Relationship between hospital volume and short-term outcomes: a nationwide population-based study including 75,280 rectal cancer surgical procedures

Surgeon factors but not hospital factors associated with length of stay after colorectal surgery - A population based study

AIM

Length of stay (LOS) after colorectal surgery (CRS) is a significant driver of healthcare utilization and adverse patient outcomes. To date, there is little high-quality evidence in the literature examining how individual surgeon and hospital factors independently impact LOS. We aimed to identify and quantify the independent impact of surgeon and hospital factors on LOS after CRS.

METHODS

A retrospective population-based cohort study was conducted using validated health administrative databases, encompassing all patients from the province of Ontario, Canada. All patients from 121 hospitals in Ontario who underwent elective CRS between 2008 and 2019 in Ontario were included, and factors pertaining to these patients and their treating surgeon and hospital were assessed. A negative binomial regression model was used to assess the independent effect of surgeon and hospital factors on LOS, accounting for a comprehensive collection of determinants of LOS. To minimize unmeasured confounding, the analysis was repeated in a subgroup comprising patients undergoing lower-complexity CRS without postoperative complications.

RESULTS

A total of 90,517 CRS patients were analysed. Independent of patient and procedural factors, low surgeon volume (lowest volume quartile) was associated with a 20% increase in LOS (95% CI: 12-29, p < 0.0001) compared to high surgeon volume (highest volume quartile). In the 22,639 patients undergoing uncomplicated lower-complexity surgeries, a 43% longer LOS was seen in the lowest volume surgeon quartile (95% CI: 26-61, p < 0.0001). In both models, more years-in-practice was associated with a small increase in LOS (RR 1.02, 95% CI: 1.02-1.03, p < 0.0001). Hospital factors were not significantly associated with increased LOS.

CONCLUSIONS

Surgeon factors, including low surgeon volume and increasing years-in-practice, were strongly and independently associated with longer LOS, whereas hospital factors did not have an independent impact. This suggests that LOS is driven primarily by surgeon-mediated care processes and may provide actionable targets for provider-level interventions to reduce LOS after CRS.

Short-term surgical outcomes of laparoscopic and open surgery for rectal cancer: A nationwide retrospective analysis

INTRODUCTION

Laparoscopy for treatment of rectal cancer is widely used in clinical practice. However, the safety and advantages of laparoscopy over open surgery at the national level remain unclear. We compared the short-term outcomes of laparoscopy and open surgery for rectal cancer.

METHODS

Using a Japanese nationwide inpatient database, this study analyzed data on patients who underwent rectal resection between July 2010 and March 2018. We performed propensity score matching analyses to compare in-hospital mortality, morbidities, blood transfusion, diverting stomas, anastomotic leakages, duration of anesthesia, postoperative length of stay, and readmission within 30 days between the laparoscopy and open surgery groups.

RESULTS

Among 99 137 eligible patients, propensity score matching generated 29 717 pairs. Laparoscopy was associated with lower in-hospital mortality (0.4% vs 0.6%, P = .006), overall morbidities (28.7% vs 33.2%, P < .001), and blood transfusion rate (11.5% vs 22.9%, P < .001); shorter postoperative duration of stay (16 days vs 18 days, P < .001); and longer duration of anesthesia (390 vs 310 minutes, P < .001). Grade C anastomotic leakage was not different between the groups.

CONCLUSION

With respect to in-hospital mortality, morbidities, blood transfusion, postoperative length of hospitalization, and readmission within 30 days, laparoscopy is advantageous over open surgery in the treatment of rectal cancer.

Impact of surgeon and hospital factors on length of stay after colorectal surgery systematic review

Background

Although length of stay (LOS) after colorectal surgery (CRS) is associated with worse patient and system level outcomes, the impact of surgeon and hospital-level factors on LOS after CRS has not been well investigated. The aim of this study was to synthesize the evidence for the impact of surgeon and hospital-level factors on LOS after CRS.

Methods

A comprehensive database search was conducted using terms related to LOS and CRS. Studies were included if they reported the effect of surgeon or hospital factors on LOS after elective CRS. The evidence for the effect of each surgeon and hospital factor on LOS was synthesized using vote counting by direction of effect, taking risk of bias into consideration.

Results

A total of 13 946 unique titles and abstracts were screened, and 69 studies met the inclusion criteria. All studies were retrospective and assessed a total of eight factors. Surgeon factors such as increasing surgeon volume, colorectal surgical specialty, and progression along a learning curve were significantly associated with decreased LOS (effect seen in 87.5 per cent, 100 per cent, and 93.3 per cent of studies respectively). In contrast, hospital factors such as hospital volume and teaching hospital status were not significantly associated with LOS.

Conclusion

Provider-related factors were found to be significantly associated with LOS after elective CRS. In particular, surgeon-related factors related to experience specifically impacted LOS, whereas hospital-related factors did not. Understanding the mechanisms underlying these relationships may allow for tailoring of interventions to reduce LOS.

German oncology certification system for colorectal cancer - relative survival rates of a single certified centre vs. national and international registry data

Objectives

To evaluate how the certification of specialised Oncology Centres in Germany affects the relative survival of patients with colorectal cancer (CRC) by means of national and international comparison.

Methods

Between 2007 and 2013, 675 patients with colorectal cancer, treated at the Hildesheim Hospital, an academic teaching hospital of the Hannover Medical School (MHH), were included. A follow-up of the entire patient group was performed until 2014. To obtain international data, a SEER-database search was done. The relative survival of 148,957 patients was compared to our data after 12, 36 and 60 months. For national survival data, we compared our rates with 41,988 patients of the Munich Cancer Registry (MCR).

Results

Relative survival at our institution tends to be higher in advanced tumour stages compared to national and international cancer registry data. Nationally we found only little variation in survival rates for low stages CRC (UICC I and II), colon, and rectal cancer. There were notable variations regarding relative survival rates for advanced CRC tumour stages (UICC IV). These variations were even more distinct for rectal cancer after 12, 36 and 60 months (Hildesheim Hospital: 89.9, 40.3, 30.1%; Munich Cancer Registry (MCR): 65.4, 28.7, 16.6%). The international comparison of CRC showed significantly higher relative survival rates for patients with advanced tumour stages after 12 months at our institution (77 vs. 54.9% for UICC IV; raw p<0.001).

Conclusions

Our findings suggest that patients with advanced tumour stages of CRC and especially rectal cancer benefit most from a multidisciplinary and guidelines-oriented treatment at Certified Oncology Centres. For a better evaluation of cancer treatment and improved national and international comparison, the creation of a centralised national cancer registry is necessary.

Association of age with treatment at high-volume hospitals and distance traveled for care, in patients with rectal cancer who seek curative resection

BACKGROUND

The association between volume and outcomes has led to recommendations that patients undergo surgery at high-volume centers. We aimed to determine if older patients with rectal cancer are undergoing operations at high-volume centers.

METHODS

We identified patients ≥50 years old who underwent rectal cancer resection using the NCDB (2004-2015). Tertiles were used to categorize facility volume and distance traveled.

RESULTS

Higher facility volume was associated with improved outcomes. Patients >75 years old were less likely than patients 50-59 years old to be treated at high-volume centers. Traveling >16.8 miles was associated with treatment at high-volume facilities, however patients >75 years old were less likely to travel >16.8 miles.

CONCLUSIONS

Higher facility volume is associated with improved outcomes after rectal cancer resection. However, older patients are less likely to be treated at high-volume facilities. Older patients travel shorter distances for care, suggesting that care integration across networks must be optimized.

Nationwide in-hospital mortality rate following rectal resection for rectal cancer according to annual hospital volume in Germany

Background

The impact of hospital volume after rectal cancer surgery is seldom investigated. This study aimed to analyse the impact of annual rectal cancer surgery cases per hospital on postoperative mortality and failure to rescue.

Methods

All patients diagnosed with rectal cancer and who had a rectal resection procedure code from 2012 to 2015 were identified from nationwide administrative hospital data. Hospitals were grouped into five quintiles according to caseload. The absolute number of patients, postoperative deaths and failure to rescue (defined as in‐hospital mortality after a documented postoperative complication) for severe postoperative complications were determined.

Results

Some 64 349 patients were identified. The overall in‐house mortality rate was 3·9 per cent. The crude in‐hospital mortality rate ranged from 5·3 per cent in very low‐volume hospitals to 2·6 per cent in very high‐volume centres, with a distinct trend between volume categories (P < 0·001). In multivariable logistic regression analysis using hospital volume as random effect, very high‐volume hospitals (53 interventions/year) had a risk‐adjusted odds ratio of 0·58 (95 per cent c.i. 0·47 to 0·73), compared with the baseline in‐house mortality rate in very low‐volume hospitals (6 interventions per year) (P < 0·001). The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue decreased significantly with increasing caseload (15·6 per cent after pulmonary embolism in the highest volume quintile versus 38 per cent in the lowest quintile; P = 0·010).

Conclusion

Patients who had rectal cancer surgery in high‐volume hospitals showed better outcomes and reduced failure to rescue rates for severe complications than those treated in low‐volume hospitals.

Outcomes After Rectal Cancer Surgery: A Population-Based Study Using Quality Indicators

Quality indicators are increasingly being used to measure the safety of cancer treatments. We examined factors associated with poorer outcomes after major resection for rectal cancer over time. We linked population-based cancer registry and cancer-related procedure data for rectal cancer cases over a 15-year period. Multivariable logistic regression models were used to examine factors associated with 30- and 90-day postoperative mortality, and overall survival (OS) was estimated using the Kaplan-Meier survival function. The study included 9,222 patients who had major resection for invasive rectal cancer. Thirty-day and 90-day mortality were 2.1% and 3.8%, respectively. Risk of 30-day mortality was elevated in older patients (p < .001); patients with ≥2 comorbidities (p < .001); and those admitted as an emergency (p < .001). An approximate 45% reduction in 30-day mortality (p = .01) was observed over time. Two-year OS was 81.5%, again with significant improvements observed over time (p < .001). No significant association was observed between hospital volume and mortality or 2-year survival. A reduction in rates of postoperative mortality and improved 2-year OS were observed over time. Quality indicators are a valuable tool to monitor clinical outcomes over time and as a means of improving clinical care for all patients.

Achieving quadruple aim goals through clinical networks: A systematic review

INTRODUCTION

Clinical Networks are complex interventions that enable healthcare professionals from various disciplines to work in a coordinated manner in the context of multiple care settings, to provide a high quality response to a specific disease. The aim of this study was to evaluate if clinical networks are able to improve effectiveness, efficiency, patients' satisfaction and professionals' behavior in the health care settings, namely the "quadruple aim" quality goals.

MATERIALS AND METHODS

A systematic review of documents published until February 28, 2018, in Medline, Embase and CINAHL was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach. A specific research strategy was created to identify studies evaluating effectiveness, efficiency, patient satisfaction and professionals well-being obtained through clinical networks implementation.

RESULTS

14249 studies were identified; 12 of these were eligible to the evaluation of "Quadruple Aim" outcomes. 9 studies focused on patients' outcomes improvement and 4 on network efficiency. Professionals' and patients' experience were not considered in any study.

CONCLUSIONS

There are some evidences that clinical network can improve patients' outcomes and health funds allocation in a small number of moderate-low quality studies. Further rigorous studies are needed to confirm these findings and to evaluate patients' and professionals' experience, taking into account also networks' structural features that could influence outcomes achievement.