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Janczewski LM, Vitello DJ, Peters X, Valukas C, Merkow RP, Bentrem DJ. Association of Hospital Volume With Quality Care Outcomes Following Minor and Major Hepatectomy for Primary Liver Cancer. J Surg Oncol 2024; 130:1033-1041. [PMID: 39328181 DOI: 10.1002/jso.27819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/25/2024] [Indexed: 09/28/2024]
Abstract
INTRODUCTION Regionalizing hepatic resections to high-volume hospitals (HVH) has improved outcomes, yet widened disparities in access. We sought to evaluate the association of hospital volume with quality care outcomes and overall survival (OS) between minor and major hepatectomy for primary liver cancer. METHODS The National Cancer Database identified patients with primary liver cancer who underwent minor/major hepatectomy (2009-2019). HVHs were defined by the top quartile in annual case volume (vs. the bottom three quartiles). Quality care outcomes (time to resection, margin status, length of stay, 30-day readmission, 30-day mortality, 90-day mortality) and OS were assessed using multivariable regression. RESULTS Overall, 6,988 patients underwent minor hepatectomy and 4880 major hepatectomy. No differences in quality care outcomes or OS based on hospital volume for minor hepatectomy were observed (all p > 0.05). Treatment at HVHs for major hepatectomy was associated with decreased odds of 30-day and 90-day mortality events (all p < 0.05). Median OS was 40.2 months [IQR 21.7-66.6] at HVHs versus 33.5 [IQR 17.0-58.7] at low-volume hospitals which remained independently predictive of improved OS on multivariable analysis (HR 0.86, 95% CI 0.79-0.93). CONCLUSION These results support regionalization to HVHs for major hepatectomy; however, minor hepatectomy can be safely performed at hospitals regardless of volume.
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Affiliation(s)
- Lauren M Janczewski
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- American College of Surgeons, Chicago, Illinois, USA
| | - Dominic J Vitello
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xane Peters
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- American College of Surgeons, Chicago, Illinois, USA
| | - Catherine Valukas
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ryan P Merkow
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - David J Bentrem
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Surgery, Jesse Brown Veterans' Affairs Medical Center, Chicago, Illinois, USA
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2
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Verm RA, Baker MM, Cohn T, Park S, Swanson J, Freeman R, Abdelsattar ZM. Fragmented care, Commission on Cancer accreditation, and overall survival in patients receiving surgery and chemotherapy for esophageal cancer. Surgery 2024; 175:618-628. [PMID: 37743107 DOI: 10.1016/j.surg.2023.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/21/2023] [Accepted: 07/08/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Increasing regionalization for esophagectomy for cancer may lead patients to travel for surgery at one institution and receive chemotherapy at another closer to home. We explore the effects on survival for care fragmentation, the Commission on Cancer status of secondary institutions providing chemotherapy, and the type of institution performing surgery. METHODS We queried the National Cancer Database to identify all patients who underwent esophagectomy for esophageal cancer and received perioperative chemotherapy between 2006 and 2019. Patients were divided into single-center care, fragmented-to-Commission on Cancer care, or fragmented-to-non-Commission on Cancer care. We identified associations using multivariable logistic regression, Kaplan-Meier survival analyses, and Cox proportional hazards models. RESULTS A total of 18,502 patients met the criteria for inclusion: 8,290 (44.8%) received single-center care; 3,414 (18.5%) fragmented-to-Commission on Cancer care; and 6,798 (36.4%) fragmented-to-non-Commission on Cancer care. Fragmented care was more likely in White patients (adjusted odds ratio = 1.25; P < .001) and in patients nonadjacent to a metropolitan area (adjusted odds ratio = 1.36; P < .001). Overall survival was equivalent between single-center and fragmented care, but undergoing an esophagectomy at an academic center was associated with improved survival (adjusted hazard ratio = 0.82; P = .016). In patients with an esophagectomy at a nonacademic center, overall survival was best if perioperative chemotherapy was administered at Commission on Cancer-accredited facilities compared with chemotherapy at fragmented-to-non-Commission on Cancer centers (P = .022). CONCLUSION Most of the esophageal cancer care in the US is fragmented at multiple institutions. When care is fragmented, it is most commonly at non-Commission on Cancer centers for perioperative chemotherapy. Overall survival is best when esophagectomy is performed at an academic center, and perioperative therapy is administered at Commission on Cancer-accredited facilities.
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Affiliation(s)
- Raymond A Verm
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL. https://twitter.com/RaymondVerm
| | - Marshall M Baker
- Department of Surgery, Edward Hines VA Medical Center, Hines, IL
| | - Tyler Cohn
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL; Department of Surgery, Edward Hines VA Medical Center, Hines, IL
| | - Simon Park
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - James Swanson
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - Richard Freeman
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - Zaid M Abdelsattar
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL; Department of Surgery, Edward Hines VA Medical Center, Hines, IL.
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3
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Woodhouse B, Barreto SG, Soreide K, Stavrou GA, Teh C, Pitt H, Di Martino M, Herman P, Lopez-Lopez V, Berrevoet F, Talamonti M, Mikhnevich M, Khatkov I, Webber L, Kaldarov A, Windsor J, Costa Filho OP, Koea J, Soreide K, Teh C, Stavrou GA, Pitt H, Di Martino M, Herman P, Lopez-Lopez V, Barreto SG, Berrevoet F, Teh C, Talamonti M, Mikhnevich M, Di Martino M, Soreide K, Khatkov I, Webber L, Kaldarov A, Pitt H, Windsor J, Costa Filho OP, Stavrou GA, Teh C, Pitt H, Di Martino M, Stavrou GA, Lopez-Lopez V, Stavrou GA, Barreto SG, Di Martino M, Lopez-Lopez V, Koea J. A core set of quality performance indicators for HPB procedures: a global consensus for hepatectomy, pancreatectomy, and complex biliary surgery. HPB (Oxford) 2023; 25:924-932. [PMID: 37198070 DOI: 10.1016/j.hpb.2023.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/10/2023] [Accepted: 04/18/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Surgery for hepatopancreaticobiliary (HPB) conditions is performed worldwide. This investigation aimed to develop a set of globally accepted procedural quality performance indicators (QPI) for HPB surgical procedures. METHODS A systematic literature review generated a dataset of published QPI for hepatectomy, pancreatectomy, complex biliary surgery and cholecystectomy. Using a modified Delphi process, three rounds were conducted with working groups composed of self-nominating members of the International Hepatopancreaticobiliary Association (IHPBA). The final set of QPI was circulated to the full membership of the IHPBA for review. RESULTS Seven "core" indicators were agreed for hepatectomy, pancreatectomy, and complex biliary surgery (availability of specific services on site, a specialised surgical team with at least two certified HPB surgeons, a satisfactory institutional case volume, synoptic pathology reporting, undertaking of unplanned reintervention procedures within 90 days, the incidence of post-procedure bile leak and Clavien-Dindo grade ≥III complications and 90-day post-procedural mortality). Three further procedure specific QPI were proposed for pancreatectomy, six for hepatectomy and complex biliary surgery. Nine procedure-specific QPIs were proposed for cholecystectomy. The final set of proposed indicators were reviewed and approved by 102 IHPBA members from 34 countries. CONCLUSIONS This work presents a core set of internationally agreed QPI for HPB surgery.
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Affiliation(s)
- Braden Woodhouse
- Department of Oncology, The University of Auckland, Auckland, New Zealand
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Catherine Teh
- Department of Surgery, National Kidney and Transplant Institute, and Department of Surgery, Makati Medical Center and Department of Surgery, St Luke's Medical Center, Metro Manila, Philippines
| | - Henry Pitt
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Jersey, USA
| | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Paulo Herman
- Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Victor Lopez-Lopez
- Clinic and University Virgen de la Arrixaca Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Frederik Berrevoet
- Department for General and HPB Surgery and Liver Transplantation, University Hospital, Ghent, Belgium
| | - Mark Talamonti
- University of Chicago Pritzker School of Medicine, Chicago, USA
| | | | - Igor Khatkov
- Moscow Clinical Scientific Centre, Moscow, Russia
| | | | - Ayrat Kaldarov
- Vishnevsky Centre of Surgery, Ministry of Health, Russia, Moscow, Russian Federation
| | - John Windsor
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Omero P Costa Filho
- Universidade Luterana do Brasil and Hospital Militar de Área de Porto Alegre and Hospital de Clinicas de Porto Alegre, Brazil
| | - Jonathan Koea
- Department of Surgery, The University of Auckland, Auckland, New Zealand.
