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Di J, Lu XS, Sun M, Zhao ZM, Zhang CD. Hospital volume-mortality association after esophagectomy for cancer: a systematic review and meta-analysis. Int J Surg 2024; 110:3021-3029. [PMID: 38353697 DOI: 10.1097/js9.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/29/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Postoperative mortality plays an important role in evaluating the surgical safety of esophagectomy. Although postoperative mortality after esophagectomy is partly influenced by the yearly hospital surgical case volume (hospital volume), this association remains unclear. METHODS Studies assessing the association between hospital volume and postoperative mortality in patients who underwent esophagectomy for esophageal cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random effects model. The dose-response association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with PROSPERO. RESULTS Fifty-six studies including 385 469 participants were included. A higher-volume hospital significantly reduced the risk of postesophagectomy mortality by 53% compared with their lower-volume counterparts (odds ratio, 0.47; 95% CI: 0.42-0.53). Similar results were found in subgroup analyses. Volume-outcome analysis suggested that postesophagectomy mortality rates remained roughly stable after the hospital volume reached a plateau of 45 esophagectomies per year. CONCLUSIONS Higher-volume hospitals had significantly lower postesophagectomy mortality rates in patients with esophageal cancer, with a threshold of 45 esophagectomies per year for a high-volume hospital. This remarkable negative correlation showed the benefit of a better safety in centralization of esophagectomy to a high-volume hospital.
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Affiliation(s)
| | | | - Min Sun
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, People's Republic of China
| | - Zhe-Ming Zhao
- Department of Surgical Oncology, The Fourth Affiliated Hospital of China Medical University, Shenyang
| | - Chun-Dong Zhang
- Central Laboratory
- Department of Surgical Oncology, The Fourth Affiliated Hospital of China Medical University, Shenyang
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Martin RK, Persson A, Moatshe G, Fenstad AM, Engebretsen L, Drogset JO, Visnes H. Low annual hospital volume of anterior cruciate ligament reconstruction is not associated with higher revision rates. Knee Surg Sports Traumatol Arthrosc 2022; 30:1575-1583. [PMID: 34236479 DOI: 10.1007/s00167-021-06655-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 07/01/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE Surgery performed in low-volume centres has been associated with longer operating time, longer hospital stays, lower functional outcomes, and higher rates of revision surgery, complications and mortality. This has been reported consistently in the arthroplasty literature, but there is a paucity of data regarding the relationship between surgical volume and outcome following anterior cruciate ligament (ACL) reconstruction. The purpose was to compare ACL reconstruction failure rates between hospitals performing different annual surgical volumes. METHODS All patients from the Norwegian Knee Ligament Register having primary autograft ACL reconstruction between 2004 and 2016 were included. Hospital volume was divided into quintiles based on the number of ACL reconstructions performed annually, defined arbitrarily as: 1-12 (V1), 13-24 (V2), 25-49 (V3), 50-99 (V4) and ≥ 100 (V5) annual procedures. Kaplan-Meier estimated survival curves and survival percentages were calculated with revision ACL reconstruction as the end point. Secondary outcome measures included (1) mean change in Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (QoL) and Sport subsections from pre-operative to 5-year follow-up and (2) subjective failure defined as KOOS QoL < 44. RESULTS Twenty thousand eight hundred and fifty patients met the inclusion criteria and 1195 (5.7%) underwent subsequent revision ACL reconstruction over the study period. Revision rates were lower in the lower volume hospitals compared with the higher volume hospitals (p < 0.001). There was no clinically significant difference in improvement between pre-operative and 5-year follow-up KOOS scores between hospital volume categories, but a higher proportion of patients having surgery at lower volume hospitals reported a subjective failure. Patients in the lower volume categories (V1-3) were more often male and older compared to the higher volume hospitals (V4-5). Concomitant meniscal injuries and participation in pivoting sports were most common in V5 compared with V1 (p < 0.001). Median operative time decreased as hospital volume increased, ranging from 90 min at V1 hospitals to 56 min at V5 hospitals (p < 0.001). CONCLUSION Patients having ACL reconstruction at lower volume hospitals had a lower rate of subsequent revision surgery relative to higher volume hospitals. However, complications occurred more frequently, operative duration was longer, and the number of patients reporting a subjective failure of ACL reconstruction was highest at these lower volume hospitals. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- R Kyle Martin
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA.
