Hospital Esophageal Cancer Resection Volume Does Not Predict Patient Mortality Risk
ABSTRACT Insurers often seek to direct esophageal cancer patients to hospitals with high volumes of esophageal resection. However, controversy exists regarding the strength and validity of evidence for the volume-outcome association. The purpose of this study was to evaluate the volume-outcome relationship for esophageal cancer resection in a large population dataset and to compare 3alternative techniques for measuring the effect of volume.
Esophageal cancer resection patients were identified in the 2007 Nationwide Inpatient Sample. Hospital volume was measured using a continuous linear function, a nonlinear function using restricted cubic splines, and using quintiles of volume. The statistical significance of the relationship between hospital volume and mortality risk was assessed, and adjusted for patient age, for comorbid disease, and for correlated events within hospitals.
A total of 6,248 esophageal cancer resection patients from 217 hospitals were identified. All 3 models demonstrated excellent performance characteristics (C index=0.94, Nagelkerke R2=0.62). However, no significant association was demonstrated between hospital procedure volume and in-hospital mortality in any model. Important predictors of mortality included age, hypertension, weight loss, and peripheral vascular disease (p<0.001).
Esophageal cancer resection volume is not a significant predictor of mortality and should not be used as a proxy measure for surgical quality.
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ABSTRACT: To examine the trends and outcomes of partial esophagectomy with an intrathoracic anastomosis compared with total esophagectomy with a cervical anastomosis. Controversy exists regarding the optimal surgical approach in the management of esophageal cancer. Using the Nationwide Inpatient Sample database, yearly trends of patients with esophageal cancer who underwent partial and total esophagectomy were analyzed. Multivariate logistic regression analysis was used to analyze serious morbidity and in-hospital mortality between partial and total esophagectomy. In addition, outcomes were analyzed according to hospital volume, with low-volume centers defined as those with fewer than 10 cases per year and high-volume centers as those with 10 or more cases per year. Between 2001 and 2010, 15,190 esophagectomies were performed for cancer. There was an overall increase in the number of esophagectomy procedures performed (1402 to 1975), with a concomitant reduction in the mortality rate (8.3% to 4.2%), particularly for partial esophagectomy. Partial esophagectomy was the predominant operation (76%). Most operations were performed at low-volume centers (62%), with a recent shift of cases to high-volume center. Compared with total esophagectomy, partial esophagectomy was associated with a shorter length of hospital stay (16 ± 6 vs 19 ± 9 days; P < 0.05), a lower in-hospital mortality rate (5.8% vs 8.3%; P < 0.05), and a lower hospital charge ($119,339 vs $138,496; P < 0.05). On multivariate regression analysis, total esophagectomy was associated with higher serious morbidity (odds ratio, 1.39; P < 0.01) and in-hospital mortality (odds ratio, 1.67; P = 0.03). There were no significant differences in risk-adjusted outcomes between low-volume centers and high-volume center. The number of esophagectomies performed for esophageal cancer has increased over the past decade accompanied by an overall reduction in mortality, particularly for the partial esophagectomy approach. The predominant operation in the United States continues to be partial esophagectomy with an intrathoracic anastomosis, which was associated with lower morbidity and in-hospital mortality than total esophagectomy. Hospital volume at a threshold of 10 cases per year was not a predictor of outcome.Annals of surgery 09/2013; 258(3):450-8. DOI:10.1097/SLA.0b013e3182a1b11d · 7.19 Impact Factor
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ABSTRACT: In the modern era of esophagectomy, we hypothesized that perioperative morbidity and mortality from cervical or thoracic sites of anastomoses would not be different. We used the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent esophagectomy for lower esophageal or gastroesophageal (GE) junction malignancies from 2005 to 2010. Patients were categorized as having either a cervical or thoracic anastomosis based on CPT codes. There were 601 (66%) cervical and 308 (34%) thoracic anastomoses. Cervical anastomoses were associated with greater than 2 units of blood transfusion in a higher proportion of patients (10% vs. 3%, P = 0.001), and higher superficial surgical site infections (13% vs. 7%, P = 0.003). There were no difference in rates of organ/space infections (6% vs. 7%, P = 0.70), overall morbidity (38% vs. 39%, P = 0.84), or mortality (3% vs. 4%, P = 0.34). Median length of stay was similar (11.5 days cervical vs. 11 days thoracic, P = 0.89), even among patients with organ/space infections (18 days cervical vs. 21 days thoracic, P = 0.49). On multivariate analysis thoracic anastomosis was not a significant predictor of increased overall morbidity (OR 1.13: 95%CI 0.83-1.54). After esophagectomy, the site of anastomosis does not predict an increased risk of perioperative morbidity or mortality. J. Surg. Oncol. © 2013 Wiley Periodicals, Inc.Journal of Surgical Oncology 12/2013; 108(7). DOI:10.1002/jso.23423 · 2.84 Impact Factor
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ABSTRACT: Service reorganization to concentrate complex vascular services in hospitals with high caseload volume aims to reduce mortality and complication rates. The present study assessed the relationship between caseload volume and outcome for iliac artery angioplasty and stenting in England using a routinely available national data set (Hospital Episode Statistics, HES). Routine administrative data for iliac artery angioplasty and stent procedures performed in England between 2007 and 2011 were analysed. Associations between centre volume and outcomes (death, complications and duration of hospital stay) were tested and compared for two methods of stratification (quartiles and quintiles) and two statistical tests (odds ratios and the Cochran-Armitage test for trend). Multivariable analysis was also performed. There were 23 308 episodes of care recorded in HES with Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures, fourth revision, codes L54.1 or L54.4 corresponding to iliac artery intervention. There was a gradual increase year by year in number of procedures performed. Univariable and multivariable analysis showed no association between centre volume and either death or complications (multivariable odds ratio, OR 1·00, 95 per cent confidence interval 1·00 to 1·00) for elective and non-elective procedures. Age was associated with higher mortality and complication rates in elective procedures, and with mortality in non-elective procedures. The risk of death after elective iliac angioplasty or stenting was significantly higher in women (multivariable OR 4·98, 2·09 to 13·26). There was no association between the outcomes of endovascular iliac artery intervention and centre volume, but outcomes were significantly worse with increasing age and female sex.British Journal of Surgery 08/2013; 100(9):1189-1196. DOI:10.1002/bjs.9199 · 5.21 Impact Factor