| | - Kjetil Soreide
- Universidade Luterana do Brasil and Hospital Militar de Área de Porto Alegre and Hospital de Clinicas de Porto Alegre, Brazil; Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Catherine Teh
- Department of Surgery, National Kidney and Transplant Institute, Metro Manila, Philippines; Department of Surgery, Makati Medical Center, Metro Manila, Philippines; Department of Surgery, St Luke's Medical Center, Metro Manila, Philippines
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Henry Pitt
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Jersey, United States of America
| | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Paulo Herman
- Hospital Das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Victor Lopez-Lopez
- Clinic and University Virgen de La Arrixaca Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Frederik Berrevoet
- Department for General and HPB Surgery and Liver Transplantation, University Hospital, Ghent, Belgium
| | - Catherine Teh
- Department of Surgery, National Kidney and Transplant Institute, Philippines; Department of Surgery, Makati Medical Center, Philippines; Department of Surgery, St Luke's Medical Center, Metro Manila, Philippines
| | - Mark Talamonti
- University of Chicago Pritzker School of Medicine, Chicago, United States of America
| | | | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Igor Khatkov
- Moscow Clinical Scientific Centre, Moscow, Russia
| | | | - Ayrat Kaldarov
- Vishnevsky Centre of Surgery, Ministry of Health, Russia, Moscow, Russian Federation
| | - Henry Pitt
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Jersey, United States of America
| | - John Windsor
- The Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Omero P Costa Filho
- Universidade Luterana Do Brazil, Brazil; Hospital Militar de Área de Porto Alegre, Brazil; Hospital de Clinicas de Porto Alegre, Brazil
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Catherine Teh
- Department of Surgery, National Kidney and Transplant Institute, Philippines; Department of Surgery, Makati Medical Center, Philippines; Department of Surgery, St Luke's Medical Center, Metro Manila, Philippines
| | - Henry Pitt
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Jersey, United States of America
| | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Victor Lopez-Lopez
- Clinic and University Virgen de La Arrixaca Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Marcello Di Martino
- Division of Hepatobiliary and Liver Transplantation Surgery, Department of Transplantation Surgery, A.O.R.N. Cardarelli, Napoli, Italy
| | - Victor Lopez-Lopez
- Clinic and University Virgen de La Arrixaca Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Jonathan Koea
- The Department of Surgery, The University of Auckland, Auckland, New Zealand
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Kulasegaran S, Woodhouse B, MacCormick AD, Srinivasa S, Koea J. Quality performance indicators for the surgical treatment of gastric adenocarcinoma: a systematic review. ANZ J Surg 2022; 92:1995-2002. [PMID: 35238137 PMCID: PMC9546246 DOI: 10.1111/ans.17583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 11/28/2022]
Abstract
Background A systematic review was undertaken to identify existing quality performance indicators (QPI) for the surgical treatment of gastric adenocarcinoma (GA) with the aim of defining a set of QPIs that can be used to assist in the accreditation of institutions for training, allow cross jurisdiction comparison of treatment and outcomes, as well as provide a basis to develop quality improvement programs. These QPI's capture key components of patient care that are fundamental to overall outcome. Methods A systematic literature review was conducted searching MEDLINE, PubMed, EMBASE, and SCOPUS with all literature available until the date of 1 August 2021 included. Search terms utilized were ‘Quality of health care OR Quality improvement or Quality control OR Quality indicators’, AND ‘Gastrectomy’ OR ‘Stomach neoplasm’ OR ‘Adenocarcinoma’ OR ‘Gastric resection’ OR ‘Gastric cancer’. Results Twelve articles were included in the final analysis. The selected studies included editorials (n = 2), retrospective review of institutional experience (n = 5), cohort studies (n = 2), survey methodology (n = 1), expert guidelines (n = 1) and consensus statement (n = 1). For GC QPIs, process measures included patient discussion at multi‐disciplinary meetings, access to perioperative multimodal diagnostic pathways, and specific surgical metrics (margin negative resections and adequate lymphadenectomy). Outcome measures included the RO resection rate, reoperation, readmission rate, and length of hospital stay. Conclusions There is a relative paucity of internationally agreed QPI for the surgical management of gastric adenocarcinoma. The data from this review will form the basis of a project to develop internationally agreed and feasible QPI for gastric cancer resections.
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Affiliation(s)
| | - Braden Woodhouse
- Discipline of Oncology, School of Medical Sciences, The University of Auckland, Auckland, New Zealand
| | | | - Sanket Srinivasa
- The Department of Surgery, North Shore Hospital, Auckland, New Zealand
| | - Jonathan Koea
- The Department of Surgery, North Shore Hospital, Auckland, New Zealand
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5
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Woodhouse B, Panesar D, Koea J. Quality performance indicators for hepato-pancreatico-biliary procedures: a systematic review. HPB (Oxford) 2021; 23:1-10. [PMID: 33158749 DOI: 10.1016/j.hpb.2020.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 09/03/2020] [Accepted: 10/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND This systematic review was undertaken to define and summarize existing, proposed quality performance indicators (QPI) for hepato-pancreatico-biliary (HPB) procedures. METHODS A systematic literature review identified studies reporting on quality indicators for cholecystectomy, hepatectomy, pancreatectomy and complex biliary surgical procedures. The databases searched were MEDLINE, EMBASE, PubMed, and SCOPUS, with all literature available until the search date of 1 May 2020 included. The reference lists of all included papers, as well as related review articles, were manually searched to identify further relevant studies. RESULTS Forty-five publications report quality indicators for pancreatectomy (n = 22), hepatectomy (n = 7), HPB resections in general (n = 12), and cholecystectomy (n = 6). No publications proposed QPI for complex biliary surgery. The 45 papers used national audit (n = 18), consensus methodology (n = 5), state-wide audit (n = 3), unit audit (n = 9), review methodology (n = 9), and survey methodology (n = 1). Sixty-one QPI were reported for pancreatectomy, 22 reported for hepatectomy, and 14 reported for HPB resections in general, in domains of infrastructure, provider, and documentation. Fourteen infrastructure and provider-based QPI were reported for cholecystectomy. CONCLUSIONS There are few internationally agreed QPI for HPB procedures that allow global comparison of provider performance and that set aspirational goals for patient care and experience.
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Affiliation(s)
- Braden Woodhouse
- The Discipline of Oncology, School of Medical Sciences, The University of Auckland, Auckland, New Zealand
| | - Divyansh Panesar
- Department of Surgery, North Shore Hospital, Private Bag, Auckland, New Zealand
| | - Jonathan Koea
- Department of Surgery, North Shore Hospital, Private Bag, Auckland, New Zealand.
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6
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Are Volume Pledge Standards Worth the Travel Burden for Major Abdominal Cancer Operations? Ann Surg 2020; 275:e743-e751. [PMID: 33074899 DOI: 10.1097/sla.0000000000004361] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The study objective is to determine the association between travel distance and surgical volume on outcomes after esophageal, pancreatic, and rectal cancer resections. SUMMARY OF BACKGROUND DATA "Take the Volume Pledge" aims to centralize esophagectomies, pancreatectomies, and proctectomies to hospitals meeting minimum volume standards. The impact of travel, and possible care fragmentation, on potential benefits of centralized surgery is not well understood. METHODS Using the National Cancer Database (2004-2016), patients who underwent esophageal, pancreatic, or rectal resections at far HVH meeting volume standards versus local intermediate (IVH) and low-volume (LVH) hospitals were identified. Perioperative outcomes and 5-year OS were compared. RESULTS Of 49,454 patients, 17,544 (34.5%) underwent surgery at far HVH, 11,739 (23.7%) at local IVH, and 20,171 (40.8%) at local LVH. The median (interquartile range) travel distances were 77.1 (51.1-125.4), 13.2 (5.8-27.3), and 7.8 (3.1-15.5) miles to HVH, IVH, and LVH, respectively. By multivariable analysis, LVH was associated with increased 30-day mortality for all resections compared to HVH, but IVH was associated with mortality only for proctectomies [odds ratio 1.90, 95% confidence interval (CI) 1.31-2.75]. Compared to HVH, both IVH (hazard ratio 1.25, 95% CI 1.19-1.31) and LVH (hazard ratio 1.35, 95% CI 1.29-1.42) were associated with decreased 5-year OS. CONCLUSIONS Compared to far HVH, 30-day mortality was higher for all resections at LVH, but only for proctectomies at IVH. Five-year OS was consistently worse at local LVH and IVH. Improving long-term outcomes at IVH may provide opportunities for greater access to quality cancer care.
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Song Y, Tieniber AD, Roses RE, Fraker DL, Kelz RR, Karakousis GC. National trends in centralization and perioperative outcomes of complex operations for cancer. Surgery 2019; 166:800-811. [PMID: 31230839 DOI: 10.1016/j.surg.2019.03.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/02/2019] [Accepted: 03/29/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Complex cancer operations performed at high-volume and teaching hospitals have been associated with better outcomes. The purpose of this study was to determine the national trends in the performance of these operations at large teaching hospitals. METHODS Patients who underwent elective esophagectomies, gastrectomies, pancreatectomies, and hepatectomies for cancer (2003-2015) were identified using the National Inpatient Sample. We determined average annual percent change (AAPC) in the proportion of operations at large teaching hospitals, inpatient complications, length of stay (LOS), and inpatient mortality. RESULTS Between 2003 and 2015, 38,932 esophageal, 104,941 gastric, 96,098 hepatic, and 137,440 pancreatic cancer resections were performed. The proportion at large teaching hospitals increased with an AAPC of 2.5 for esophagectomies (P < .001), 3.6 for gastrectomies (P < .001), and 1.5 for pancreatectomies (P = .039), but did not change for hepatectomies (AAPC 0.48, P = .50). During the study period, mean LOS and inpatient mortality rates at large teaching hospitals decreased across hospital types. By 2013 to 2015, the operations at large hospitals were associated with decreased mortality only for pancreatectomies (odds ratio, 0.62, 95% confidence interval, 0.43-0.91, P = .015). CONCLUSIONS Complex cancer operations are performed increasingly at large teaching hospitals, but perioperative outcomes have improved nationally across hospital types. Further studies should identify actionable areas for improvement to ensure accessible quality cancer care.
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Affiliation(s)
- Yun Song
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Andrew D Tieniber
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
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8
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McCarthy AJ, Rouzbahman M, Thiryayi SA, Chapman WB, Clarke BA. Neoadjuvant therapy in gynaecological malignancies: What pathologists need to know. J Clin Pathol 2019; 72:102-111. [PMID: 30670562 DOI: 10.1136/jclinpath-2018-205634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 11/04/2022]
Abstract
In recent times, there has been a growing tendency to treat advanced gynaecological malignancies with neoadjuvant chemotherapy (NACT), with the goal of reducing tumour volume and enhancing operability resulting in optimal cytoreduction. This approach is used in particular for patients with advanced high-grade serous carcinoma of the ovary, fallopian tube or peritoneum. Pathology plays a crucial role in the management of these patients, both before and after NACT. Prior to initiation of NACT, a biopsy should be performed, usually of the omental cake, to confirm that a malignancy is present, to identify the site of origin of the tumour and to type and grade the tumour. Histopathologists must be aware of the resultant morphological effects of NACT when examining specimens following interval cytoreduction surgery. Tumour typing and grading, and even the identification of residual neoplasia, are particular challenges. Immunohistochemistry, when used judiciously, can be a useful adjunct in certain scenarios. A pathological assessment of the response to chemotherapy, and the pathological stage should be provided in the pathology report, as these may inform prognosis and subsequent management. We present a comprehensive overview of the relevant clinical and pathological aspects pertaining to NACT for gynaecological malignancies for the practicing surgical pathologist.
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Affiliation(s)
- Aoife J McCarthy
- Department of Anatomical Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada .,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marjan Rouzbahman
- Department of Anatomical Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sakinah A Thiryayi
- Department of Anatomical Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - William B Chapman
- Department of Anatomical Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Blaise A Clarke
- Department of Anatomical Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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9
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Wylie N, Hider P, Armstrong D, Srinivasa S, Rodgers M, Brown A, Koea J. The volume, cost and outcomes of pancreatic resection in a regional centre in New Zealand. ANZ J Surg 2017; 88:1258-1262. [DOI: 10.1111/ans.13984] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/13/2017] [Accepted: 02/19/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Neil Wylie
- Upper Gastrointestinal Unit, Department of Surgery; North Shore Hospital; Auckland New Zealand
| | - Phillip Hider
- Department of Population Health; University of Otago; Christchurch New Zealand
| | - Delwyn Armstrong
- Upper Gastrointestinal Unit, Department of Surgery; North Shore Hospital; Auckland New Zealand
| | - Sanket Srinivasa
- Upper Gastrointestinal Unit, Department of Surgery; North Shore Hospital; Auckland New Zealand
| | - Michael Rodgers
- Upper Gastrointestinal Unit, Department of Surgery; North Shore Hospital; Auckland New Zealand
| | - Anna Brown
- Upper Gastrointestinal Unit, Department of Surgery; North Shore Hospital; Auckland New Zealand
| | - Jonathan Koea
- Upper Gastrointestinal Unit, Department of Surgery; North Shore Hospital; Auckland New Zealand
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10
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Kaur G, Willsmore T, Gulati K, Zinonos I, Wang Y, Kurian M, Hay S, Losic D, Evdokiou A. Titanium wire implants with nanotube arrays: A study model for localized cancer treatment. Biomaterials 2016; 101:176-88. [PMID: 27289379 DOI: 10.1016/j.biomaterials.2016.05.048] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 03/21/2016] [Accepted: 05/27/2016] [Indexed: 12/11/2022]
Abstract
Adverse complications associated with systemic administration of anti-cancer drugs are a major problem in cancer therapy in current clinical practice. To increase effectiveness and reduce side effects, localized drug delivery to tumour sites requiring therapy is essential. Direct delivery of potent anti-cancer drugs locally to the cancer site based on nanotechnology has been recognised as a promising alternative approach. Previously, we reported the design and fabrication of nano-engineered 3D titanium wire based implants with titania (TiO2) nanotube arrays (Ti-TNTs) for applications such as bone integration by using in-vitro culture systems. The aim of present study is to demonstrate the feasibility of using such Ti-TNTs loaded with anti-cancer agent for localized cancer therapy using pre-clinical cancer models and to test local drug delivery efficiency and anti-tumour efficacy within the tumour environment. TNF-related apoptosis-inducing ligand (TRAIL) which has proven anti-cancer properties was selected as the model drug for therapeutic delivery by Ti-TNTs. Our in-vitro 2D and 3D cell culture studies demonstrated a significant decrease in breast cancer cell viability upon incubation with TRAIL loaded Ti-TNT implants (TRAIL-TNTs). Subcutaneous tumour xenografts were established to test TRAIL-TNTs implant performance in the tumour environment by monitoring the changes in tumour burden over a selected time course. TRAIL-TNTs showed a significant regression in tumour burden within the first three days of implant insertion at the tumour site. Based on current experimental findings these Ti-TNTs wire implants have shown promising capacity to load and deliver anti-cancer agents maintaining their efficacy for cancer treatment.
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Affiliation(s)
- Gagandeep Kaur
- School of Chemical Engineering, The University of Adelaide, Adelaide, SA, 5005, Australia; School of Medicine, Discipline of Surgery, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Tamsyn Willsmore
- School of Medicine, Discipline of Surgery, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Karan Gulati
- School of Chemical Engineering, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Irene Zinonos
- School of Medicine, Discipline of Surgery, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Ye Wang
- School of Chemical Engineering, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Mima Kurian
- School of Chemical Engineering, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Shelley Hay
- School of Medicine, Discipline of Surgery, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Dusan Losic
- School of Chemical Engineering, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Andreas Evdokiou
- School of Medicine, Discipline of Surgery, The University of Adelaide, Adelaide, SA, 5005, Australia.
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Butler J, Gildea C, Poole J, Meechan D, Nordin A. Specialist surgery for ovarian cancer in England. Gynecol Oncol 2015; 138:700-6. [PMID: 25839910 DOI: 10.1016/j.ygyno.2015.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 03/04/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the impact of the 1999 national recommendations for ovarian cancer surgery in England to be performed by specialist surgeons in specialist centres. METHODS A retrospective analysis of English cancer registry records, Hospital Episode Statistics (HES) data for all English NHS providers and General Medical Council (GMC) sub-specialty accreditation, to consider changes to the annual proportion of ovarian cancer (ICD10 C56-C57) patients undergoing major gynaecological surgery in gynaecological cancer centres (GCCs) or by specialist gynaecological oncologists (GOs). RESULTS From 2000 to 2009, 2428 consultants were responsible for surgery on 30,753 patients. There were significant increases in the proportions of patients undergoing surgery at GCCs (43% to 76%, P<0.001), by GMC accredited GOs (5% to 36%, P<0.001), and by high ovarian cancer caseload (≥18 cases) surgeons (22% to 56%, P<0.001). CONCLUSION There have been increased centralisation and specialisation of surgery for ovarian cancer patients since the NHS Cancer Plan (2000) and there has also been improved survival. However, by 2009, many ovarian cancer patients were still not receiving specialist surgery; the majority of patients were not operated on by GMC accredited gynaecological oncologists and there was considerable regional variation. Systems of accreditation should be reviewed and trusts should ensure that HES data accurately records clinical activity.
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Affiliation(s)
- John Butler
- Department of Gynaecological Oncology, Royal Marsden Hospital, London SW3 6JJ, UK.
| | - Carolynn Gildea
- Public Health England Knowledge & Intelligence Team (East Midlands), 5 Old Fulwood Road, Sheffield S10 3TG, UK
| | - Jason Poole
- Public Health England Knowledge & Intelligence Team (East Midlands), 5 Old Fulwood Road, Sheffield S10 3TG, UK
| | - David Meechan
- Public Health England Knowledge & Intelligence Team (East Midlands), 5 Old Fulwood Road, Sheffield S10 3TG, UK
| | - Andrew Nordin
- East Kent Gynaecological Centre, East Kent Hospitals University NHS Foundation Trust, QEQM Hospital, St Peters Road, Margate, Kent, UK; Gynaecological Site Specific Clinical Reference Group (SSCGR), National Cancer Intelligence Network (NCIN), 5th Floor, Wellington House, 133-155 Waterloo Road, London SE1 8UG, UK
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12
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Stratilatovas E, Baušys A, Baušys R, Sangaila E. Mortality after gastrectomy: a 10 year single institution experience. Acta Chir Belg 2015; 115:123-130. [PMID: 26021945 DOI: 10.1080/00015458.2015.11681081] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the general postoperative mortality rate after gastrectomy is decreasing worldwide, it still varies in individual centers and regions of the world. The objective of our work was to analyze the postoperative mortality rate at the Institute of Oncology, Vilnius University over a period of 10 years. METHODS All patients who underwent total and subtotal gastrectomy for gastric cancer between 2003-2012 were retrospectively analyzed. Comprehensive evaluation of postoperative mortality was done according to the age, sex, comorbidities, BMI, tumor stage, extent or resection and lymphadenectomy, splenectomy, neoadjuvant chemotherapy and stage of disease. The causes of death were also analyzed. RESULTS The analysis of postoperative mortality for patients treated for gastric cancer in the period of 2003-2012 revealed that 1676 surgeries were performed with 54 lethal outcomes (3.22%). Complication rate was 20.58%. 1011 subtotal gastrectomies were performed with 24 lethal cases (2.37%). 30 patients died after 665 total gastrectomies (4.51%). The vast majority of deceased patients were older than 60 years (92.6%) and had advanced gastric cancer--stage III and IV (70.4%). 33 of 54 patients died from non-surgical complications (61.1%). Surgical complications accounted for 35.2% of dead patients, which totals 19 of 54 patients. Progression of cancer and cachexia caused the deaths of 3.7% of patients. CONCLUSIONS Elderly age, comorbidities, advanced stage of tumor and disease, and more radical surgery are related with higher postoperative mortality. The most common cause of death was pulmonary arterial thromboembolism. Therefore, risk assessment of venous thrombosis and thromboembolism prophylaxis should be an important component of gastric cancer surgical treatment.