- Department of Orthopaedic Surgery, University of Minnesota, 1900 CentraCare Circle, Saint Cloud, MN, 56303, USA.
| | - Andreas Persson
- Oslo Sports Trauma Research Center, Norwegian School of Sports Sciences, Oslo, Norway
- Department of Orthopedic Surgery, Martina Hansens Hospital, Baerum, Norway
- Norwegian National Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Gilbert Moatshe
- Oslo Sports Trauma Research Center, Norwegian School of Sports Sciences, Oslo, Norway
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Anne Marie Fenstad
- Norwegian National Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
| | - Lars Engebretsen
- Oslo Sports Trauma Research Center, Norwegian School of Sports Sciences, Oslo, Norway
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Jon Olav Drogset
- Norwegian National Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
- Department of Orthopaedic Surgery, Trondheim University Hospital, Trondheim, Norway
| | - Håvard Visnes
- Oslo Sports Trauma Research Center, Norwegian School of Sports Sciences, Oslo, Norway
- Norwegian National Knee Ligament Register, Haukeland University Hospital, Bergen, Norway
- Department of Orthopaedics, Sorlandet Hospital Kristiansand, Kristiansand, Norway
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Kassahun WT, Mehdorn M, Wagner TC, Babel J, Danker H, Gockel I. The effect of preoperative patient-reported anxiety on morbidity and mortality outcomes in patients undergoing major general surgery. Sci Rep 2022; 12:6312. [PMID: 35428818 DOI: 10.1038/s41598-022-10302-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/05/2022] [Indexed: 01/03/2023] Open
Abstract
Excessive levels of anxiety may negatively influence treatment outcomes and likely increase patient suffering. We designed a prospective observational study to assess whether preoperative patient-reported anxiety affects major general surgery outcomes. We prospectively administered the State-Trait Anxiety Inventory (STAI) to measure preoperative anxiety in patients awaiting major general surgical procedures. Patients were grouped by STAI scores according to established cutoffs: no anxiety (STAI < 40) and anxiety (STAI ≥ 40). Four hundred patients completed the questionnaires and underwent surgery, with an average interval from questionnaire completion to surgery of 4 days. Applying a state anxiety (STAI-S) score ≥ 40 as a reference point, the prevalence of patient-reported anxiety was 60.5% (241 of 400). The mean STAI-S score for these patients was 50.48 ± 7.77. The mean age of the entire cohort was 58.5 ± 14.12 years. The majority of participants were male (53.8%). The distribution of sex by anxiety status showed that 53.5% of women and 46.5% of men had anxiety (p = 0.003). In the entire cohort, postoperative complications occurred in 23.9% and 28.6% of the no anxiety and anxiety groups, respectively. The difference was nonsignificant. In a subgroup of patients who underwent high-risk complex procedures (N = 221), however, postoperative complications occurred in 31.4% and 45.2% of the no anxiety and anxiety groups, respectively. This difference was significant at p = 0.004. Of the patients who were anxious, 3.3% (8 of 241) died during hospitalization following surgery, compared with 4.4% of the patients (7 of 159) who were not anxious (p = 0.577). In the multivariable analysis adjusted for covariates and based on the results of subgroup analysis, preoperative anxiety assessed by the STAIS score was associated with morbidity (OR 2.12, CI 1.14–3.96; p = 0.018) but not mortality. The majority of enrolled patients in this study were classified as having high- to very high-level preoperative clinical anxiety, and we found a significant quantitative effect of patient-reported anxiety on morbidity but not mortality after surgery.
