Exploring the Underlying Mechanisms of the Volume-Outcome Relationship in Complex Cancer Care

Regional variation in cancer survival in Norway

BACKGROUND

Cancer services in Norway are intended to provide high quality services and equal access for all citizens. Still, regional variation in cancer survival has been reported. Currently, the public hospitals are organized in Health Trusts (HTs), respectively within one of four regional trusts (RHTs). We aimed to evaluate the extent and rank pattern of regional and intraregional variation in cancer survival systematically over the last three decades. We postulated that organizational reforms during this period might have modulated the variation.

METHODS

Excess hazard ratios (EHR) of death from cancer were estimated for all individuals identified in The Cancer Registry of Norway as diagnosed with cancer from 1984 to 2018. The model covariates included continuous age at diagnosis, sex, cancer site, stage, 5-year time period of diagnosis and place of residence. In addition to analyses for all cancers combined, selected cohorts with predominantly centralized vs. not centralized primary surgery were evaluated.

RESULTS

For all cancer sites combined and for the centralized surgery cohort, the range of variation in EHR among the four regions was in the order of 0.10. The ranks among the regions were fairly consistent over time. For the not centralized surgery cohort, the range of inter-regional EHR-variation was in the order of 0.10 - 0.15, with no consistent ranks. Intra-regionally, the ranges of EHR-variation were similar, but with more complex rank patterns.

CONCLUSIONS

The range of inter- and intra-regional variation in cancer survival was minor, as compared to the general improvement in cancer survival in the period, with no evidence of effect from organizational reforms on regional variation.

Trends in Major Gastrectomy for Cancer: Frequency and Outcomes

BACKGROUND

Declining incidence of gastric cancer in the USA has presumably resulted in lower rates of major gastrectomy for cancer. The impact on perioperative outcomes remains undefined. The aims of this study were to characterize national trends in frequency of major gastrectomy for cancer, identify factors associated with in-hospital mortality, and examine outcome disparities by race/ethnicity.

METHODS

Nationwide inpatient sample data from 1993 to 2013 were queried for procedural and diagnostic codes (ICD-9) relating to total and partial gastrectomy procedures. Gastric resections for cancer were compared to those for peptic ulcer disease for reference. Patient demographics, comorbidity score, mortality, and hospital characteristics were recorded as covariates.

RESULTS

A significant decrease in annual rates of partial and total gastrectomy was observed from 1993 to 2013 (p < 0.0001). The change in absolute number and percent decline was greater for partial gastrectomy (- 39.3%) than total gastrectomy (- 19%). There was a 34.0% decrease in gastrectomy for cancer in Whites and a 61.2% increase among Hispanic patients over two decades. In-hospital mortality also significantly decreased over the study period (7.7% to 2.7%). Factors associated with lower mortality rates included male sex and treatment at urban teaching hospitals. Analysis of trends revealed that gastrectomy for cancer was performed with increasing frequency at urban teaching hospitals.

CONCLUSIONS

The frequency of major gastric resections in the USA has declined over two decades. Overall, in-hospital mortality rates also have decreased significantly. Declining in-hospital mortality after gastrectomy for cancer is associated with more frequent treatment at urban teaching hospitals.