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Affiliation(s)
- E Stratilatovas
- Centre of Abdominal Surgery, Vilnius University Hospital Santariskiu Clinics, Vilnius, Lithuania
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Wei AC, Urbach DR, Devitt KS, Wiebe M, Bathe OF, McLeod RS, Kennedy ED, Baxter NN. Improving quality through process change: a scoping review of process improvement tools in cancer surgery. BMC Surg 2014; 14:45. [PMID: 25038587 PMCID: PMC4112620 DOI: 10.1186/1471-2482-14-45] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 07/14/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgery is a cornerstone of treatment for malignancy. However, significant variation has been reported in patterns and quality of cancer care for important health outcomes, including perioperative mortality. Surgical process improvement tools (SPITs) have been developed that focus on enhancing the processes of care at the point of care, as a means of quality improvement. This study describes SPITs and develops a conceptual framework by synthesizing the available literature on these novel quality improvement tools. METHODS A scoping review was conducted based on instruments developed for quality improvement in surgery. The search was executed on electronically indexed sources (MEDLINE, EMBASE, and the Cochrane library) from January 1990 to March 2011. Data were extracted, tabulated and reported thematically using a narrative synthesis approach. These results were used to develop a conceptual framework that describes and classifies SPITs. RESULTS 232 articles were reviewed for data extraction and analysis. SPITs identified were classified into 3 groups: clinical mapping tools, structure communication tools and error reduction instruments. The dominant instrument reported were clinical mapping tools, including: clinical pathways (113, 48%), fast track (46, 20%) and enhanced recovery after surgery protocols (36, 15%). Outcomes reported included: length of stay (174, 75%), readmission rates (116, 50%), morbidity (116, 50%), mortality (104, 45%), and economic (60, 26%). Many gaps in the literature were recognized. CONCLUSION We have developed a conceptual framework of SPITs and identified gaps in current knowledge. These results will guide the design and development of new quality instruments in surgery.
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Affiliation(s)
- Alice C Wei
- Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - David R Urbach
- Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Katharine S Devitt
- Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Meagan Wiebe
- Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Oliver F Bathe
- Department of Surgery and Oncology, University of Calgary, Calgary, AB, Canada
| | - Robin S McLeod
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of General Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Erin D Kennedy
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of General Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of General Surgery, St. Michael’s Hospital, Toronto, ON, Canada
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Hicks CW, Frank SM, Wasey JO, Efron J, Gearhart S, Fang S, Safar B, Makary MA, Wick EC. A Novel Means of Assessing Institutional Adherence to Blood Transfusion Guidelines. Am J Med Qual 2014; 30:584-90. [DOI: 10.1177/1062860614542972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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16
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Piccoli M, Agresta F, Trapani V, Nigro C, Pende V, Campanile FC, Vettoretto N, Belluco E, Bianchi PP, Cavaliere D, Ferulano G, La Torre F, Lirici MM, Rea R, Ricco G, Orsenigo E, Barlera S, Lettieri E, Romano GM, Ferulano G, Giuseppe F, La Torre F, Filippo LT, Lirici MM, Maria LM, Rea R, Roberto R, Ricco G, Gianni R, Orsenigo E, Elena O, Barlera S, Simona B, Lettieri E, Emanuele L, Romano GM, Maria RG. Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference. Int J Colorectal Dis 2014; 29:863-75. [PMID: 24820678 DOI: 10.1007/s00384-014-1887-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome. METHOD An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM). RESULTS AND CONCLUSION The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.
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Wilson NP, Wilson FP, Neuman M, Epstein A, Bell R, Armstrong K, Murayama K. Determinants of surgical decision making: a national survey. Am J Surg 2014; 206:970-7; discussion 977-8. [PMID: 24296100 DOI: 10.1016/j.amjsurg.2013.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 08/28/2013] [Accepted: 08/29/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND We conducted a national survey of general surgeons to address the association between surgeon characteristics and the tendency to recommend surgery. METHODS We used a web-based survey with 25 hypothetical clinical scenarios with clinical equipoise regarding the decision to operate. The respondent-level tendency to operate (TTO) score was calculated as the average score over the 25 scenarios. Surgical volume was based on self-report. Linear regression models were used to evaluate the associations between TTO, other covariates of interest, and surgical volume. RESULTS There were 907 respondents. The mean surgical TTO was 3.05 ± .43. Surgeons had significantly lower TTO scores when responding to questions within their area of practice (P < .0001). There was no association between TTO and malpractice concerns, financial incentives, or compensation structure. CONCLUSIONS Surgeons recommend intervention far less frequently within their area of specialization. Malpractice concerns, volume, and financial compensation do not significantly affect surgical decision making.
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Affiliation(s)
- Niamey P Wilson
- Robert Wood Johnson Clinical Scholars Program, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, West Pavilion, 3rd Floor, Philadelphia, PA 19104, USA; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Okabe T, Frisch DR. Device implantation complications during fellowship training: it is always the fellow's fault, or is it? Heart Rhythm 2013; 10:1759-60. [PMID: 24055939 DOI: 10.1016/j.hrthm.2013.09.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Indexed: 11/25/2022]
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Shah N, Hamilton M. Clinical review: Can we predict which patients are at risk of complications following surgery? Crit Care 2013; 17:226. [PMID: 23672931 PMCID: PMC3672530 DOI: 10.1186/cc11904] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
There are a vast number of operations carried out every year, with a small proportion of patients being at highest risk of mortality and morbidity. There has been considerable work to try and identify these high-risk patients. In this paper, we look in detail at the commonly used perioperative risk prediction models. Finally, we will be looking at the evolution and evidence for functional assessment and the National Surgical Quality Improvement Program (in the USA), both topical and exciting areas of perioperative prediction.
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Affiliation(s)
- Nirav Shah
- General Intensive Care Unit, St George's Hospital, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Mark Hamilton
- General Intensive Care Unit, St George's Hospital, Blackshaw Road, Tooting, London, SW17 0QT, UK
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20
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Nordby T, Ikdahl T, Lothe IMB, Ånonsen K, Hauge T, Edwin B, Line PD, Labori KJ, Buanes T. Opportunities of improvement in the management of pancreatic and periampullary tumors. Scand J Gastroenterol 2013; 48:617-625. [PMID: 23597153 PMCID: PMC3665210 DOI: 10.3109/00365521.2013.781218] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 02/21/2013] [Accepted: 02/22/2013] [Indexed: 02/05/2023]
Abstract
Abstract Objective. The first objective of the present study was to identify opportunities of improvement for clinical practice, assessed by local quality indicators, then to analyze possible reasons why we did not reach defined treatment quality measures. The second objective was to characterize patients, considered unresectable according to present criteria, for future arrangement of interventional studies with improved patient selection. Material and methods. Prospective observational cohort study from October 2008 to December 2010 of patients referred to the authors' institution with suspected pancreatic or periampullary neoplasm. Results. Of 330 patients, 135 underwent surgery, 195 did not, 129 due to unresectable malignancies. The rest had benign lesions. Perioperative morbidity rate was 32.6%, mortality 0.7%. Radical resection (R0) was obtained in 23 (41.8%) of 55 patients operated for pancreatic adenocarcinoma and 6.3% underwent reconstructive vascular surgery. Diagnostic failure/delay resulted in unresectable carcinoma, primarily misconceived as serous cystic adenoma in two patients. One resected lesion turned out to be focal autoimmune pancreatitis. One case with misdiagnosed cancer was revised to be a pseudoaneurysm. Palliative treatment was offered to 144 patients with malignant tumors, 62 due to locally advanced disease and all pancreatic adenocarcinomas. Conclusions. Quality improvement opportunities were identified for patient selection and surgical technique: Too few patients underwent reconstructive vascular surgery. The most important quality indicators are those securing resectional, radical (R0) surgery. Altogether 143 patients (57.9%) of those with malignant tumors were found unresectable, most of these patients are eligible for inclusion in future interventional studies with curative and/or palliative intention.
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Affiliation(s)
- Tom Nordby
- Department of Gastroenterological Surgery, Division of Cancer, Surgery and Transplantation, Oslo University Hospital (OuS), Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tone Ikdahl
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Kim Ånonsen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Edwin
- The Interventional Centre, Oslo University Hospital, Oslo, Norway
| | - Pål-Dag Line
- Department of Gastroenterological Surgery, Division of Cancer, Surgery and Transplantation, Oslo University Hospital (OuS), Oslo, Norway
| | - Knut Jørgen Labori
- Department of Gastroenterological Surgery, Division of Cancer, Surgery and Transplantation, Oslo University Hospital (OuS), Oslo, Norway
| | - Trond Buanes
- Department of Gastroenterological Surgery, Division of Cancer, Surgery and Transplantation, Oslo University Hospital (OuS), Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Israels T, Moreira C, Scanlan T, Molyneux L, Kampondeni S, Hesseling P, Heij H, Borgstein E, Vujanic G, Pritchard-Jones K, Hadley L. SIOP PODC: clinical guidelines for the management of children with Wilms tumour in a low income setting. Pediatr Blood Cancer 2013; 60:5-11. [PMID: 23015404 DOI: 10.1002/pbc.24321] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 08/16/2012] [Indexed: 12/27/2022]
Abstract
Wilms tumour is a relatively common and curable paediatric tumour. Known challenges to cure in low income countries are late presentation with advanced disease, malnutrition, failure to complete treatment and limited facilities. In this article, management recommendations are given for a low income setting where only the minimal requirements for treatment with curative intent are available (setting 1). These include general management, supportive care, social support and registration of patients. Recommendations specific for Wilms tumour care include diagnostic procedures with emphasis on the role of ultrasonography, preoperative chemotherapy with a reduced dosage for malnourished children and postoperative chemotherapy based on surgical staging.
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Affiliation(s)
- Trijn Israels
- Department of Paediatric Oncology, VU University Medical Center, Amsterdam, The Netherlands.
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Visser BC, Ma Y, Zak Y, Poultsides GA, Norton JA, Rhoads KF. Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes. HPB (Oxford) 2012; 14:539-47. [PMID: 22762402 PMCID: PMC3406351 DOI: 10.1111/j.1477-2574.2012.00496.x] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION There are little data available regarding compliance with the National Comprehensive Cancer Network (NCCN) guidelines. We investigated variation in the management of pancreatic cancer (PC) among large hospitals in California, USA, specifically to evaluate whether compliance with NCCN guidelines correlates with patient outcomes. METHODS The California Cancer Registry was used to identify patients treated for PC from 2001 to 2006. Only hospitals with ≥ 400 beds were included to limit evaluation to centres possessing resources to provide multimodality care (n= 50). Risk-adjusted multivariable models evaluated predictors of adherence to stage-specific NCCN guidelines for PC and mortality. RESULTS In all, 3706 patients were treated for PC in large hospitals during the study period. Compliance with NCCN guidelines was only 34.5%. Patients were less likely to get recommended therapy with advanced age and low socioeconomic status (SES). Using multilevel analysis, controlling for patient factors (including demographics and comorbidities), hospital factors (e.g. size, academic affiliation and case volume), compliance with NCCN guidelines was associated with a reduced risk of mortality [odds ratio (OR) for death 0.64 (0.53-0.77, P < 0.0001)]. CONCLUSIONS There is relatively poor overall compliance with the NCCN PC guidelines in California's large hospitals. Higher compliance rates are correlated with improved survival. Compliance is an important potential measure of the quality of care.
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Affiliation(s)
- Brendan C Visser
- Department of Surgery, Stanford University Medical Center, CA 94305-5641, USA.
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Abstract
AIM The review aimed to offer a contemporary perspective of the quality of current colorectal surgery. METHOD A literature search was undertaken to identify relevant indicators. Citations were included if they related to quality in colorectal surgery. The search terms used included the Medical Subject Heading terms and Boolean characters: 'colon' OR 'colorectal', OR 'rectal' OR 'rectum' AND 'Quality Indicators', OR 'Quality Assurance', OR 'Quality of healthcare', OR 'Reference Standards', OR 'Quality' plus a variable floating term. A two-person independent review was undertaken from resulting citations and their consequent reference lists. The search was limited to citations from 2000 to 2010 in humans and to the English language. RESULTS Metrics identified as potential quality indicators in colorectal surgery are discussed according to the structure, process and outcome framework. CONCLUSION A clear appreciation of the scope of individual metrics for quality appraisal purposes is necessary if they are to be used meaningfully for performance benchmarking.
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Affiliation(s)
- A M Almoudaris
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
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Raval MV, Bilimoria KY, Talamonti MS. Quality improvement for pancreatic cancer care: is regionalization a feasible and effective mechanism? Surg Oncol Clin N Am 2010; 19:371-90. [PMID: 20159520 DOI: 10.1016/j.soc.2009.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Variability exists in the quality of pancreatic cancer care provided in the United States. High-volume centers have been shown to have improved outcomes for pancreatectomy. Regionalization of pancreatic cancer care to high-volume centers has the potential to improve care and outcomes. Practical limitations such as overloading currently available high-volume centers, extending patient travel times, sharing patients within a multipayer health system, and incorporating patient preferences must be addressed for regionalization to become a reality. The benefits and limitations of regionalization of pancreatic cancer care are discussed in this review. To improve the overall quality of pancreatic cancer care at all hospitals in the United States, a combination of referral of patients with pancreatic cancer to high- and moderate-volume hospitals in conjunction with specific quality-improvement efforts at those institutions is proposed.
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Affiliation(s)
- Mehul V Raval
- Department of Surgery, Northwestern University, 251 East Huron Street, Galter 3-150, Chicago, IL 60611, USA
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Gregoire E, Hoti E, Gorden DL, de la Serna S, Pascal G, Azoulay D. Utility or futility of prognostic scoring systems for colorectal liver metastases in an era of advanced multimodal therapy. Eur J Surg Oncol 2010; 36:568-74. [PMID: 20413243 DOI: 10.1016/j.ejso.2010.03.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Revised: 01/19/2010] [Accepted: 03/22/2010] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES To assess the general applicability of prognostic scores for colorectal liver metastases (CRLM). METHODS Review of English language studies from 1980 to 2008 (Medline and Embase). Search keywords included "Colorectal neoplasms", "liver metastases", "liver resection", "prognostic scoring system". RESULTS Six scoring systems and fourteen prognostic factors within these studies were identified. No prognostic factor was common in all scoring methods. Five scores retained the number of metastases as a prognostic factor. Size of metastases and time between the onset of the primary tumor and the discovery of metastases were present in four scores. Three scores predicted 5-year survival using carcinoembryonic antigen (CEA) and R1 resection. Only two scores were assessed preoperatively. Successive scoring methods had improved predictive accuracy compared to earlier systems. However, their applicability in general populations remains debatable. An evaluation of the scores applicability to different patient populations demonstrated that the models were minimally effective in predicting disease-specific survival and recurrence, suggesting that stratification of patients by clinical and pathologic factors alone, may be clinically unreliable and not applicable for selection of patients for surgery. CONCLUSION The utility of prognostic models on general populations is inconsistent. Current clinicopathologic factors may be inadequate to determine disease prognosis in CRLM. Future attempts to develop prognostic scores should include additional biologic and clinical variables, and be validated in larger populations.
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Affiliation(s)
- E Gregoire
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12-14 Avenue Paul Vaillant Couturier, F-94804 Villejuif, France
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Faiz O, Brown T, Bottle A, Burns EM, Darzi AW, Aylin P. Impact of hospital institutional volume on postoperative mortality after major emergency colorectal surgery in English National Health Service Trusts, 2001 to 2005. Dis Colon Rectum 2010; 53:393-401. [PMID: 20305437 DOI: 10.1007/dcr.0b013e3181cc6fd2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this study was to investigate the effects of institutional volume on postoperative mortality in patients undergoing emergency major colorectal surgical procedures in England between 2001 and 2005. METHODS All of the emergency excisional colorectal procedures performed between the above dates were included from the Hospital Episode Statistics data set. Institutions were divided into high-, medium-, and low-volume tertiles according to the total major emergency colorectal caseload. RESULTS During the study period, 37,094 emergency excisional colorectal procedures were performed in 166 English National Health Service institutions. Overall 30-day postoperative mortality was 15.49%, increasing to 29.18% at 1 year after surgery. Overall 30- and 365-day mortality rates were similar among institutional volume tertiles (P > .05) after adjustment for age, sex, social deprivation, diagnosis, procedure type, and comorbidity score. CONCLUSION Hospital Episode Statistics data suggest that institutions with high volumes of emergency colorectal caseload do not demonstrate lower mortality after emergency major excisional colorectal surgery.
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Affiliation(s)
- Omar Faiz
- Department of Biosurgery and Surgical Technology, St. Mary's Hospital, London,
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Kelly KJ, Wong J, Gladdy R, Moore-Dalal K, Woo Y, Gonen M, Brennan M, Allen P, Fong Y, Coit D. Prognostic impact of RT-PCR-based detection of peritoneal micrometastases in patients with pancreatic cancer undergoing curative resection. Ann Surg Oncol 2009; 16:3333-9. [PMID: 19763694 DOI: 10.1245/s10434-009-0683-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2009] [Revised: 07/29/2009] [Accepted: 07/29/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Positive peritoneal fluid cytology predicts poor outcome in patients with resected pancreatic cancer. Reverse transcription-polymerase chain reaction (RT-PCR) has been proposed as a more sensitive means of detection of peritoneal micrometastases than conventional cytology. The clinical significance of RT-PCR positivity in the absence of other evidence of peritoneal disease is unknown. The purpose of the current study was to determine the outcome RT-PCR positive/cytology-negative patients who underwent potentially curative resection. METHODS Peritoneal washings were collected prospectively from 115 patients with pancreatic cancer undergoing diagnostic laparoscopy at a single institution. Specimens were analyzed by a cytopathologist and by RT-PCR for carcinoembryonic antigen (CEA). RESULTS Of the 115 patients, 62 (54%) underwent R0 resection. Eleven of the 62 patients (18%) had peritoneal washings that were negative by conventional cytology but positive for CEA by RT-PCR. Those 11 patients experienced early peritoneal and overall disease recurrence versus those who were RT-PCR negative (P = 0.001, P = 0.003, respectively) independent of nodal status. CONCLUSIONS RT-PCR for CEA is a sensitive and specific method for the detection of clinically significant peritoneal micrometastases from pancreatic cancer and it might identify a subgroup of patients with otherwise negative findings at staging laparoscopy who might respond better to treatment other than primary surgical resection.
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Affiliation(s)
- Kaitlyn J Kelly
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Abstract
INTRODUCTION Risk stratification in major colorectal surgery, in general, has used preoperative, intraoperative, and postoperative variables, and has been used for purposes of comparative audit. To enable preoperative clinical use, this study aimed to stratify risk by use of preoperative risk factors only. METHODS This is a single-institutional prospective observational study. RESULTS There were 887 major colorectal procedures assessed. Independent risk factors for mortality were American Society of Anesthesiologists' physical status Grades III to V, age, high comorbidity count, and low surgeon case volume. For major morbidity, risk factors were American Society of Anesthesiologists' Grades III to V, urgent operation, and operation to excise the rectum. Overall, mortality was 4.51%, and major morbidity was 19.6%. The estimated risk of mortality was stratified by risk factor profile from 0.12% (95% CI, 0.02-0.93) to 42.4% (95% CI, 23.5-63.9). The risk of major morbidity was stratified from 7.22% (95% CI, 4.82-10.7) to 49.2% (95% CI, 34.2-64.4). Model discrimination was favorable to the existing risk adjustment models applied to our cohort. The Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (including Portsmouth and ColoRectal modifications), and Association of ColoProctology of Great Britain and Ireland Colorectal Cancer models (mortality: area under receiver operating characteristic (AU ROC) curves 0.87 compare 0.70-0.81, major morbidity: 0.69 compare 0.66)). CONCLUSIONS Simple and readily available preoperative risk factors can achieve risk stratification. Risk stratification based on preoperative risk factors only possibly has comparable efficacy with those models that use preoperative, intraoperative, and postoperative risk factors.
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Bilimoria KY, Bentrem DJ, Lillemoe KD, Talamonti MS, Ko CY. Assessment of pancreatic cancer care in the United States based on formally developed quality indicators. J Natl Cancer Inst 2009; 101:848-59. [PMID: 19509366 PMCID: PMC2697207 DOI: 10.1093/jnci/djp107] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2008] [Revised: 03/08/2009] [Accepted: 04/03/2009] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pancreatic cancer outcomes vary considerably among hospitals. Assessing pancreatic cancer care by using quality indicators could help reduce this variability. However, valid quality indicators are not currently available for pancreatic cancer management, and a composite assessment of the quality of pancreatic cancer care in the United States has not been done. METHODS Potential quality indicators were identified from the literature, consensus guidelines, and interviews with experts. A panel of 20 pancreatic cancer experts ranked potential quality indicators for validity based on the RAND/UCLA Appropriateness Methodology. The rankings were rated as valid (high or moderate validity) or not valid. Adherence with valid indicators at both the patient and the hospital levels and a composite measure of adherence at the hospital level were assessed using data from the National Cancer Data Base (2004-2005) for 49 065 patients treated at 1134 hospitals. Summary statistics were calculated for each individual candidate quality indicator to assess the median ranking and distribution. RESULTS Of the 50 potential quality indicators identified, 43 were rated as valid (29 as high and 14 as moderate validity). Of the 43 valid indicators, 11 (25.6%) assessed structural factors, 19 (44.2%) assessed clinical processes of care, four (9.3%) assessed treatment appropriateness, four (9.3%) assessed efficiency, and five (11.6%) assessed outcomes. Patient-level adherence with individual indicators ranged from 49.6% to 97.2%, whereas hospital-level adherence with individual indicators ranged from 6.8% to 99.9%. Of the 10 component indicators (contributing 1 point each) that were used to develop the composite score, most hospitals were adherent with fewer than half of the indicators (median score = 4; interquartile range = 3-5). CONCLUSIONS Based on the quality indicators developed in this study, there is considerable variability in the quality of pancreatic cancer care in the United States. Hospitals can use these indicators to evaluate the pancreatic cancer care they provide and to identify potential quality improvement opportunities.
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Affiliation(s)
- Karl Y Bilimoria
- Cancer Programs, American College of Surgeons, 633 N. St Clair St., Chicago, IL 60611, USA.
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Brien SE, Dixon E, Ghali WA. Measuring and reporting on quality in health care: A framework and road map for improving care. J Surg Oncol 2009; 99:462-6. [PMID: 19466720 DOI: 10.1002/jso.21188] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Susan E Brien
- Centre for Health and Policy Studies, Community Health Sciences, Faculty of Medicine, University of Calgary, Alberta, Canada
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The impact of surgeon specialization on patient mortality: examination of a continuous Herfindahl-Hirschman index. Ann Surg 2009; 249:708-16. [PMID: 19387335 DOI: 10.1097/sla.0b013e3181a335f8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To examine the effect of surgeon specialization on patient outcomes, controlling for volume. BACKGROUND There is great interest in the degree to which surgical specialization affects outcomes, particularly considering drives to measure and reward quality in healthcare. Although surgical specialization has been previously analyzed with respect to outcomes, most studies have treated it as a dichotomous variable based on academic credentials. We treat it here as a continuous variable defined quantitatively by procedural diversity. METHODS We used 2002 to 2005 patient data from the National Surgical Quality Improvement Program for the Department of Surgery, Barnes Jewish Hospital, St. Louis, Missouri. To quantitate procedural specialization, Herfindahl-Hirschman indices for surgeons were calculated using billing codes. These indices were calculated according to 3 different levels of procedural aggregation. Using conditional logit models, we examined the relationship between these indices and 30-day postoperative mortality rates. RESULTS Surgeon specialization was inversely related to mortality rates after adjusting for case volume when indices were calculated using medium procedural aggregation (odds ratio for mortality = 0.580 per 0.1 unit Herfindahl increase; P = 0.025) or low aggregation (odds ratio for mortality = 0.510 per 0.1 unit Herfindahl increase; P = 0.015). No relationship was observed at the high level of aggregation. CONCLUSIONS The procedural concentration component of surgical specialization is correlated with improved mortality rates independently of case volume. However, how broadly or narrowly "specialization" is defined has an impact on this relationship.
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Bilimoria KY, Phillips JD, Rock CE, Hayman A, Prystowsky JB, Bentrem DJ. Effect of Surgeon Training, Specialization, and Experience on Outcomes for Cancer Surgery: A Systematic Review of the Literature. Ann Surg Oncol 2009; 16:1799-808. [DOI: 10.1245/s10434-009-0467-8] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Revised: 02/24/2009] [Accepted: 02/25/2009] [Indexed: 11/18/2022]
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Guarga A, Pla R, Benet J, Pozuelo A. Planificación de los servicios de alta especialización en Cataluña. Med Clin (Barc) 2008; 131 Suppl 4:55-9. [DOI: 10.1016/s0025-7753(08)76476-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Aranda MA, McGory M, Sekeris E, Maggard M, Ko C, Zingmond DS. Do racial/ethnic disparities exist in the utilization of high-volume surgeons for women with ovarian cancer? Gynecol Oncol 2008; 111:166-72. [PMID: 18829086 PMCID: PMC4535425 DOI: 10.1016/j.ygyno.2008.08.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 08/11/2008] [Accepted: 08/12/2008] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Determine if racial/ethnic disparities exist for access to high-volume surgeons (HVS) for patients with ovarian cancer. METHODS Retrospective study of ovarian cancer surgeries identified by the California Cancer Registry (CCR) linked to hospital discharge data (1991-2002). Surgeon volume was defined as HVS (>10 ovarian cancer surgeries/year), middle volume (MVS; 2-9/year), and low volume (LVS; =1/year). Multivariate ordered logistic regression predicting surgeon volume provided estimates of relative risk (RR) of surgeon volume by patient race/ethnicity. RESULTS 13,186 women had ovarian cancer (mean age 57.8 years; 72% non-Hispanic White (NHW), 4% Black, 8% Hispanic). 25% of cases were treated by HVS, 31% by MVS, and 44% by LVS. Compared to NHW, Black (RR: 0.70, p<0.05) and Hispanic women (RR: 0.75, p<0.05) were less likely to have care by a HVS. Hispanic women were significant more likely to have surgery by LVS (RR: 1.1; p<0.05). CONCLUSIONS Disparities in access to HVS for cancer care exist for minority women. Selective referral to high-volume providers should be considered to improve outcomes among minority women.
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Affiliation(s)
- Michelle A. Aranda
- Department of Surgery, the David Geffen School of Medicine at UCLA, 72-215 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Marcia McGory
- Department of Surgery, the David Geffen School of Medicine at UCLA, 72-215 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Evan Sekeris
- Department of Surgery, the David Geffen School of Medicine at UCLA, 72-215 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Melinda Maggard
- Department of Surgery, the David Geffen School of Medicine at UCLA, 72-215 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Clifford Ko
- Department of Surgery, the David Geffen School of Medicine at UCLA, 72-215 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - David S. Zingmond
- Division of General Internal Medicine and Health Services Research, the David Geffen School of Medicine at UCLA, 911 Broxton Plaza, Los Angeles, CA 90095-1736, USA
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Bilimoria KY, Bentrem DJ, Feinglass JM, Stewart AK, Winchester DP, Talamonti MS, Ko CY. Directing Surgical Quality Improvement Initiatives: Comparison of Perioperative Mortality and Long-Term Survival for Cancer Surgery. J Clin Oncol 2008; 26:4626-33. [DOI: 10.1200/jco.2007.15.6356] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose Quality-improvement initiatives are being developed to decrease volume-based variability in surgical outcomes. Resources for national and hospital quality-improvement initiatives are limited. It is unclear whether quality initiatives in surgical oncology should focus on factors affecting perioperative mortality or long-term survival. Our objective was to determine whether differences in hospital surgical volume have a larger effect on perioperative mortality or long-term survival using two methods. Patients and Methods From the National Cancer Data Base, 243,103 patients who underwent surgery for nonmetastatic colon, esophageal, gastric, liver, lung, pancreatic, or rectal cancer were identified. Multivariable modeling was used to evaluate 60-day mortality and 5-year conditional survival (excluding perioperative deaths) across hospital volume strata. The number of potentially avoidable perioperative and long-term deaths were calculated if outcomes at low-volume hospitals were improved to those of the highest-volume hospitals. Results Risk-adjusted perioperative mortality and long-term conditional survival worsened as hospital surgical volume decreased for all cancer sites, except for liver resections where there was no difference in survival. When comparing low- with high-volume hospitals, the hazard ratios for perioperative mortality were substantially larger than for long-term survival. However, the number of potentially avoidable deaths each year in the United States, if outcomes at low-volume hospitals were improved to the level of highest-volume centers, was significantly larger for long-term survival. Conclusion Although the magnitude of the hazard ratios implies that quality-improvement efforts should focus on perioperative mortality, a larger number of deaths could be avoided by focusing quality initiatives on factors associated with long-term survival.
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Affiliation(s)
- Karl Y. Bilimoria
- From the Department of Surgery; Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University; Cancer Programs, American College Surgeons, Chicago; Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL; Department of Surgery, University of California, Los Angeles; and VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - David J. Bentrem
- From the Department of Surgery; Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University; Cancer Programs, American College Surgeons, Chicago; Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL; Department of Surgery, University of California, Los Angeles; and VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Joseph M. Feinglass
- From the Department of Surgery; Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University; Cancer Programs, American College Surgeons, Chicago; Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL; Department of Surgery, University of California, Los Angeles; and VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Andrew K. Stewart
- From the Department of Surgery; Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University; Cancer Programs, American College Surgeons, Chicago; Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL; Department of Surgery, University of California, Los Angeles; and VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - David P. Winchester
- From the Department of Surgery; Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University; Cancer Programs, American College Surgeons, Chicago; Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL; Department of Surgery, University of California, Los Angeles; and VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Mark S. Talamonti
- From the Department of Surgery; Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University; Cancer Programs, American College Surgeons, Chicago; Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL; Department of Surgery, University of California, Los Angeles; and VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Clifford Y. Ko
- From the Department of Surgery; Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University; Cancer Programs, American College Surgeons, Chicago; Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL; Department of Surgery, University of California, Los Angeles; and VA Greater Los Angeles Healthcare System, Los Angeles, CA
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Hyung WJ, Kim SS, Choi WH, Cheong JH, Choi SH, Kim CB, Noh SH. Changes in treatment outcomes of gastric cancer surgery over 45 years at a single institution. Yonsei Med J 2008; 49:409-15. [PMID: 18581590 PMCID: PMC2615336 DOI: 10.3349/ymj.2008.49.3.409] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Although many studies have demonstrated improvements in short-and long-term outcomes of gastric cancer surgery, changes in long-term survival over time are not well-established. This study was conducted to evaluate changes in host, tumor, and treatment factors in patients treated at a single institution over a period of 45-yr. PATIENTS AND METHODS We retrospectively evaluated 9282 patients with gastric cancer from 1955 to 1999, and divided the 45-yr into 4 time frames based on published articles: 1955 to 1962 (n=228), 1963 to 1972 (n=891), 1973 to 1988 (n=2789), and 1989 to 1999 (n=5374). RESULTS Remarkable changes were noted in host, tumor, treatment factors, and prognosis. Among host factors, patients of more advanced age were identified in the 4th period and mean age shifted from 49 to 55 yrs. Among tumor factors, early gastric cancers and upper body tumors increased up to 32% and from 7% to 13%, respectively. An increase in the annual number of patients (from 29 to 649), gastrectomies (from 14 to 600), rate of resection (from 50% to 90%), rate of curative resection (up to 92%), and proportion of total gastrectomy (from 8% to 29%) was noted. Operative mortality was reduced from 6.1% to 0.7%. The overall 5-yr survival rate significantly increased from 22% to 65%. CONCLUSION Treatment results of gastric cancer surgery have improved remarkably over the 45-year period. Increase of early stage gastric cancer with early diagnosis considerably influenced the improved survival of patients with gastric cancer.
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Affiliation(s)
- Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Cancer Metastasis Research Center, Yonsei University College of Medicine, Seoul, Korea
- Insititute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Ho Cheong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Cancer Metastasis Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Ho Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Choong Bai Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hoon Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Cancer Metastasis Research Center, Yonsei University College of Medicine, Seoul, Korea
- Insititute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Bilimoria KY, Talamonti MS, Sener SF, Bilimoria MM, Stewart AK, Winchester DP, Ko CY, Bentrem DJ. Effect of hospital volume on margin status after pancreaticoduodenectomy for cancer. J Am Coll Surg 2008; 207:510-9. [PMID: 18926452 DOI: 10.1016/j.jamcollsurg.2008.04.033] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2007] [Revised: 04/29/2008] [Accepted: 04/30/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND The volume-outcome relationship has been repeatedly demonstrated for pancreatectomy, but identifying underlying reasons for this association has been challenging. Some have suggested that differences in surgical technique may affect longterm survival, but it is unknown whether margin-positive resection rates vary by hospital volume. Our objective was to evaluate the effect of hospital pancreatectomy volume on margin status. STUDY DESIGN Patients who underwent pancreaticoduodenectomy for localized pancreatic adenocarcinoma were identified from the National Cancer Data Base (1998 to 2004). Regression modeling adjusting for patient, tumor, and hospital factors was used to assess predictors of margin involvement and to evaluate the effect of margin status on survival. Volume quintiles were based on average annual hospital pancreatectomy volume. RESULTS Of 12,101 patients, 24.4% had positive resection margins (14.6% microscopic/R1; 9.8% macroscopic/R2). From 1998 to 2004, there was not a significant change in margin-positive resection rates (p=0.43). On multivariable analysis, patients were more likely to have a margin-positive resection if they had a higher T classification or nodal involvement, were uninsured or living in lower-income areas, or underwent resection at lowest-volume hospitals compared with highest-volume hospitals (25.9% versus 22.6%, p < 0.0001; odds ratio, 1.21; 95% confidence interval, 1.01 to 1.43). On multivariable analysis, margin involvement was associated with a higher risk of longterm mortality compared with margin-negative resections (p < 0.0001). CONCLUSIONS Involved resection margins are a poor prognostic factor after a pancreaticoduodenectomy. Patients undergoing pancreaticoduodenectomy at low-volume centers are more likely to have margin-positive resections. Standardization of pathologic evaluation for pancreatectomy specimens is needed.
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Affiliation(s)
- Karl Y Bilimoria
- Cancer Programs, American College of Surgeons, Chicago, IL 60611, USA
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Ferrone CR, Brennan MF, Gonen M, Coit DG, Fong Y, Chung S, Tang L, Klimstra D, Allen PJ. Pancreatic adenocarcinoma: the actual 5-year survivors. J Gastrointest Surg 2008; 12:701-6. [PMID: 18027062 DOI: 10.1007/s11605-007-0384-8] [Citation(s) in RCA: 193] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Accepted: 10/03/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Most reports of patients undergoing resection for pancreatic adenocarcinoma report estimated (actuarial) 5-year survival rates. Actual 5-year survival is rarely described, and factors associated with long-term survival are not well described. METHODS Review of a prospectively maintained database identified 618 patients who underwent resection for pancreatic adenocarcinoma between 1/1983-1/2001. Patient, tumor, and treatment-related variables were assessed for their association with 5-year survival. RESULTS There were 75 patients who survived >5 years after resection (75 out of 618, 12%), and 18 patients who survived >10 years (18 out of 352, 5%). Patient age, gender, and tumor location were not associated with 5-year survival, whereas early American Joint Committee on Cancer (AJCC) stage (p < 0.001) and negative margins (p = 0.001) were associated with 5-year survival. Patients with stage IA disease had an actual 5 year survival of 26%. Median follow-up was 108 months. Recurrent disease developed in 38 patients (51%) and all died from disease. Adjuvant therapy was received by 21% (16 out of 75), and tumors were moderately differentiated in 58% (42 out of 75) and had a median size of 2.8 cm (0.8-13 cm). CONCLUSIONS Actual 5-year survival after resection of pancreatic adenocarcinoma was 12%. AJCC stage and negative margins were the only significant predictors of long-term survival. Early detection and intervention for patients with pancreatic cancer is crucial.
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Affiliation(s)
- Cristina R Ferrone
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, Howard 1223, 1275 York Avenue, New York, NY 10021, USA
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Prognostic Score Predicting Survival After Resection of Pancreatic Neuroendocrine Tumors. Ann Surg 2008; 247:490-500. [DOI: 10.1097/sla.0b013e31815b9cae] [Citation(s) in RCA: 285] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Shah SA, Bromberg R, Coates A, Rempel E, Simunovic M, Gallinger S. Survival after liver resection for metastatic colorectal carcinoma in a large population. J Am Coll Surg 2007; 205:676-83. [PMID: 17964443 DOI: 10.1016/j.jamcollsurg.2007.06.283] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2007] [Revised: 05/24/2007] [Accepted: 06/06/2007] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous reports of liver resection for metastatic colorectal cancer (CRC) are typically from single centers and cannot account for selection or referral bias. We measured longterm survival after liver resection for metastatic CRC in the province of Ontario, Canada (population 12 million). STUDY DESIGN The Ontario Cancer Registry is an administrative database that links all hospital records, pathology reports, and vital statistics for patients with a diagnosis of cancer. We used the Registry to identify and obtain information on all patients who underwent liver resection for metastatic CRC in calendar years 1996 to 2004. Pathology reports of the original CRC resection and subsequent liver resections were individually reviewed. RESULTS Eight hundred forty-one resections were performed at 43 centers across Ontario during the 9-year period, including wedge resection (n = 303; 36%); lobectomy (n = 466; 55%); and trisectionectomy (n = 72; 9%). Ninety-one percent and 54% of resections were performed at teaching and high-volume centers (> 80 resections), respectively. Most liver resections were performed more than 120 days after original CRC operation (672 of 841; 80%). Perioperative mortality was 3%. Unadjusted 1-, 3-, and 5-year survival after liver resection was 88%, 59%, and 43%, respectively. Survival was improved when resection was performed for fewer than 2 tumor nodules, at high-volume centers, or in the years 2001 to 2004. CONCLUSIONS Results in this population-based series are consistent with those of single-hospital series assessing longterm survival after liver resection for metastatic CRC. These findings support continued efforts to aggressively identify and resect CRC liver metastases.
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Affiliation(s)
- Shimul A Shah
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA 01655, USA.
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Vernooij F, Heintz P, Witteveen E, van der Graaf Y. The outcomes of ovarian cancer treatment are better when provided by gynecologic oncologists and in specialized hospitals: a systematic review. Gynecol Oncol 2007; 105:801-12. [PMID: 17433422 DOI: 10.1016/j.ygyno.2007.02.030] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Revised: 02/11/2007] [Accepted: 02/14/2007] [Indexed: 12/13/2022]
Abstract
OBJECTIVE There is much debate on the effect of specialized care for ovarian cancer patients. In this review we present an overview and summary of the recent literature on this subject. METHODS The Pubmed database was searched for studies on the relationship between care setting (type of gynecologist or hospital) and care outcomes which were published between January 1991 and November 2006. Studies were included if they were of sufficient quality and included patients treated from 1990 onwards. RESULTS Nineteen articles were retrieved. There were no randomized controlled trials on this subject. Staging and debulking were consistently found to be performed more adequately by gynecologic oncologists (pooled relative risk of optimal debulking by a gynecologic oncologist to <2 cm residual disease 1.4 (95%CI 1.2-1.5) and to no macroscopic disease 2.3 (95%CI 1.5-3.5)) and in specialized hospitals (odds ratios for optimal debulking varied between 1.9 and 6.0). There were no differences in postoperative complication rates between different providers. Chemotherapy was given 1-15% more often in specialized settings. Differences in chemotherapy did not lead to differences in survival of patients treated by gynecologic oncologists, but did influence the effect of hospital on survival. Long-term survival was better after treatment in a specialized hospital. Surgery by a gynecologic oncologist resulted in longer survival in subgroups of patients, leading to a 5- to 8-month median survival benefit for patients with advanced stage disease. CONCLUSIONS The outcome of ovarian cancer is better when treatment is provided by a gynecologic oncologist or in a specialized hospital.
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Affiliation(s)
- Flora Vernooij
- Department of Gynecologic Surgery and Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Schwarz RE. Factors influencing change of preoperative treatment intent in a gastrointestinal cancer practice. World J Surg Oncol 2007; 5:32. [PMID: 17355626 PMCID: PMC1838912 DOI: 10.1186/1477-7819-5-32] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Accepted: 03/13/2007] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Postoperative assessment of indications for cancer directed surgical procedures frequently differs from preoperative plans. METHODS Specifically defined preoperative indications and postoperative results were followed prospectively over 48 months in a single surgeon academic practice, and relationships to postoperative outcomes evaluated. RESULTS Operations were performed on 406 patients with a median age of 61 (range: 18-90). Major operations (n = 303, 75%) involved 270 abdominal resections including pancreatectomies (37%), liver resections (23%), gastrectomies (19%), and others (21%). Preoperative curative (70%), diagnostic (38%), palliative (12%), access (9%), and non-cancer related therapy (21%) goals were in part combined in 176 patients (43%). Postoperative assessment differed from preoperative goals in 118 patients (29%). Predominant reasons were proof of benign disease (n = 35), incomplete resection (R1 or R2, n = 23), unresectability by laparoscopy (n = 21) or laparotomy (n = 21), or others (n = 18). Potential preoperative cure or palliation goals were not achieved in 37% or 15% of cases, respectively. Circumstances of changed treatment intent were specific for disease site. CONCLUSION Preoperative therapeutic intent frequently differs from postoperative assessments in gastrointestinal cancer, based on shortcomings in diagnosis or therapy. Formulations of precise operative indications are recommended to optimize individual outcomes and avoid unnecessary or ineffective procedures.
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Affiliation(s)
- Roderich E Schwarz
- Department of Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Division of Surgical Oncology, The Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA.
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Galandiuk S, Mahid SS, Polk HC, Turina M, Rao M, Lewis JN. Differences and similarities between rural and urban operations. Surgery 2006; 140:589-96. [PMID: 17011906 DOI: 10.1016/j.surg.2006.07.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Accepted: 07/13/2006] [Indexed: 01/23/2023]
Abstract
BACKGROUND The importance of rural operations is magnified by super-specialization, uneven geographic distribution, and special educational needs. Definition of practice patterns and quality measures are needed. METHODS A statewide network of 60 operative specialists studied costs, quality, and outcomes in 17,319 patients undergoing 46 different specialty operations between 1998 and 2003, comparing 9,544 rural to 7,775 urban patients. These data are augmented by additional data from 5,339 operative patients in 2004. RESULTS Both high volume rural and urban surgeons achieved fewer deaths than less frequent practitioners of colon or rectal resections (2/309 vs 5/167). Urban surgeons had sicker patients undergoing more extensive procedures, and used fewer consultations, but had more complications and reoperations. Laparoscopic cholecystectomy had similar outcomes with 5 deaths among 1,788 patients. Urban surgeons converted to an open procedure more frequently, whereas rural surgeons used hepatobiliary iminodiacetic acid (HIDA) scans as indication for cholecystectomy more often (P < .01). Indications for upper and lower endoscopy varied, but abnormalities were noted in 64%; only 11 of 6,938 patients undergoing endoscopy were admitted for complications, 5 required operations, 3 due to totally obstructing cancers. Hysterectomy, urologic procedures, and tympanostomy had admission/readmission rates as low as 1/400. Documented patient preoperative education occurred in 94% of both groups. Overall, performance measures were addressed more consistently by rural surgeons (P < .001). CONCLUSIONS Operative practice reaches high standards in both settings; indications for operations vary, and rural practice is broader than urban practice. Rural surgeons exceed their urban colleagues on some quality process measures.
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Affiliation(s)
- Susan Galandiuk
- Department of Surgery, Price Institute for Surgical Research, University of Louisville School of Medicine, Louisville, KY, USA.
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Weitz J, Beiglböck A, Kienle P, Kalle CV, Jäger D, Büchler MW. Das Nationale Centrum für Tumorerkrankungen Heidelberg. Visc Med 2006. [DOI: 10.1159/000096445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
Until relatively recently, quality in healthcare was difficult both to define and measure. Now that this is possible, healthcare providers must quickly adopt information technology to facilitate both the assessment of performance and improvement. Such improvements require recognition of the role of systems of care and the need to change these systems in order to improve performance. In the coming years, the tension between the pressure for quality improvement and the pressure for cost-containment is likely to increase.
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Affiliation(s)
- Robert S Rhodes
- University of Pennsylvania School of Medicine, American Board of Surgery, Suite 860, PA 19103, USA.
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