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Geiger JT, Fleming FJ, Stoner M, Doyle A. Surgeon volume and established hospital perioperative mortality rate together predict for superior outcomes after open abdominal aortic aneurysm repair. J Vasc Surg 2021; 75:504-513.e3. [PMID: 34560221 DOI: 10.1016/j.jvs.2021.08.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND In 2018, the Society for Vascular Surgery (SVS) published hospital volume guidelines for elective open abdominal aortic aneurysm (AAA) repair, recommending that elective open surgical repair of AAAs should be performed at centers with an annual volume of ≥10 open aortic operations of any type and a documented perioperative mortality of ≤5%. Recent work has suggested a yearly surgeon volume of at least seven open aortic cases for improved outcomes. The objective of the present study was to assess the importance of hospital volume and surgeon volume at these cut points for predicting 1-year mortality after open surgical repair of AAAs. METHODS We evaluated patients who had undergone elective open AAA repair using the New York Statewide Planning and Research Cooperative System database from 2003 to 2014. The effect of the SVS guidelines on postoperative mortality and complications was evaluated. Confounding between the hospital and surgeon volumes was identified using mixed effects multivariate Cox proportional hazards analysis. The effect of the interactions between hospital volume, established hospital perioperative survival, and surgeon volume on postoperative outcomes was also investigated. RESULTS The cohort consisted of 7594 elective open AAA repairs performed by 542 surgeons in 137 hospitals during the 12-year study period. Analysis of the 2018 guidelines using the Statewide Planning and Research Cooperative System database revealed 1-year and 30-day mortality rates of 9.2% (range, 8.3%-10.1%) and 3.5% (range, 2.9%-4.1%) for centers that were within the SVS guidelines and 13.6% (range, 12.5%-14.7%) and 6.9% (range, 6.1%-7.8%) for those that were outside the guidelines, respectively (P < .001 for both). Multivariate survival analysis revealed a hazard ratio for a surgeon volume of ≥7, hospital volume of ≥10, and hospital 3-year perioperative mortality of ≤5% of 0.80 (95% confidence interval [CI], 0.70-0.93; P = .003), 0.91 (95% CI, 0.77-1.08; P = .298), and 0.72 (95% CI, 0.62-0.82; P < .001), respectively. Additionally, procedures performed by surgeons with a yearly average volume of open aortic operations of at least seven and at hospitals with an established elective open AAA repair perioperative mortality rate of ≤5% showed improved 1-year (33.2% relative risk reduction; P < .001) and 30-day (P = .001) all-cause survival and improved postoperative complication rates. CONCLUSIONS These data have demonstrated that centers that meet the SVS AAA volume guidelines are associated with improved 1-year and 30-day all-cause survival. However, the results were confounded by surgeon volume. A surgeon open aortic volume of at least seven procedures and an established hospital perioperative mortality of ≤5% each independently predicted for 1-year survival after open AAA repair, with the hospital volume less important. These results indicate that surgeons with an annual volume of at least seven open aortic operations of any type should perform elective open AAA repair at centers with a documented perioperative mortality of ≤5%.
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Affiliation(s)
- Joshua T Geiger
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, NY
| | - Michael Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Adam Doyle
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
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Lam MB, Riley KE, Mehtsun W, Phelan J, Orav EJ, Jha AK, Burke LG. Association of Teaching Status and Mortality After Cancer Surgery. Ann Surg Open 2021; 2:e073. [PMID: 34458890 PMCID: PMC8389472 DOI: 10.1097/as9.0000000000000073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/14/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To examine patient outcomes for nine cancer-specific procedures performed in teaching versus non-teaching hospitals. SUMMARY BACKGROUND DATA Few contemporary studies have evaluated patient outcomes in teaching versus non-teaching hospitals across a comprehensive set of cancer-specific procedures. METHODS Use of national Medicare data to compare 30-, 60-, and 90-day mortality rates in teaching and non-teaching hospitals for cancer-specific procedures. Risk-adjusted 30-day, all-cause, postoperative mortality overall and for each specific surgery, as well as overall 60- and 90-day mortality rates, were assessed. RESULTS The sample consisted of 159,421 total cancer surgeries at 3,151 hospitals. Overall thirty-day mortality rates, adjusted for procedure type, state, and invasiveness of procedure were 1.3% lower at major teaching hospitals (95%CI=-1.6% to -1.1%; p<0.001) relative to non-teaching hospitals. After accounting for patient characteristics, major teaching hospitals continued to demonstrate lower mortality rates compared with non-teaching hospitals (-1.0% difference [95%CI -1.2% to -0.7%]; p<0.001). Further adjustment for surgical volume as a mediator reduced the difference to -0.7% (95%CI -0.9% to -0.4%, p<0.001). Cancer surgeries for four of the nine disease sites (bladder, lung, colorectal and ovarian) followed this overall trend. Sixty- and ninety-day overall mortality rates, adjusted for procedure type, state, and invasiveness of procedure showed that major teaching hospitals had a 1.7% (95%CI -2.1% to -1.4%; p<0.001) and 2.0% (95%CI -2.4 to -1.6%, p<0.001) lower mortality relative to non-teaching hospitals. These trends persisted after adjusting for patient characteristics. CONCLUSIONS Among cancer-specific procedures for Medicare beneficiaries, major teaching hospital status was associated with lower 30-, 60-, and 90-day mortality rates overall and across four of the nine cancer types.
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Affiliation(s)
- Miranda B. Lam
- From the Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kristen E. Riley
- From the Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
| | - Winta Mehtsun
- Harvard Medical School, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital/Dana Farber Cancer Institute, Boston, MA
| | - Jessica Phelan
- From the Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
| | - E. John Orav
- Harvard Medical School, Boston, MA
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Ashish K. Jha
- Brown University School of Public Health, Providence, RI
| | - Laura G. Burke
- From the Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Taylor LJ, Maloney JD. Crisis of confidence in cardiothoracic trainees: National trends in the use of minimally invasive esophagectomy. JTCVS Open 2021; 5:193-194. [PMID: 36003170 PMCID: PMC9390678 DOI: 10.1016/j.xjon.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | - James D. Maloney
- Address for reprints: James D. Maloney, MD, 600 Highland Ave, Madison, WI 53792.
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Đuzel A, Pavlov M, Babić Z. Importance of acute cardiac care registries at the national level. Acta Clin Croat 2020; 59:233-241. [PMID: 33456110 PMCID: PMC7808236 DOI: 10.20471/acc.2020.59.02.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 12/24/2019] [Indexed: 12/04/2022] Open
Abstract
Improving organization and patient care quality in intensive care units is increasingly important as intensive care unit diagnostic and therapeutic procedures account for a growing proportion of hospital services. We identified the lack of comprehensive national and international registries available in the contemporary literature. This paper aims to describe and analyze cardiac intensive care unit (CICU) network at the national level in Croatia and its comparison with more developed countries. Thirty-four representatives from all Croatian acute hospitals (response rate of 100%) filled in a web based questionnaire on CICU organization and competence during September and October 2016. Organization and available technical procedures for health care in general, and especially in very expensive CICU treatment, highly depends on gross domestic product (GDP) per capita. That is why one could expect that Croatia, with the second lowest GDP among European Union countries and 4.7 CICU per million inhabitants will have worse results in this field in comparison with most of these countries. Results such as one nurse responsible for a mean of 2.7 CICU patients, 52% of cardiologists among physicians during working hours but 37% during night shifts, 24/7 transesophageal echocardiography in only 26.5% of CICUs, one-third without therapeutic hypothermia, and 23.5% without extracorporeal membrane oxygenation treatment are some of these results, revealing much room for improvement. This representative, nationwide sample of Croatian CICUs also demonstrated considerable variation of key elements of structures with respect to hospital size, academic status and financial issues, as well as a trend towards current guidelines. This kind of investigation is very important for proposing standards, reimbursement master plan, or quality assessment of the national health system.
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Affiliation(s)
- Ana Đuzel
- Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Marin Pavlov
- Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Zdravko Babić
- Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
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Gupta V, Levy J, Allen-Ayodabo C, Amirazodi E, Davis L, Li Q, Mahar A, Coburn NG. Population Registry of Esophageal and Stomach Tumours in Ontario (PRESTO): protocol for a multicentre clinical and pathological database including 25 000 patients. BMJ Open 2020; 10:e032729. [PMID: 32474423 PMCID: PMC7264637 DOI: 10.1136/bmjopen-2019-032729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Oesophagogastric cancers carry a high mortality, economic burden and rising incidence. There is a need to monitor and improve care for this disease. Pathologic information is a cornerstone of cancer diagnosis, treatment and prognosis. Few population-based studies combine pathology information and clinical outcomes. The objective of this study is to develop a clinical and pathological database of oesophagogastric cancers to study practice patterns, resource utilisation and clinical outcomes. METHODS AND ANALYSIS The Population Registry of Esophageal and Stomach Tumours in Ontario (PRESTO) will include all patients with oesophagogastric cancer diagnosed from 2002 onwards within the province of Ontario. We estimate that the sample over the first 14 years of the study will include 26 000 patients. Pathologic information from diagnostic procedures, endomucosal resection specimens and surgical resection specimens is being abstracted into a purpose-built database. Pathology information will be linked to administrative data, which capture baseline demographics, patient-reported symptoms, physician billings, hospital visits, hospital characteristics, geography and vital statistics. The registry will be updated prospectively. ETHICS AND DISSEMINATION Ethics approval for this study was obtained from the Sunnybrook Health Sciences Centre Research Ethics Board. The PRESTO database will enable the study of oesophagogastric cancer in Ontario under six themes of inquiry: treatment, surgical outcomes, pathology, survival, health system and resource utilisation and cost. This information will be a valuable addition to the global efforts to understand ways to optimise care for these diseases.
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Affiliation(s)
- Vaibhav Gupta
- Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Levy
- Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Elmira Amirazodi
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Laura Davis
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Qing Li
- Analysis, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Alyson Mahar
- Community Health Sciences, University of Manitoba College of Medicine, Winnipeg, Ontario, Canada
| | - Natalie G Coburn
- Division of General Surgery, Department of Surgery and Institute of Health Policy, Management, and Evaluation, Odette Cancer Centre, Toronto, Ontario, Canada
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Geiger JT, Aquina CT, Esce A, Zhao P, Glocker R, Fleming F, Iannuzzi J, Stoner M, Doyle A. One-year patient survival correlates with surgeon volume after elective open abdominal aortic surgery. J Vasc Surg 2020; 73:108-116.e1. [PMID: 32442607 DOI: 10.1016/j.jvs.2020.04.509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 04/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Volume-outcome relationships in surgery have been well established. Studies have shown that high-volume surgeons provide improved outcomes in performing open abdominal aneurysm repairs. The hypothesis of this study was that high-volume surgeons provide superior short-term and midterm outcomes of elective open aortic operations compared with low-volume surgeons. METHODS We evaluated patients undergoing elective open abdominal aortic aneurysm repair, aortofemoral bypass, and aortomesenteric bypass by board-certified vascular surgeons using the New York Statewide Planning and Research Cooperative System database from 2002 to 2014. The Contal and O'Quigley technique was used to estimate a cut point objectively and provided an estimate of significance. A division using average yearly volumes (averaged during 3 years) of seven or more cases and fewer than seven cases per year returned the highest Q statistic, and this grouping was used to classify high-volume and low-volume provider groups. Rates of complications during index hospitalization, length of stay, 30-day survival, 90-day survival, 1-year survival, and cause of death were analyzed using mixed effect models. RESULTS In 118 hospitals during the 13-year period, 266 board-certified vascular surgeons performed 244 aortomesenteric bypasses, 4202 aortofemoral bypasses, and 6126 abdominal aortic aneurysm repairs. High-volume surgeons' rates of complications during index hospitalization, 30-day survival, 90-day survival, and 1-year survival were superior to those of low-volume surgeons. The Contal and O'Quigley technique returned an estimate of seven operations per year for optimal survival during 1 year. This cutoff is associated with an adjusted 1-year hazard ratio of 0.687 (P = .003), a 2.69% difference in 1-year all-cause survival (P = .003), and a 1.76-day reduction in the mean length of stay at index hospitalization (P < .001). Higher volume surgeons showed a 25.0%, 43.4%, 42.4%, 40.6%, and 45.0% reduction in postoperative rates of acute renal failure (P < .001), hemorrhage (P < .001), pulmonary failure (P < .001), sepsis (P < .001), and venous thromboembolism (P < .001), respectively. Abdominal abscess, acute renal failure, hemorrhage, myocardial infarction, and sepsis were associated with increased cardiovascular cause-specific mortality after open aortic operations (P < .001). CONCLUSIONS These data demonstrate that high-volume surgeons performing elective open aortic operations provide reduced complications and improved short-term and midterm survival compared with low-volume surgeons. Clinical and postoperative variables that are associated with increased cardiovascular cause-specific mortality are also identified. These data provide further evidence that elective open abdominal vascular surgery should be centralized to high-volume surgeons.
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Affiliation(s)
- Joshua T Geiger
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Christopher T Aquina
- Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Antoinette Esce
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY; Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Peng Zhao
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Roan Glocker
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Fergal Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - James Iannuzzi
- Division of Vascular Surgery, University of California, San Francisco, Calif
| | - Michael Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Adam Doyle
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
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Sultan I, Gleason TG, Kagawa H, Keebler M, Mathier M, Kormos RL, Kilic A. The impact of centre volume on outcomes of orthotopic heart transplant in older recipients. Interact Cardiovasc Thorac Surg 2019; 29:576-582. [PMID: 31280304 DOI: 10.1093/icvts/ivz148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 05/15/2019] [Accepted: 05/23/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the impact of overall and older-recipient-specific centre volumes on outcomes of orthotopic heart transplant (OHT) in older recipients. METHODS Patients aged ≥60 years undergoing OHT were identified in the United Network for Organ Sharing (UNOS) registry. The primary outcome was 1-year post-OHT mortality. Secondary outcomes included the incidence and impact on 1-year survival of postoperative complications including infection, renal failure requiring dialysis and stroke. Patients were divided into equal size tertiles based on overall and older-recipient-specific OHT centre volumes. RESULTS A total of 5373 older recipients were identified. Mean overall and older-recipient-specific volumes were 27.5 ± 19.5 and 9.4 ± 7.3 OHT/year, respectively. Although overall and older-recipient-specific low-volume centres were at higher risk of mortality in separate multivariable analysis, only older-recipient-specific volume contributed significantly to post-OHT mortality in the combined multivariable analysis (P < 0.05). In the receiver operating characteristic analysis, an older-recipient-specific volume of 8 OHTs/year was identified as the most discriminative volume threshold for mortality (area under the receiver operating characteristic curve = 0.68). Although low older-recipient-specific volume centres did not have significantly higher incidences of postoperative complications, they had significantly worse 1-year survival rates compared to higher volume centres in patients with postoperative infection or dialysis (each P < 0.01). CONCLUSIONS This large-cohort analysis demonstrates that older-recipient-specific centre volume contributes to post-OHT outcomes in the older recipients more significantly than overall volume. This may be a consequence of higher older-recipient-specific volume centres to better manage specific complications in this patient population.
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Affiliation(s)
- Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hiroshi Kagawa
- Division of Cardiac Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mary Keebler
- Division of Cardiac Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Mathier
- Division of Cardiac Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert L Kormos
- Division of Cardiac Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Kerlin MP, Epstein A, Kahn JM, Iwashyna TJ, Asch DA, Harhay MO, Ratcliffe SJ, Halpern SD. Physician-Level Variation in Outcomes of Mechanically Ventilated Patients. Ann Am Thorac Soc 2018; 15:371-9. [PMID: 29283699 DOI: 10.1513/AnnalsATS.201711-867OC] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
RATIONALE Physicians are increasingly being held accountable for patient outcomes, yet their specific contribution to the outcomes remains uncertain. OBJECTIVES To determine variation in outcomes of mechanically ventilated patients among intensivists, as well as associations between intensivist experience and patient outcomes. METHODS We performed a retrospective cohort study of mechanically ventilated Medicare fee-for-service patients in acute care hospitals in Pennsylvania using administrative, clinical, and physician data from Centers for Medicare and Medicaid Services and the American Medical Association from 2008 and 2009. We identified intensivists by training background, board certification, and claims for services provided to patients admitted to an intensive care unit. We assigned patients to intensivists for outcome attribution based on submitted claims for critical care and in-patient services. We estimated the physician-specific adjusted odds ratios (ORs) for 30-day mortality using a hierarchical model with a random effect for physician, adjusted for patient and hospital characteristics. We tested for independent association of physician experience with patient outcomes using mixed-effects regression for the primary outcome of 30-day mortality. We defined physician experience in two ways: years since training completion ("duration") and annual number of mechanically ventilated patients ("volume"). RESULTS We assigned 345 physicians to 11,268 patients. The 30-day mortality was 43% and median hospital length of stay was 11 days (interquartile range = 6-18). The physician adjusted OR varied from 0.72 to 1.64 (median = 0.99; interquartile range = 0.92-1.09). A total of 48% of physicians was outliers, with an adjusted OR significantly different from 1. However, among intensivists, physician experience was not associated with 30-day mortality (duration OR = 1.00 per additional year; 95% confidence interval = 1.00-1.01; volume OR = 1.00 per additional patient; 95% confidence interval = 1.00-1.00). CONCLUSIONS Intensivists independently contribute to outcomes of Medicare patients who undergo mechanical ventilation, as evidenced by the variation in risk-adjusted mortality across intensivists. However, physician experience does not underlie this relationship between intensivists, suggesting the need to identify modifiable physician factors to improve outcomes.
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Dossett LA. Cancer Hospital Network Affiliation and Complex Cancer Surgery-What Is in a Name? JAMA Netw Open 2019; 2:e191910. [PMID: 30977841 DOI: 10.1001/jamanetworkopen.2019.1910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor
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Abstract
Purpose The purpose of this paper is to examine the association between outpatient orthopedic surgery costs and Japan's healthcare facilities using a large-scale Japanese medical claims database. Design/methodology/approach The authors obtained reimbursement claims data for 8,588 patients who underwent orthopedic surgery between April 1 and September 30, 2014 at 3,347 Japanese healthcare facilities. Regression analysis, using ordinary least squares, examined the association between outpatient orthopedic surgery costs and healthcare facility characteristics. By using surgical fees as proxy for the surgical costs, the authors defined three dependent variables: surgical cost for each outpatient orthopedic surgery; pre- and post-operative cost one month before and after a surgical operation; and total cost for each patient. The authors also defined five independent variables, which capture healthcare facility characteristics and patient-specific factors: bed count; whether healthcare facilities are reimbursed in a diagnosis procedure combination system; patient's age; sex; and anatomical surgical sites. Findings The authors analyzed 6,456 outpatient orthopedic surgical cases performed at 3,085 healthcare facilities. There were significant differences in the surgical costs for outpatient orthopedic surgery among different healthcare facilities by total beds ( p=0.000). Multivariate regression analysis shows that surgical costs for outpatient orthopedic surgery are positively and significantly associated with healthcare facilities classified by total beds after adjusting for patient-specific characteristics ( p<0.05). Originality/value This is the first research to examine the association between costs for outpatient orthopedic surgery and healthcare facility characteristics in Japan. This study via the multivariate regression method showed that outpatient orthopedic surgery is likely to cost higher as healthcare facility size increased. The average incremental costs for each outpatient orthopedic surgery per 100 beds were calculated at $48.5 for surgery, $40.7 for pre- and post-operative care, and $89.2 total cost.
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Affiliation(s)
- Yuichi Watanabe
- Graduate School of Economics, Waseda University , Tokyo, Japan
| | - Yoshinori Nakata
- Graduate School of Public Health, Teikyo University , Tokyo, Japan
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Esce A, Medhekar A, Fleming F, Noyes K, Glocker R, Ellis J, Raman K, Stoner M, Doyle A. Superior 3-Year Value of Open and Endovascular Repair of Abdominal Aortic Aneurysm with High-Volume Providers. Ann Vasc Surg 2018; 46:17-29. [DOI: 10.1016/j.avsg.2017.08.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/12/2017] [Accepted: 08/30/2017] [Indexed: 12/27/2022]
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15
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Giwa F, Salami A, Abioye AI. Hospital esophagectomy volume and postoperative length of stay: A systematic review and meta-analysis. Am J Surg 2018; 215:155-162. [DOI: 10.1016/j.amjsurg.2017.03.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/05/2017] [Accepted: 03/16/2017] [Indexed: 12/22/2022]
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Rosemurgy AS, Downs DJ, Swaid F, Ryan CE, Smart AE, Spence JD, Ross SB. Regional differences for pancreaticoduodenectomy in Florida: Location matters. Am J Surg 2017; 214:862-870. [PMID: 28760357 DOI: 10.1016/j.amjsurg.2017.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Regionalization of care raises potential for differences in cost of care and outcome. This study was undertaken to determine if costs and outcome after pancreaticoduodenectomy vary by region in Florida, and whether costs and outcome are related. METHODS Inpatient data for pancreaticoduodenectomy in Florida during 2010-2012 were obtained from the Florida Agency for Health Care Administration. Seven geographically different regions were designated based on "cost of living index" and "urban to rural population ratio". Hospital costs, LOS, in-hospital mortality, and the frequency with which surgeons performed pancreaticoduodenectomy were evaluated for these regions. RESULTS Median hospital costs for pancreaticoduodenectomy by region ranged from $101,436-$214,971. Median hospital costs by region correlated positively with LOS (p < 0.0001) and in-hospital mortality (p < 0.0001), and negatively with the frequency of pancreaticoduodenectomies performed by high-volume surgeons (p < 0.0001). CONCLUSIONS There are regional differences for hospital costs and outcome with pancreaticoduodenectomy in Florida. Regions with lower costs had more pancreaticoduodenectomies performed by high-volume surgeons, shorter LOS, and lower in-hospital mortality rates. Regional differences in cost and quality-of-care need to be studied and abrogated to provide uniform optimal care.
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Affiliation(s)
- Alexander S Rosemurgy
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA.
| | - Darrell J Downs
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Forat Swaid
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Carrie E Ryan
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Amanda E Smart
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Janelle D Spence
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Sharona B Ross
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
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Cho HW, Chu C. What Matters in the Performance of a Medial Institution? Osong Public Health Res Perspect 2017; 8:1-2. [PMID: 28443218 PMCID: PMC5402842 DOI: 10.24171/j.phrp.2017.8.1.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Hae-Wol Cho
- Editor-in-Chief, Osong Public Health and Research Perspectives, Korea Centers for Disease Control and Prevention, Cheongju, Korea.,Professor Emeritus, College of Medicine, Eulji University, Daejeon, Korea
| | - