjusted IRR = 3.81; 95% CI: 1.36-10.62) and fewer patients received "high-quality surgery" (Adjusted OR = 0.55; 95% CI: 0.33-0.90). Differences in 30-day mortality, or "quality-of-treatment" indicators did not entirely explain the observed survival difference between hospital-volume groups. CONCLUSION In an Australian environment, a "high" hospital-volume was significantly associated with better quality surgery and two-year survival following pancreaticoduodenectomy.
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Affiliation(s)
- Aaditya Narendra
- University of Queensland, Princess Alexandra Hospital, Burke Street Centre, Level 1, B2, 2 Burke Street, Woolloongabba, QLD, 4102, Australia.
| | - Peter D Baade
- Cancer Council Queensland, 553 Gregory Terrace, Fortitude Valley, QLD, 4006, Australia
| | - Joanne F Aitken
- University of Queensland, University of Southern Queensland, Cancer Council Queensland, 553 Gregory Terrace, Fortitude Valley, QLD, 4006, Australia
| | - Jonathan Fawcett
- University of Queensland, Hepato-pancreatico-biliary Unit, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia
| | - Bernard Mark Smithers
- Cancer Alliance Queensland, University of Queensland, Upper-GI, Soft Tissue and Melanoma Unit, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia
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17
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Weniger M, Miksch RC, Maisonneuve P, Werner J, D'Haese JG. Improvement of survival after surgical resection of pancreatic cancer independent of adjuvant chemotherapy in the past two decades – A meta-regression. Eur J Surg Oncol 2020; 46:1516-1523. [DOI: 10.1016/j.ejso.2020.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/30/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023] Open
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18
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Roberts KJ, Boteon APCS, Marcon F, Abradelo M, Dasari B, Muiesan P, Marudanayagam R, Sutcliffe RP, Isaac J, Mirza DF. Risk adjusted assessment of individual surgeon's pancreatic fistula outcomes. HPB (Oxford) 2020; 22:452-460. [PMID: 31445781 DOI: 10.1016/j.hpb.2019.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 07/19/2019] [Accepted: 07/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is a major cause of morbidity following pancreatoduodenectomy. The risk of POPF varies between individuals and thus assessment without risk adjustment is crude. However, despite the availability of numerous scores to determine risk, no study has provided a risk adjusted assessment of POPF outcomes. METHODS The observed and risk adjusted occurrence of POPF from consecutive patients operated upon by eight surgeons were recorded. Surgeons varied in experience from newly appointed (n = 5) to established (n = 3). CUSUM (cumulative sum) analysis was used to assess performance. RESULTS 104 POPF occurred among 519 patients (20.0%). The occurrence of POPF was significantly lower among experienced surgeons (20/186, 10.7% vs 84/333, 25.2%; p < 0.001). Following risk adjustment surgeons observed 16.6 fewer to 6.5 excess POPF per 100 patients than predicted. Analysis of the CUSUM plots demonstrated the experienced surgeons performed steadily with a gradual reduction in observed POPF compared to what was predicted. The new surgeon's performance was less consistent and evidence of a learning curve was observed with steady improvement occurring after 50-70 patients. CONCLUSIONS Risk adjusted assessment of POPF demonstrates differences between experienced and less experienced surgeons. This method could be used to audit practice and observe effects of changes to technique.
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Affiliation(s)
- Keith J Roberts
- University of Birmingham, Birmingham, United Kingdom; Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom.
| | - Amanda P C S Boteon
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Francesca Marcon
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Manuel Abradelo
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Bobby Dasari
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Paolo Muiesan
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Ravi Marudanayagam
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - John Isaac
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Darius F Mirza
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
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Is Treatment at a High-volume Center Associated with an Improved Survival for Primary Malignant Bone Tumors? Clin Orthop Relat Res 2020; 478:631-642. [PMID: 31714413 PMCID: PMC7145092 DOI: 10.1097/corr.0000000000001034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Centralization of cancer care to high-volume facilities has been shown to improve the overall survival of patients with soft-tissue sarcomas. Current evidence regarding the impact of increased hospital volume on treatment patterns and survival rates for patients with primary malignant bone tumors remains limited. Understanding the facility volume-outcome relationship for primary malignant bone tumors will further discussion on ways to promote delivery of quality cancer care across the nation. QUESTIONS/PURPOSES (1) Is there a difference in overall survival for patients with primary malignant bone tumors undergoing treatment at a high-volume facility (at least 20 patients per year) versus those treated at a low-volume facility (less than 20 patients per year)? (2) Do surgical treatment patterns (limb-salvage versus amputation) and margin status (positive versus negative) vary between high-volume and low-volume facilities? METHODS The 2004 to 2015 National Cancer Database was queried using International Classification of Disease for Oncology topographical codes to identify patients undergoing treatment (surgery, chemotherapy, and/or radiation therapy) for primary malignant bone tumors of the extremities (C40.0-C40.3, C40.8, and C40.9) or pelvis (C41.4). Histologic codes were used to group the tumors into the following categories: osteosarcomas, Ewing's sarcomas, chondrosarcomas, chordomas, and other or unspecified. Patients who did not receive any treatment (surgery, chemotherapy, and/or radiotherapy) at the reporting facility were excluded from the study. Facility volume was calculated based on the average number of patients per year for the entire study period. A preliminary stratified Cox regression model was used to identify evidence-based thresholds or cutoffs for high-volume and low-volume facilities, while adjusting for differences in patient, tumor, and treatment characteristics. We identified high-volume facilities as those treating at least 20 patients per year and low-volume facilities as those treating fewer than 20 patients per year. A Kaplan-Meier survival analysis was used to report overall unadjusted 5-year survival rates at high-volume and low-volume facilities. Multivariate Cox regression analyses were used to assess whether undergoing treatment at a high-volume facility was associated with a lower risk of overall mortality, after controlling for differences in baseline demographics, tumor presentation, and treatment characteristics. For patients undergoing surgery, multivariate regression models were used to evaluate whether patients receiving care in a high-volume facility were more likely to receive resections with limb salvage surgery than to receive amputation and whether facility volume was associated with a patient's likelihood of having a positive or negative surgical margin. RESULTS A total of 14,039 patients were included, 15% (2115) of whom underwent treatment in a high-volume facility. Patients undergoing treatment at a high-volume facility were more likely to be white, have tumors involving the pelvis, have larger tumor sizes, and have a higher tumor grade at presentation than those undergoing treatment at a low-volume facility. Unadjusted 5-year overall survival rates were greater for high-volume facilities than for low-volume facilities (65% versus 61%; p = 0.003). After controlling for differences in patient demographics, tumor characteristics (including histologic type, grade, stage, size, and location) and treatment factors, we found that patients treated at high-volume facilities had a slightly lower overall mortality risk than those treated at low-volume facilities (hazard ratio 0.85 [95% CI 0.77 to 0.93]; p < 0.001). Patients treated at high-volume facilities were also slightly more likely to undergo resection with limb-salvage surgery to than to undergo amputation (odds ratio 1.34 [95% CI 1.14 to 1.59]; p = 0.001). Patients undergoing surgical treatment at high-volume facilities also had a lower odds of having positive resection margins than those undergoing treatment at low-volume facilities (OR 0.56 [95% CI 0.44 to 0.72]; p < 0.001). CONCLUSIONS Patients undergoing treatment for primary malignant bone tumors at high-volume facilities experience a slightly better overall survival than those receiving treatment at low-volume facilities. Further research questioning the value of care at high-volume facilities is required before sweeping changes in regionalization can be considered. LEVEL OF EVIDENCE Level III, therapeutic study.
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Polonski A, Izbicki JR, Uzunoglu FG. Centralization of Pancreatic Surgery in Europe. J Gastrointest Surg 2019; 23:2081-2092. [PMID: 31037503 DOI: 10.1007/s11605-019-04215-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of this article is a review and an analysis of the current state of centralization of pancreatic surgery in Europe. Numerous recent publications demonstrate higher postoperative in-hospital mortality rates in low-volume clinics after pancreatic resection than previously assumed due to their not publishing significantly worse outcomes when compared to high-volume centres. Although the benefits of centralization of pancreatic surgery in high-volume centres have been demonstrated in many studies, numerous countries have so far failed to establish centralization in their respective health care systems. METHODS A systematic literature search of the Medline database for studies concerning centralization of pancreatic surgery in Europe was conducted. The studies were reviewed independently for previously defined inclusion and exclusion criteria. We included 14 studies with a total of 117,634 patients. All data were extracted from or provided by health insurance company or governmental registry databases. RESULTS Thirteen out of the 14 studies demonstrate an improvement in their respective outcome related to volume. Twelve studies showed a significantly lower postoperative mortality rate in the highest annual volume group in comparison to overall postoperative mortality rate in the whole patient cohort. CONCLUSION As the available data indicate, most European countries have so far failed to establish centralization of pancreatic surgery to high-volume centres due to numerous reasons. Considering a plateau in survival rates of patients undergoing treatment for pancreatic cancer in Europe during the last 15 years, this review enforces the worldwide plea for centralization to lower post-operative mortality after pancreatic surgery.
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Affiliation(s)
- Adam Polonski
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany. .,Department of General Visceral and Thoracic Surgery, University of Hamburg Medical Institutions, Martinistr 52, 20252, Hamburg, Germany.
| | - Faik G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
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Is Centralization Needed for Patients Undergoing Distal Pancreatectomy?: A Nationwide Study of 3314 Patients. Pancreas 2019; 48:1188-1194. [PMID: 31593018 DOI: 10.1097/mpa.0000000000001410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The centralization of complex surgical procedures is associated with better postoperative outcomes. However, little is known about the impact of hospital volume on the outcome after distal pancreatectomy. METHODS Using the French national hospital discharge database, we identified all patients having undergone distal pancreatectomy in France between 2012 and 2015. A spline model was applied to determine the caseload cut-off in annual distal pancreatectomy that influenced 90-day postoperative mortality. RESULTS A total of 3314 patients were identified. Use of a spline model did not reveal a cut-off in the annual distal pancreatectomy caseload. By taking the median number of distal pancreatectomy (n = 5) and the third quartile (n = 15), we stratified centers into low, intermediate, and high hospital volume groups. The overall postoperative mortality rate was 3.0% and did not differ significantly between these groups. In a multivariable analysis, age, Charlson comorbidity score, septic complications, hemorrhage, shock, and reoperation were independently associated with a greater overall risk of death. However, hospital volume had no impact on mortality after distal pancreatectomy (odds ratio, 0.954; 95% confidence interval, 0.552-1.651, P = 0.867). CONCLUSIONS Hospital volume does not seem to influence mortality after distal pancreatectomy in France, and centralization may not necessarily improve outcomes.
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Lambert A, Schwarz L, Borbath I, Henry A, Van Laethem JL, Malka D, Ducreux M, Conroy T. An update on treatment options for pancreatic adenocarcinoma. Ther Adv Med Oncol 2019; 11:1758835919875568. [PMID: 31598142 PMCID: PMC6763942 DOI: 10.1177/1758835919875568] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
Pancreatic cancer is one of the most lethal solid organ tumors. Due to the rising incidence, late diagnosis, and limited treatment options, it is expected to be the second leading cause of cancer deaths in high income countries in the next decade. The multidisciplinary treatment of this disease depends on the stage of cancer at diagnosis (resectable, borderline, locally advanced, and metastatic disease), and combines surgery, chemotherapy, chemoradiotherapy, and supportive care. The landscape of multidisciplinary pancreatic cancer treatment is changing rapidly, especially in locally advanced disease, and the number of treatment options in metastatic disease, including personalized medicine, innovative targets, immunotherapy, therapeutic vaccines, adoptive T-cell transfer, or stemness inhibitors, will probably expand in the near future. This review summarizes the current literature and provides an overview of how new therapies or new therapeutic strategies (neoadjuvant therapies, conversion surgery) will guide multidisciplinary disease management, future clinical trials, and, hopefully, will increase overall survival.
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Affiliation(s)
- Aurélien Lambert
- Department of Medical Oncology, Institut de Cancérologie de Lorraine and Université de Lorraine, Nancy, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Rouen University Hospital and Université de Rouen Normandie, France
| | - Ivan Borbath
- Department of Gastroenterology and Digestive Oncology, Cliniques Universitaires Saint-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - Aline Henry
- Department of Supportive Care in Oncology, Institut de Cancérologie de Lorraine, Nancy, France
| | - Jean-Luc Van Laethem
- Department of Gastroenterology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Belgium
| | - David Malka
- Department of Medical Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Michel Ducreux
- Department of Medical Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Thierry Conroy
- Institut de Cancérologie de Lorraine, 6 avenue de Bourgogne, 50519 Vandoeuvre-lès-Nancy CEDEX, France
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Failure-to-rescue in Patients Undergoing Pancreatectomy: Is Hospital Volume a Standard for Quality Improvement Programs? Nationwide Analysis of 12,333 Patients. Ann Surg 2019; 268:799-807. [PMID: 30048329 DOI: 10.1097/sla.0000000000002945] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the influence of hospital volume on failure-to-rescue (FTR) after pancreatectomy in France. BACKGROUND There are growing evidences that FTR is an important source of postoperative mortality (POM) after pancreatectomy. However, few studies have analyzed the volume-FTR relationship following pancreatic surgery. METHODS All patients undergoing pancreatectomy between 2012 and 2015 were included. FTR is defined as the 90-day POM rate among patients with major complications. According to the spline model, the critical cutoff was 20 resections per year and hospitals were divided into low (<10 resections/an), intermediate (11-19 resections/yr), and high volume centers (≥20 resections/yr). RESULTS Overall, 12,333 patients who underwent pancreatectomy were identified. The POM was 6.9% and decreased significantly with increased hospital volume. The rate of FTR was 14.5% and varied significantly with hospital volume (18.3% in low hospital volume vs 11.9% in high hospital volume, P < 0.001), age (P < 0.001) and ChCl (CCl0-2: 11.5%, ChCl3: 13%, CCl ≥4:18.6%; P < 0.001). FTR for renal failure was the highest of all complications (40.2%), followed by postoperative shock (36.4%) and cardiac complications (35.1%). The FTR was significantly higher in low and intermediate compared with high volume hospitals for shock, digestive, and thromboembolic complications and reoperation. In multivariable analysis, intermediate (OR = 1.265, CI95%[1.103-1.701], P = 0.045) and low volume centers (OR = 1.536, CI95%[1.165-2.025], P = 0.002) were independently associated with increased FTR rates. CONCLUSION FTR after pancreatectomy is high and directly correlated to hospital volume, highlighting variability in the management of postoperative complications. Measurement of the FTR rate should become a standard for quality improvement programs.
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Abstract
Pancreatic cancer is likely to become the second most frequent cause of cancer-associated mortality within the next decade. Surgical resection with adjuvant systemic chemotherapy currently provides the only chance of long-term survival. However, only 10-20% of patients with pancreatic cancer are diagnosed with localized, surgically resectable disease. The majority of patients present with metastatic disease and are not candidates for surgery, while surgery remains underused even in those with resectable disease owing to historical concerns regarding safety and efficacy. However, advances made over the past decade in the safety and efficacy of surgery have resulted in perioperative mortality of around 3% and 5-year survival approaching 30% after resection and adjuvant chemotherapy. Furthermore, owing to advances in both surgical techniques and systemic chemotherapy, the indications for resection have been extended to include locally advanced tumours. Many aspects of pancreatic cancer surgery, such as the management of postoperative morbidities, sequencing of resection and systemic therapy, and use of neoadjuvant therapy followed by resection for tumours previously considered unresectable, are rapidly evolving. In this Review, we summarize the current status of and new developments in pancreatic cancer surgery, while highlighting the most important research questions for attempts to further optimize outcomes.
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Huang L, Jansen L, Balavarca Y, Molina-Montes E, Babaei M, van der Geest L, Lemmens V, Van Eycken L, De Schutter H, Johannesen TB, Fristrup CW, Mortensen MB, Primic-Žakelj M, Zadnik V, Becker N, Hackert T, Mägi M, Cassetti T, Sassatelli R, Grützmann R, Merkel S, Gonçalves AF, Bento MJ, Hegyi P, Lakatos G, Szentesi A, Moreau M, van de Velde T, Broeks A, Sant M, Minicozzi P, Mazzaferro V, Real FX, Carrato A, Molero X, Besselink MG, Malats N, Büchler MW, Schrotz-King P, Brenner H. Resection of pancreatic cancer in Europe and USA: an international large-scale study highlighting large variations. Gut 2019; 68:130-139. [PMID: 29158237 DOI: 10.1136/gutjnl-2017-314828] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/24/2017] [Accepted: 11/11/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Resection can potentially cure resectable pancreatic cancer (PaC) and significantly prolong survival in some patients. This large-scale international study aimed to investigate variations in resection for PaC in Europe and USA and determinants for its utilisation. DESIGN Data from six European population-based cancer registries and the US Surveillance, Epidemiology, and End Results Program database during 2003-2016 were analysed. Age-standardised resection rates for overall and stage I-II PaCs were computed. Associations between resection and demographic and clinical parameters were assessed using multivariable logistic regression models. RESULTS A total of 153 698 records were analysed. In population-based registries in 2012-2014, resection rates ranged from 13.2% (Estonia) to 21.2% (Slovenia) overall and from 34.8% (Norway) to 68.7% (Denmark) for stage I-II tumours, with great international variations. During 2003-2014, resection rates only increased in USA, the Netherlands and Denmark. Resection was significantly less frequently performed with more advanced tumour stage (ORs for stage III and IV versus stage I-II tumours: 0.05-0.18 and 0.01-0.06 across countries) and increasing age (ORs for patients 70-79 and ≥80 versus those <60 years: 0.37-0.63 and 0.03-0.16 across countries). Patients with advanced-stage tumours (stage III-IV: 63.8%-81.2%) and at older ages (≥70 years: 52.6%-59.5%) receiving less frequently resection comprised the majority of diagnosed cases. Patient performance status, tumour location and size were also associated with resection application. CONCLUSION Rates of PaC resection remain low in Europe and USA with great international variations. Further studies are warranted to explore reasons for these variations.
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Affiliation(s)
- Lei Huang
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lina Jansen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Yesilda Balavarca
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Esther Molina-Montes
- Geneticand Molecular Epidemiology Group, Spanish National Cancer Research Centre (CNIO), CIBERONC, ISCIII, Madrid, Spain
| | - Masoud Babaei
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lydia van der Geest
- Netherlands Cancer Registry (NCR), Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
| | - Valery Lemmens
- Netherlands Cancer Registry (NCR), Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
| | | | | | - Tom B Johannesen
- Registry Department, The Cancer Registry of Norway (CRN), Oslo, Norway
| | | | - Michael B Mortensen
- Danish Pancreatic Cancer Group, HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Maja Primic-Žakelj
- Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Vesna Zadnik
- Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Margit Mägi
- Estonian Cancer Registry, National Institute for Health Development, Tallinn, Estonia
| | - Tiziana Cassetti
- Pancreatic Cancer Registry of Reggio Emilia Province, Unit of Gastroenterology and Digestive Endoscopy AUSL-RE, Local Health Authority-IRCCS, Reggio Emilia, Italy
| | - Romano Sassatelli
- Pancreatic Cancer Registry of Reggio Emilia Province, Unit of Gastroenterology and Digestive Endoscopy AUSL-RE, Local Health Authority-IRCCS, Reggio Emilia, Italy
| | - Robert Grützmann
- Department of Surgery, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Ana F Gonçalves
- Departments of Epidemiology, Portuguese Oncology Institute of Porto (IPOP), Porto, Portugal
| | - Maria J Bento
- Departments of Epidemiology, Portuguese Oncology Institute of Porto (IPOP), Porto, Portugal
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Gábor Lakatos
- Department of Oncology, St. Istvan and St. Laszlo Hospital and Out-Patient Department, Budapest, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Michel Moreau
- Department of Surgical Oncology, Jules Bordet Institute (IJB), Brussels, Belgium
| | - Tony van de Velde
- Biometrics Department, The Netherlands Cancer Institute (NKI), Amsterdam, Netherlands
| | - Annegien Broeks
- Biometrics Department, The Netherlands Cancer Institute (NKI), Amsterdam, Netherlands
| | - Milena Sant
- Analytical Epidemiology and Health Impact Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS, Istituto Nazionale dei Tumori (INT), Milan, Italy
| | - Pamela Minicozzi
- Analytical Epidemiology and Health Impact Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS, Istituto Nazionale dei Tumori (INT), Milan, Italy
| | - Vincenzo Mazzaferro
- Hepato-Biliary Surgery Unit, Istituto Nazionale dei Tumori (INT), and University of Milan, Milan, Italy
| | - Francisco X Real
- Epithelial Carcinogenesis Group, Spanish National Cancer Research Centre (CNIO), CIBERONC, Madrid, Spain.,Department de Ciencies Experimentals i de la, Universitat Pompeu Fabra, Barcelona, Spain
| | - Alfredo Carrato
- Department of Oncology, Ramon y Cajal University Hospital, IRYCIS, Alcala University, CIBERONC, Madrid, Spain
| | - Xavier Molero
- Hospital Universitari Vall d'Hebron, Exocrine Pancreas Research Unit and Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Campus de la UAB, Barcelona, Spain.,CIBEREHD and CIBERESP, Madrid, Spain
| | - Marc G Besselink
- Dutch Pancreatic Cancer Group, Academic Medical Centre Amsterdam, Amsterdam, Netherlands
| | - Núria Malats
- Geneticand Molecular Epidemiology Group, Spanish National Cancer Research Centre (CNIO), CIBERONC, ISCIII, Madrid, Spain
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Petra Schrotz-King
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
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Liu Z, Peneva IS, Evison F, Sahdra S, Mirza DF, Charnley RM, Savage R, Moss PA, Roberts KJ. Ninety day mortality following pancreatoduodenectomy in England: has the optimum centre volume been identified? HPB (Oxford) 2018; 20:1012-1020. [PMID: 29895441 DOI: 10.1016/j.hpb.2018.04.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 04/10/2018] [Accepted: 04/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Mortality following pancreatoduodenectomy is related to centre volume although the optimal volume is not defined. METHODS Patients undergoing PD between 2001 and 2016 were identified from UK national databases. The effects of patient variables, centre volume and time period upon 90 day mortality were studied. RESULTS 90 day mortality (970/14,935, 6.5%) was related to advanced age, comorbidity, diagnosis, ethnicity, deprivation, centre volume and time period. Mortality rates fell markedly from 10.0% in 2001-4 to 4.1% in 2013-16. There was no difference in 90 day mortality between high (36 -60 PD per year) and very high volume (>60) centres. However, patients operated upon at very high volume centres were more elderly (66, 58 -73 vs 65, 56 -72; median, IQR; p = 0.006), deprived (38.7 vs 34.6%; p < 0.001) and co morbid (48.9 vs 46.1%; p = 0.027). CONCLUSION Although a plateau in the centre volume and mortality relationship appears to have been demonstrated those patients treated at the highest volume centres were at higher risk of mortality. This data suggests therefore that to further understand outcomes from specialist centres characteristics of the patient population should be defined, not just centre volume.
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Affiliation(s)
- Z Liu
- Depts of Statistics and Mathematics for Real World Systems CDT, University of Warwick, UK
| | - I S Peneva
- Depts of Statistics and Mathematics for Real World Systems CDT, University of Warwick, UK
| | - F Evison
- Department of Informatics, University Hospitals Birmingham, UK
| | - S Sahdra
- Department of Informatics, University Hospitals Birmingham, UK
| | - D F Mirza
- Department of HPB & Transplant Surgery, University Hospitals Birmingham, UK
| | - R M Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
| | - R Savage
- Depts of Statistics and Mathematics for Real World Systems CDT, University of Warwick, UK
| | - P A Moss
- School of Cancer Studies, University of Birmingham, UK
| | - K J Roberts
- Department of HPB & Transplant Surgery, University Hospitals Birmingham, UK.
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Petrucciani N, Debs T, Nigri G, Giannini G, Sborlini E, Kassir R, Ben Amor I, Iannelli A, Valabrega S, D'Angelo F, Gugenheim J, Ramacciato G. Pancreatectomy combined with multivisceral resection for pancreatic malignancies: is it justified? Results of a systematic review. HPB (Oxford) 2018; 20:3-10. [PMID: 28943396 DOI: 10.1016/j.hpb.2017.08.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/08/2017] [Accepted: 08/12/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Multivisceral resections combined with pancreatectomy have been proposed in selected patients with tumor invasion into adjacent organs, in order to allow complete tumor resection. Some authors have also reported multivisceral resection combined with metastasectomy in very selected cases. The utility of this practice is debated. The aim of the review is to compare the postoperative results and survival of pancreatectomies combined with multivisceral resections with those of standard pancreatectomies. METHODS A systematic literature search was performed to identify all studies published up to February 2017 that analyzed data of patients undergoing multivisceral and standard pancreatectomies. Clinical effectiveness was synthetized through a narrative review with full tabulation of results. RESULTS Three studies were retrieved, including 713 (80%) patients undergoing standard pancreatectomies and 176 (20%) undergoing multivisceral resections (MVR). Postoperative morbidity ranged from 37% to 50% after standard resections and from 56% to 69% after MVR. In-hospital mortality ranged from 4% after standard pancreatectomies to 10% after MVR. Median survival ranged from 20 to 23 months in standard resections and from 12 to 20 months after MVR, without significant differences. DISCUSSION The current literature suggests that multivisceral pancreatectomies are feasible and may increase the number of completely resected patients. Morbidity and mortality are higher than after standard pancreatectomies, and these procedures should be reserved to selected patients in referral centers. Further studies on the role of neoadjuvant therapy in this setting are advisable.
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Affiliation(s)
- Niccolò Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, St Andrea Hospital, Rome, Italy; Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France.
| | - Tarek Debs
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Giuseppe Nigri
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, St Andrea Hospital, Rome, Italy
| | - Giulia Giannini
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, St Andrea Hospital, Rome, Italy
| | - Elena Sborlini
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, St Andrea Hospital, Rome, Italy
| | - Radwan Kassir
- Department of General and Thoracic Surgery, St Etienne University Hospital, St Etienne, France
| | - Imed Ben Amor
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Antonio Iannelli
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Stefano Valabrega
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, St Andrea Hospital, Rome, Italy
| | - Francesco D'Angelo
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, St Andrea Hospital, Rome, Italy
| | - Jean Gugenheim
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Giovanni Ramacciato
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, St Andrea Hospital, Rome, Italy
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Mesman R, Faber MJ, Berden BJ, Westert GP. Evaluation of minimum volume standards for surgery in the Netherlands (2003–2017): A successful policy? Health Policy 2017; 121:1263-1273. [DOI: 10.1016/j.healthpol.2017.09.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/16/2017] [Accepted: 09/19/2017] [Indexed: 01/29/2023]
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30
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Fischer C, Lingsma H, Klazinga N, Hardwick R, Cromwell D, Steyerberg E, Groene O. Volume-outcome revisited: The effect of hospital and surgeon volumes on multiple outcome measures in oesophago-gastric cancer surgery. PLoS One 2017; 12:e0183955. [PMID: 29073140 PMCID: PMC5658198 DOI: 10.1371/journal.pone.0183955] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
Background Most studies showing a volume outcome effect in resection surgery for oesophago-gastric cancer were conducted before the centralisation of clinical services. This study evaluated the relation between hospital- and surgeon volume and different risk-adjusted outcomes after oesophago-gastric (OG) cancer surgery in England between 2011 and 2013. Methods In data from the National Oesophago-Gastric Cancer Audit from the UK, multivariable random-effects logistic regression models were used to quantify the effect of surgeon and hospital volume on three outcomes: 30-day and 90-day mortality and anastomotic leakage. The models included patient risk factors to adjust for differences in case-mix among hospitals and surgeons. The between-cluster heterogeneity was estimated with the median odds ratio (MOR). Results The study included patients treated at 42 hospitals and 329 surgeons. The median (interquartile range) of the annual hospital and surgeon volumes were 110 patients (82 to 137) and 13 patients (8 to 19), respectively. The overall rates for 30-day and 90-day mortality were 2.3% and 4.4% respectively, and the anastomotic leakage was 6.3%. Higher hospital volume was associated with lower 30-day mortality (OR: 0.94; 95% CI: 0.91–0.98) and lower anastomotic leakage rates (OR: 0.96; 95% CI: 0.93–0.98) but not 90-day mortality. Higher surgeon volume was only associated with lower anastomotic leakage rates (OR: 0.81; 95% CI: 0.72–0.92). Hospital volume explained a part of the between-hospital variation in 30-day mortality whereas surgeon volume explained part of the between-hospital variation in anastomotic leakage. Conclusions In the setting of centralized O-G cancer surgery in England, we could still observe an effect of volume on short-term outcomes. However, the effect is inconsistent, depending on the type of outcome measure under consideration, and much smaller than in previous studies. Efforts to centralise O-G cancer services further should carefully address the effects of both hospital and surgeon volume on the range of outcome measures that are relevant to patients.
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Affiliation(s)
- Claudia Fischer
- Erasmus MC, Department of Public Health, Rotterdam, The Netherlands
| | - Hester Lingsma
- Erasmus MC, Department of Public Health, Rotterdam, The Netherlands
| | - Niek Klazinga
- Amsterdam Medical Center, Department of Public Health, Amsterdam, The Netherlands
| | - Richard Hardwick
- Cambridge Oesophago-Gastric Centre, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - David Cromwell
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ewout Steyerberg
- Erasmus MC, Department of Public Health, Rotterdam, The Netherlands
| | - Oliver Groene
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- OptiMedis AG, Hamburg, Germany
- * E-mail:
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Standardization and streamlining of a pancreas surgery practice improves outcomes and resource utilization: A single institution's 20-year experience. Am J Surg 2017; 214:450-455. [DOI: 10.1016/j.amjsurg.2017.01.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/15/2017] [Accepted: 01/29/2017] [Indexed: 12/18/2022]
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Wellner UF, Klinger C, Lehmann K, Buhr H, Neugebauer E, Keck T. The pancreatic surgery registry (StuDoQ|Pancreas) of the German Society for General and Visceral Surgery (DGAV) - presentation and systematic quality evaluation. Trials 2017; 18:163. [PMID: 28381291 PMCID: PMC5382382 DOI: 10.1186/s13063-017-1911-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 03/21/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pancreatic resections are among the most complex procedures in visceral surgery. While mortality has decreased substantially over the past decades, morbidity remains high. The volume-outcome correlation in pancreatic surgery is among the strongest in the field of surgery. The German Society for General and Visceral Surgery (DGAV) established a national registry for quality control, risk assessment and outcomes research in pancreatic surgery in Germany (DGAV SuDoQ|Pancreas). METHODS Here, we present the aims and scope of the DGAV StuDoQ|Pancreas Registry. A systematic assessment of registry quality is performed based on the recommendations of the German network for outcomes research (DNVF). RESULTS The registry quality was assessed by consensus criteria of the DNVF in regard to the domains Systematics and Appropriateness, Standardization, Validity of the sampling procedure, Validity of data collection, Validity of statistical analysis and reports, and General demands for registry quality. In summary, DGAV StuDoQ|Pancreas meets most of the criteria of a high-quality clinical registry. CONCLUSION The DGAV StuDoQ|Pancreas provides a valuable platform for quality assessment, outcomes research as well as randomized registry trials in pancreatic surgery.
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Affiliation(s)
- Ulrich F. Wellner
- German Society for General and Visceral Surgery (DGAV), Haus der Bundespressekonferenz, Schiffbauerdamm 40, Mieteinheit 3.200, 10117 Berlin, Germany
- German Society for General and Visceral Surgery (DGAV), Integrated National Study Group Pancreas, Berlin, Germany
- Klinik für Chirurgie, UKSH Campus Lübeck, Lübeck, Germany
| | - Carsten Klinger
- German Society for General and Visceral Surgery (DGAV), Haus der Bundespressekonferenz, Schiffbauerdamm 40, Mieteinheit 3.200, 10117 Berlin, Germany
- German Society for General and Visceral Surgery (DGAV), StuDoQ Registry, Berlin, Germany
| | - Kai Lehmann
- German Society for General and Visceral Surgery (DGAV), Haus der Bundespressekonferenz, Schiffbauerdamm 40, Mieteinheit 3.200, 10117 Berlin, Germany
- German Society for General and Visceral Surgery (DGAV), StuDoQ Registry, Berlin, Germany
| | - Heinz Buhr
- German Society for General and Visceral Surgery (DGAV), Haus der Bundespressekonferenz, Schiffbauerdamm 40, Mieteinheit 3.200, 10117 Berlin, Germany
| | - Edmund Neugebauer
- German Society for General and Visceral Surgery (DGAV), Integrated National Study Group Pancreas, Berlin, Germany
- Private Universität Witten/Herdecke, Witten, Germany
| | - Tobias Keck
- German Society for General and Visceral Surgery (DGAV), Haus der Bundespressekonferenz, Schiffbauerdamm 40, Mieteinheit 3.200, 10117 Berlin, Germany
- German Society for General and Visceral Surgery (DGAV), Integrated National Study Group Pancreas, Berlin, Germany
- Klinik für Chirurgie, UKSH Campus Lübeck, Lübeck, Germany
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Wellner UF, Keck T. Quality Indicators in Pancreatic Surgery: Lessons Learned from the German DGAV StuDoQ|Pancreas Registry. Visc Med 2017; 33:126-130. [PMID: 28560227 DOI: 10.1159/000456045] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Political and public interest in quality management in surgery is increasing. The German Society for General and Visceral Surgery (DGAV) established the DGAV StuDoQ, a nationwide registry for quality assessment in visceral surgery, with the organ-specific module DGAV StuDoQ|Pancreas. The first prerequisite for the measurement of quality is the definition of quality indicators. These can be related to risk factors which are also documented in the registry. METHODS Quality indicators for pancreatic surgery were developed by review of the current literature and expert consensus. After ranking the potential quality indicators, three essential indicators for outcome quality were selected for further review of the literature. Current figures were extracted from the DGAV StuDoQ|Pancreas registry and the correlation with selected risk factors was tested. RESULTS Three essential outcome quality indicators were selected: in-hospital mortality, TV30, and severe complications according to the Clavien-Dindo Classification. Preliminary data confirms the validity of risk factors included in the DGAV StuDoQ|Pancreas registry. CONCLUSION Essential quality indicators were defined for pancreatic surgery. The DGAV StuDoQ|Pancreas constitutes a valid platform for risk-adjusted quality assessment in Germany.
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Affiliation(s)
- Ulrich F Wellner
- Clinic for Surgery, German Society for General and Visceral Surgery (DGAV), Berlin, Germany.,Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Tobias Keck
- Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lübeck, Germany
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No Difference in Overall Survival Between Hospital Volumes for Patients With Colorectal Cancer in The Netherlands. Dis Colon Rectum 2016; 59:943-52. [PMID: 27602925 DOI: 10.1097/dcr.0000000000000660] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND High-volume hospitals have been associated with improved patient outcomes for tumors with a relatively low incidence that require complex surgeries, such as esophageal and pancreatic cancer. The volume-outcome association for colorectal cancer is under debate. OBJECTIVE This study investigated whether hospital volume for colorectal cancer is associated with surgical care characteristics and 5-year overall survival. DESIGN This is a population-based study. SETTING Data were gathered from the Netherlands Cancer Registry. Hospitals were grouped by volume for colon (<50, 50-74, 75-99, and ≥100 resections per year) and rectum (<20, 20-39, and ≥40 resections per year). PATIENTS All of the patients with primary nonmetastatic colorectal cancer who underwent resection between 2005 and 2012 were included. MAIN OUTCOME MEASURES Differences in surgical approach, anastomotic leakage, and postoperative 30-day mortality between hospital volumes were analyzed using χ tests and multivariable logistic regression analyses. Cox proportional hazard models were used to investigate the effect of hospital volume on overall survival. RESULTS This study included 61,394 patients with colorectal cancer. In 2012, 31 of the 91 hospitals performed less than 50 colon cancer resections per year, and 21 of the 90 hospitals performed less than 20 rectal cancer resections per year. No differences in anastomotic leakage rates between hospital volumes were observed. Only small differences between hospital volumes were revealed for conversion of laparoscopic to open resection (OR of less than 50 versus 100 or more resections per year = 1.25 (95% CI, 1.06-1.46)) and postoperative 30-day mortality (colon: OR of less than 50 versus 100 or more resections per year = 1.17 (95% CI, 1.02-1.35); rectum: OR of less than 20 versus 40 or more resections per year = 1.42 (95% CI, 1.09-1.84)). No differences in overall survival were found between hospital volumes. LIMITATIONS Although we adjusted for several patient and tumour characteristics, data regarding comorbidity, surgeon volume, local recurrences, and specific postoperative complications other than anastomotic leakage were not available. CONCLUSIONS In the Netherlands, no differences in 5-year survival rates were revealed between hospital volumes for patients with nonmetastatic colorectal cancer.
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Liang T, Liu S, Mok K, Shi H. Associations of Volume and Thyroidectomy Outcomes. Otolaryngol Head Neck Surg 2016; 155:65-75. [DOI: 10.1177/0194599816634627] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/03/2016] [Indexed: 08/30/2023]
Abstract
ObjectiveThis study explored how different hospital volumes and surgeon volumes affect thyroidectomy outcomes in terms of length of stay (LOS), costs, and in‐hospital mortality.Data SourcesMEDLINE and EMBASE databases.Review MethodsThis study retrospectively analyzed a cohort of 125,037 thyroidectomy patients treated at Taiwan hospitals from 1996 to 2010. Relationships between hospital/surgeon volume and patient outcomes were retrospectively analyzed by propensity score matching. In conjunction with the retrospective study, a systematic review and meta‐analysis of the relevant literature also were performed.ResultsThe mean LOS for all thyroidectomies performed during the study period was 3.3 days, and the mean cost was $1193.5. Both high‐volume hospitals and high‐volume surgeons were associated with significantly shorter LOS and lower costs compared with their low‐volume counterparts (P <. 001). Different volume groups had similar in‐hospital mortality rates. The meta‐analysis results consistently showed that the benefits of high‐volume hospitals/surgeons are reduced LOS and costs. However, low in‐hospital mortality rates were associated with high‐volume surgeons but not with high‐volume hospitals.ConclusionsThis meta‐analysis showed that patients who received thyroidectomies performed by high‐volume hospitals and surgeons had shorter LOS and lower costs compared with those treated by low‐volume hospitals and surgeons. In addition, in‐hospital survival rates were better in patients treated by high‐volume surgeons. Further research is needed to define the learning curve for thyroidectomy and to clarify how hospital volume and surgeon volume affect its success rate.
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Affiliation(s)
- Tsung‐Jung Liang
- Division of General Surgery Department of Surgery Kaohsiung Veterans General Hospital Kaohsiung Taiwan
- Department of Healthcare Administration and Medical Informatics Kaohsiung Medical University Kaohsiung Taiwan
| | - Shiuh‐Inn Liu
- Division of General Surgery Department of Surgery Kaohsiung Veterans General Hospital Kaohsiung Taiwan
| | - King‐Tong Mok
- Division of General Surgery Department of Surgery Kaohsiung Veterans General Hospital Kaohsiung Taiwan
| | - Hon‐Yi Shi
- Department of Healthcare Administration and Medical Informatics Kaohsiung Medical University Kaohsiung Taiwan
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van der Geest LG, van Rijssen LB, Molenaar IQ, de Hingh IH, Groot Koerkamp B, Busch OR, Lemmens VE, Besselink MG. Volume-outcome relationships in pancreatoduodenectomy for cancer. HPB (Oxford) 2016; 18:317-24. [PMID: 27037200 PMCID: PMC4814615 DOI: 10.1016/j.hpb.2016.01.515] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 01/05/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Volume-outcome relationships in pancreatic surgery are well established, but an optimal volume remains to be determined. Studies analyzing outcomes in volume categories exceeding 20 procedures annually are lacking. STUDY DESIGN A consecutive 3420 patients underwent PD for primary pancreatic or periampullary carcinoma (2005-2013) and were registered in the Netherlands Cancer Registry. Relationships between hospital volume (< 5, 5-19, 20-39 and ≥ 40 PDs/year) and mortality and survival were explored. RESULTS There was a non-significant decrease in 90-day mortality from 8.1 to 6.7% during the study period (p = 0.23). Ninety-day mortality was 9.7% in centers performing < 5 PDs/year (n = 185 patients), 8.9% for 5-19 PDs/year (n = 1432), 7.3% for 20-39 PDs/year (n = 240) and 4.3% for ≥ 40 PDs/year (n = 562, p = 0.004). Within volume categories, 90-day mortality did not change over time. After adjustment for confounding factors, significantly lower mortality was found in the ≥ 40 category compared to 20-39 PDs/year (OR = 1.72 (1.08-2.74)). Overall survival adjusted for confounding factors was better in the ≥ 40 category compared to categories under 20 PDs/year: HR (≥ 40 vs 5-19/year) = 1.24 (1.09-1.42). In the ≥ 40 category significantly more patients received adjuvant chemotherapy and had > 10 lymph nodes retrieved compared to lower volume categories. CONCLUSIONS Volume-outcome relationships in pancreatic surgery persist in centers performing ≥ 40 PDs annually, regarding both mortality and survival. The volume plateau for pancreatic surgery has yet to be determined.
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Affiliation(s)
- Lydia G.M. van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands,Correspondence: Lydia G.M. van der Geest, Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, 3511 DT Utrecht, The Netherlands. Tel: +31 (0)88 234 6479.
| | | | | | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Olivier R.C. Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Valery E.P.P. Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
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Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Kelly KN, Hensley BJ, Rickles AS, Noyes K, Fleming FJ, Monson JR. High volume improves outcomes: The argument for centralization of rectal cancer surgery. Surgery 2016; 159:736-48. [DOI: 10.1016/j.surg.2015.09.021] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/04/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022]
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Identifying Factors Influencing Pancreatic Cancer Management to Inform Quality Improvement Efforts and Future Research: A Scoping Systematic Review. Pancreas 2016; 45:161-6. [PMID: 26752254 DOI: 10.1097/mpa.0000000000000484] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Pancreatic cancer (PC) patients appear to receive suboptimal care. We conducted a systematic review to identify factors that influence PC management which are amenable to quality improvement. MEDLINE, EMBASE, and the references of eligible studies were searched from 1996 to July 2014. Two authors independently selected and reviewed eligible studies. Identified factors were mapped onto a framework of determinants of care delivery and outcomes. Methodological quality of studies was assessed using Downs and Black criteria. Most of the 33 eligible studies were population-based observational studies conducted in the United States. Patient (age, socioeconomic status, race) and institutional (case volume, academic status) factors influence care delivery and outcomes (complications, mortality, readmission, survival). Two studies implemented interventions to improve quality of care (centralization to high-volume hospitals, multidisciplinary care). One study examined system determinants (referral wait times). No studies examined the influence of guideline or provider characteristics. The overall lack of health services research in PC is striking. Factors and interventions identified here can be used to plan PC quality improvement programs. Further research is needed to explore the influence of guideline and provider factors on PC management and evaluate the impact of quality improvement interventions.
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van der Geest LGM, Besselink MGH, Busch ORC, de Hingh IHJT, van Eijck CHJ, Dejong CHC, Lemmens VEPP. Elderly Patients Strongly Benefit from Centralization of Pancreatic Cancer Surgery: A Population-Based Study. Ann Surg Oncol 2016; 23:2002-9. [DOI: 10.1245/s10434-016-5089-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Indexed: 12/24/2022]
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40
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Coupland VH, Konfortion J, Jack RH, Allum W, Kocher HM, Riaz SP, Lüchtenborg M, Møller H. Resection rate, hospital procedure volume and survival in pancreatic cancer patients in England: Population-based study, 2005-2009. Eur J Surg Oncol 2015; 42:190-6. [PMID: 26705143 DOI: 10.1016/j.ejso.2015.11.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/14/2015] [Accepted: 11/08/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE We assessed the association between population resection rates, hospital procedure volume and death rates in pancreatic cancer patients in England. DESIGN Patients diagnosed with pancreatic cancer were identified from a linked cancer registration and Hospital Episode Statistics dataset. Cox regression analyses were used to assess all-cause mortality according to resection quintile and hospital volume, adjusting for sex, age, deprivation and comorbidity. RESULTS There were 31,973 pancreatic cancer patients studied, 2580 had surgery. Increasing resection rates were associated with lower mortality among all patients (χ(2)(1df) = 176.18, ptrend < 0.001), with an unadjusted hazard ratio (HR) of 0.78 95%CI [0.75 to 0.81] in the highest versus the lowest resection quintile. Adjustment changed the estimate slightly (HR 0.82, 95%CI [0.79 to 0.85], (χ(2)(1df) = 99.44, ptrend < 0.001)). Among patients that underwent surgery, higher procedure volume was associated with lower mortality (HR = 0.88 95%CI [0.75-1.03] in hospitals carrying out 30+ versus <15 operations a year, shared frailty model, χ(2)(1df) = 1.82, ptrend = 0.177). CONCLUSION Higher population resection rates were associated with lower mortality. The association with hospital procedure volume was less clear possibly due to small number of patients who underwent surgery. Nevertheless these results suggest survival is higher in hospitals that carry out a greater number of operations a year, particularly those doing 30+ operations, supporting the benefit of centralising perioperative expertise in specialist centres. Ensuring people are increasingly diagnosed when they are suitable candidates for surgery, and have access to these specialist centres may lead to an increase in the proportion of patients that undergo surgical resection which could plausibly increase survival of pancreatic cancer patients.
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Affiliation(s)
- V H Coupland
- Public Health England, National Cancer Intelligence Network, London, UK.
| | - J Konfortion
- Public Health England, National Cancer Intelligence Network, London, UK
| | - R H Jack
- Public Health England, National Cancer Intelligence Network, London, UK
| | - W Allum
- The Royal Marsden NHS Foundation Trust, Department of Surgery, London, UK
| | - H M Kocher
- Centre for Tumour Biology, Barts Cancer Institute - a Cancer Research UK Centre of Excellence, Queen Mary University of London, London EC1M 6BQ, UK
| | - S P Riaz
- Public Health England, National Cancer Intelligence Network, London, UK
| | - M Lüchtenborg
- Public Health England, National Cancer Intelligence Network, London, UK; King's College London, Division of Cancer Studies, London, UK
| | - H Møller
- King's College London, Division of Cancer Studies, London, UK
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Alsfasser G, Leicht H, Günster C, Rau BM, Schillinger G, Klar E. Volume-outcome relationship in pancreatic surgery. Br J Surg 2015; 103:136-43. [PMID: 26505976 DOI: 10.1002/bjs.9958] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 06/12/2015] [Accepted: 09/03/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Volume-outcome relationships related to major surgery may be of limited value if observation ends at the point of discharge without taking transfers and later events into consideration. METHODS The volume-outcome relationship in patients who underwent pancreatic surgery between 2008 and 2010 was assessed using claims data for all inpatient episodes from Germany's largest provider of statutory health insurance covering about 30 per cent of the population. Multiple logistic regression models with random effects were used to analyse the effect of hospital volume (using volume quintiles) on 1-year mortality, adjusting for age, sex, primary disease, type of surgery and co-morbidities. Additional outcomes were in-hospital (including transfer to other hospitals until final discharge) and 90-day mortality. RESULTS Of 9566 patients identified, risk-adjusted 1-year mortality was significantly higher in the three lowest-volume quintiles compared with the highest-volume quintile (odds ratio 1·73, 1·53 and 1·37 respectively). A similar, but less pronounced, effect was demonstrated for in-hospital and 90-day mortality. The effect of hospital volume on 1-year mortality was comparable to the effect of co-morbid conditions such as renal failure. CONCLUSION Although mortality related to pancreatic surgery is influenced by many factors, this study demonstrated lower mortality at 1 year in high-volume centres in Germany.
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Affiliation(s)
- G Alsfasser
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | - H Leicht
- Research Institute of the Local Health Care Funds (AOK), Berlin, Germany
| | - C Günster
- Research Institute of the Local Health Care Funds (AOK), Berlin, Germany
| | - B M Rau
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
| | | | - E Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany
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van Rijssen LB, van der Geest LGM, Bollen TL, Bruno MJ, van der Gaast A, Veerbeek L, Ten Kate FJW, Busch ORC. National compliance to an evidence-based multidisciplinary guideline on pancreatic and periampullary carcinoma. Pancreatology 2015; 16:133-7. [PMID: 26560441 DOI: 10.1016/j.pan.2015.10.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 10/01/2015] [Accepted: 10/06/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND We evaluated national compliance to selected quality indicators from the Dutch multidisciplinary evidence-based guideline on pancreatic and periampullary carcinoma and identified areas for improvement. METHODS Compliance to 3 selected quality indicators from the guideline was evaluated before and after implementation of the guideline in 2011: 1) adjuvant chemotherapy after tumor resection for pancreatic carcinoma, 2) discussion of the patient within a multidisciplinary team (MDT) meeting and 3) a maximum 3-week interval between final MDT meeting and start of treatment. RESULTS In total 5086 patients with pancreatic or periampullary carcinoma were included. In 2010, 2522 patients were included and in 2012, 2564 patients. 1) Use of adjuvant chemotherapy following resection for pancreatic carcinoma increased significantly from 45% (120 out of 268) in 2010 to 54% (182 out of 336) in 2012 which was mainly caused by an increase in patients aged <75 years. 2) In 2012, 64% (896 of 1396) of patients suspected of a pancreatic or periampullary carcinoma was discussed within a MDT meeting which was higher in patients aged <75 years and patients starting treatment with curative intent. 3) In 2012, the recommended 3 weeks between final MDT meeting and start of treatment was met in 39% (141 of 363) of patients which was not influenced by patient and tumor characteristics. CONCLUSION Compliance to three selected quality indicators in pancreatic cancer care was low in 2012. Areas for improvement were identified. Future compliance will be investigated through structured audit and feedback from the Dutch Pancreatic Cancer Audit.
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Affiliation(s)
- Lennart B van Rijssen
- Dutch Pancreatic Cancer Group (DPCG), The Netherlands; Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Lydia G M van der Geest
- Dutch Pancreatic Cancer Group (DPCG), The Netherlands; Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Thomas L Bollen
- Dutch Pancreatic Cancer Group (DPCG), The Netherlands; Department of Radiology, St. Antonius Hospital, Nieuwegein/Utrecht, The Netherlands
| | - Marco J Bruno
- Dutch Pancreatic Cancer Group (DPCG), The Netherlands; Department of Gastroenterology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ate van der Gaast
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Laetitia Veerbeek
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Fibo J W Ten Kate
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier R C Busch
- Dutch Pancreatic Cancer Group (DPCG), The Netherlands; Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Pandanaboyana S, Bell R, Windsor J. Artery first approach to pancreatoduodenectomy: current status. ANZ J Surg 2015; 86:127-32. [PMID: 26246127 DOI: 10.1111/ans.13249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The need for an early determination of resectability and before an irreversible step is taken during pancreatoduodenectomy promoted the development of an 'artery first approach' (AFA). The aim of this study was to review the current evidence related to this approach, with particular reference to margins and survival. METHODS An electronic search was performed in MEDLINE, EMBASE and PubMed databases from 1960 to 2015 using both subject headings (MeSH) and truncated word searches to identify all published related articles to this topic. RESULTS Six different AFAs have been published. Four studies evaluated the impact of AFA on perioperative outcomes and survival. Three studies showed no difference in the perioperative outcomes, margin status, lymph node yield and survival while one study showed improved margin status and survival comparing AFA with standard resection. CONCLUSION The current evidence regarding the benefits of AFA in relation to decreasing margin positivity or increasing survival is sparse. Further larger studies and randomized controlled trails are needed to ascertain the benefits of AFA.
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Affiliation(s)
- Sanjay Pandanaboyana
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Richard Bell
- Department of Hepatobiliary and Pancreatic Surgery, St James Hospital, Leeds, UK
| | - John Windsor
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
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Onete VG, Besselink MG, Salsbach CM, Van Eijck CH, Busch OR, Gouma DJ, de Hingh IH, Sieders E, Dejong CH, Offerhaus JG, Molenaar IQ. Impact of centralization of pancreatoduodenectomy on reported radical resections rates in a nationwide pathology database. HPB (Oxford) 2015; 17:736-42. [PMID: 26037776 PMCID: PMC4527860 DOI: 10.1111/hpb.12425] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 04/04/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Centralization of a pancreatoduodenectomy (PD) leads to a lower post-operative mortality, but is unclear whether it also leads to improved radical (R0) or overall resection rates. METHODS Between 2004 and 2009, pathology reports of 1736 PDs for pancreatic and peri-ampullary neoplasms from a nationwide pathology database were analysed. Pre-malignant lesions were excluded. High-volume hospitals were defined as performing ≥ 20 PDs annually. The relationship between R0 resections, PD-volume trends, quality of pathology reports and hospital volume was analysed. RESULTS During the study period, the number of hospitals performing PDs decreased from 39 to 23. High-volume hospitals reported more R0 resections in the pancreatic head and distal bile duct tumours than low-volume hospitals (60% versus 54%, P = 0.035) although they operated on more advanced (T3/T4) tumours (72% versus 58%, P < 0.001). The number of PDs increased from 258 in 2004 to 394 in 2009 which was partly explained by increased overall resection rates of pancreatic head and distal bile duct tumours (11.2% in 2004 versus 17.5% in 2009, P < 0.001). The overall reported R0 resection rate of pancreatic head and distal bile duct tumours increased (6% in 2004 versus 11% in 2009, P < 0.001). Pathology reports of low-volume hospitals lacked more data including tumour stage (25% versus 15%, P < 0.001). CONCLUSIONS Centralization of PD was associated with both higher resection rates and more reported R0 resections. The impact of this finding on overall survival should be further assessed.
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Affiliation(s)
- Veronica G Onete
- Department of Surgery, University Medical Center UtrechtUtrecht, The Netherlands,Department of Surgery, Academic Medical CenterAmsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical CenterAmsterdam, The Netherlands,Correspondence Marc G. Besselink, Dutch Pancreatic Cancer Group, Academic Medical Center Amsterdam, Department of Surgery, Room G4-196, PO Box 22660, 1100 DD Amsterdam, The Netherlands. Tel.: +31-20-5669111. Fax: +31-20-5669243. E-mail:
| | - Chanielle M Salsbach
- Department of Surgery, University Medical Center UtrechtUtrecht, The Netherlands,Department of Surgery, Erasmus Medical CenterRotterdam, The Netherlands
| | | | - Olivier R Busch
- Department of Surgery, Academic Medical CenterAmsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical CenterAmsterdam, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital EindhovenEindhoven, The Netherlands
| | - Egbert Sieders
- Department of Surgery, University Medical Center GroningenGroningen, The Netherlands
| | - Cornelis H Dejong
- Department of Surgery, University Medical Center Maastricht, Maastricht and NUTRIM School for Nutrition, Toxicology and MetabolismMaastricht, The Netherlands
| | - Johan G Offerhaus
- Department of Pathology, University Medical Center UtrechtUtrecht, The Netherlands,Department of Pathology, Academic Medical Center AmsterdamAmsterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center UtrechtUtrecht, The Netherlands
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de Cruppé W, Malik M, Geraedts M. Minimum volume standards in German hospitals: do they get along with procedure centralization? A retrospective longitudinal data analysis. BMC Health Serv Res 2015. [PMID: 26197817 PMCID: PMC4511553 DOI: 10.1186/s12913-015-0944-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Compliance with minimum volume standards for specific procedures serves as a criterion for high-quality patient care. International experiences report a centralization of the respective procedures. In Germany, minimum volume standards for hospitals were introduced in 2004 for 5 procedures (complex esophageal and pancreatic interventions; liver, kidney and stem cell transplantations), in 2006 total knee replacement was added. This study explores whether any centralization is discernible for these procedures in Germany. METHODS A retrospective longitudinal analysis of secondary data serves to determine a possible centralization of procedures from the system perspective. Centralization means that over time, fewer hospitals perform the respective procedure, the case volume in high-volume hospitals increases together with their percentage of the annual total case volume, and the case volume in low-volume hospitals decreases together with their percentage of the annual total case volume. Using data from the mandatory hospital quality reports for the years 2006, 2008 and 2010 we performed Kruskal Wallis and chi-square tests to evaluate potential centralization effects. RESULTS No centralization was found for any of the six types of interventions over the period from 2006 to 2010. The annual case volume and the number of hospitals performing interventions rose at differing rates over the 5-year period depending on the type of intervention. Seven percent of esophagectomies and 14% of pancreatectomies are still performed in hospitals with less than 10 interventions per year. CONCLUSIONS For the purpose of further centralization of interventions it will be necessary to first analyze and then appropriately address the reasons for non-compliance from the hospital and patient perspective.
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Affiliation(s)
- Werner de Cruppé
- Institute for Health Systems Research, School of Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Strasse 50, 58448, Witten, Germany.
| | - Marc Malik
- Institute for Health Systems Research, School of Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Strasse 50, 58448, Witten, Germany.
| | - Max Geraedts
- Institute for Health Systems Research, School of Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Strasse 50, 58448, Witten, Germany.
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Dasari BV, Farid S, Roberts K, Morris-Stiff G. Overview of pancreatic resections: indications and procedures. Br J Hosp Med (Lond) 2015; 76:C34-7. [PMID: 25761816 DOI: 10.12968/hmed.2015.76.3.c34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Bobby Vm Dasari
- Specialty Registrar in the Department of Hepatobiliary and Pancreatic Surgery, Mater Hospital, Belfast Health and Social Care Trust, Belfast BT14 6AB
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Coolsen MME, van Dam RM, Chigharoe A, Olde Damink SWM, Dejong CHC. Improving outcome after pancreaticoduodenectomy: experiences with implementing an enhanced recovery after surgery (ERAS) program. Dig Surg 2014; 31:177-84. [PMID: 25097014 DOI: 10.1159/000363583] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 05/13/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreaticoduodenectomies (PDs) are complex surgical procedures that require high-standard perioperative care. The objective of this study was to evaluate the effects of implementing an Enhanced Recovery After Surgery (ERAS) program for PD on patient outcome. METHODS 230 patients undergoing PD in the Maastricht University Medical Centre between January 1995 and January 2012 were included. Group 1 (no ERAS; 1995-2005) received traditional care. From January 2006, several elements of an ERAS pathway for pancreatic surgery were implemented (group 2: 'ERAS-like'). From 2009 onwards the ERAS pathway was fully implemented (group 3: ERAS). Mortality, complications, readmissions and length of hospital stay (LOS) were evaluated in the subgroups and compared. RESULTS Median LOS was significantly reduced from 20 days in group 1 to 13 days in group 2 and 14 days in group 3 (p = 0.001). Median LOS of patients without complications was 16, 10 and 9 days in groups 1, 2 and 3, respectively (p < 0.0001). Over time, the average age of patients undergoing PD increased significantly. Complication rates as well as mortality and readmission rates did not change over time. CONCLUSION Implementing an ERAS program contributed to a decrease of LOS without compromising other outcomes. Mortality, morbidity and readmission rates stayed unchanged and more complications were managed non-operatively.
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Affiliation(s)
- Marielle M E Coolsen
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands
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Gooiker GA, Lemmens VEPP, Besselink MG, Busch OR, Bonsing BA, Molenaar IQ, Tollenaar RAEM, de Hingh IHJT, Wouters MWJM. Impact of centralization of pancreatic cancer surgery on resection rates and survival. Br J Surg 2014; 101:1000-5. [PMID: 24844590 DOI: 10.1002/bjs.9468] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Centralization of pancreatic surgery has been shown to reduce postoperative mortality. It is unknown whether resection rates and survival have also improved. The aim of this study was to analyse the impact of nationwide centralization of pancreatic surgery on resection rates and long-term survival. METHODS All patients diagnosed in the Netherlands between 2000 and 2009 with cancer of the pancreatic head were identified in the Netherlands Cancer Registry. Changes in referral pattern, resection rates and survival after pancreatoduodenectomy were analysed. Multivariable regression analysis was used to assess the impact of hospital volume (20 or more procedures per year) on survival after resection. RESULTS Between 2000 and 2009, 11,160 patients were diagnosed with cancer of the pancreatic head. The resection rate increased from 10.7 per cent in 2000-2004 to 15.3 per cent in 2005-2009 (P < 0.001). No significant difference in survival after resection was observed between the two intervals (P = 0.135), although survival was significantly better in high-volume hospitals (median survival 18 months versus 16 months in low/medium-volume hospitals; P = 0.017). After adjustment for patient and tumour characteristics, high hospital volume remained associated with better overall survival after resection (hazard ratio 0.70, 95 per cent confidence interval 0.58 to 0.84; P < 0.001). CONCLUSION Centralization of pancreatic cancer surgery led to increased resection rates. High-volume centres had significantly better survival rates. Centralization improves patient outcomes and should be encouraged.
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Affiliation(s)
- G A Gooiker
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Accuracy of endoscopic ultrasound in the evaluation of cystic pancreatic neoplasms: a community hospital experience. Pancreas 2014; 43:465-9. [PMID: 24622081 DOI: 10.1097/mpa.0000000000000057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Reports on the use of endoscopic ultrasound (EUS) in differentiating benign, premalignant, and malignant pancreatic lesions have been widely variable, particularly with cystic neoplasms. We evaluated the use of EUS for cystic pancreatic lesions in a community hospital setting. METHODS All patients who underwent EUS for cystic pancreatic neoplasms from 2007 to 2010 were reviewed. A final EUS diagnosis was determined based on the examiner's impression and fine-needle aspiration results if available. Lesions were stratified as benign, premalignant, or malignant. Patients underwent surgical resection, serial imaging studies, or medical oncology/palliative care consultation as indicated. RESULTS One hundred eighteen patients with cystic pancreatic lesions underwent EUS during the study period. Endoscopic ultrasound diagnoses included 75 benign (63.6%), 35 premalignant (29.7%), and 8 malignant (4.2%) lesions. Thirty-eight patients (32.2%) underwent surgery, 77 (65.3%) were monitored with imaging, and 3 (2.5%) had unresectable malignancies. Elevated carcinoembryonic antigen levels showed a trend toward predicting mucinous cysts (P = 0.062). Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for cystic lesions were 87.3%, 86.8%, 87.5%, 76.7%, and 93.3%, respectively. CONCLUSIONS Endoscopic ultrasound is a valuable diagnostic modality in the evaluation of cystic pancreatic neoplasms in a community hospital setting.
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McCahill LE, May M, Morrow JB, Khandavalli S, Shabahang B, Kemmeter P, Pimiento JM. Esophagectomy outcomes at a mid-volume cancer center utilizing prospective multidisciplinary care and a 2-surgeon team approach. Am J Surg 2013; 207:380-6; discussion 385-6. [PMID: 24581762 DOI: 10.1016/j.amjsurg.2013.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 09/17/2013] [Accepted: 09/18/2013] [Indexed: 09/30/2022]
Abstract
BACKGROUND Esophagectomy is associated with high morbidity and mortality, leading to calls for restricted performance at high-volume centers. METHODS Patients with esophageal cancer were evaluated prospectively in a multidisciplinary tumor board from January 2012 - December 2012. A 2-surgeon team was utilized and detailed outcomes were assessed prospectively. RESULTS Thirty-one patients underwent esophagectomy, 20 patients underwent laparoscopic transhiatal (65%) approach, and 11 patients underwent laparoscopically assisted Ivor-Lewis (35%) approach. Eighty-one percent of the patients were male, with a median age of 64 years (range: 35 to 83 years) and 73% of the patients had adenocarcinoma. Neoadjuvant chemoradiation was performed in 79% of the patients. R0 resection was achieved in 29 (94%) patients, median nodes identified were 15. Major complications (grade III to V) occurred in 13 (42%) patients and did not correlate with surgical techniques, anastomotic leak occurred in 5 (16%) patients, and significant pulmonary complications occurred in 11 (35%) patients. The length of stay at the hospital was 10 days, readmission rate 23%, and 30-day mortality rate 6%. CONCLUSIONS High-quality esophagectomy can be performed safely at a mid-volume cancer center. Our outcomes question the reliance on volume alone as an indicator of cancer surgical quality.
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Affiliation(s)
- Laurence E McCahill
- Metro Cancer Center, Metro Health Hospital, 5950 Metro Way, Wyoming, MI 49519, USA; College of Human Medicine, Michigan State University, Grand Rapids, MI, USA.
| | - Mary May
- Lacks Cancer Center at Mercy Health-Saint Mary's, Grand Rapids, MI, USA
| | | | - Sharif Khandavalli
- Metro Cancer Center, Metro Health Hospital, 5950 Metro Way, Wyoming, MI 49519, USA; Lacks Cancer Center at Mercy Health-Saint Mary's, Grand Rapids, MI, USA
| | - Behooz Shabahang
- Lacks Cancer Center at Mercy Health-Saint Mary's, Grand Rapids, MI, USA
| | | | - Jose M Pimiento
- College of Human Medicine, Michigan State University, Grand Rapids, MI, USA; Lacks Cancer Center at Mercy Health-Saint Mary's, Grand Rapids, MI, USA
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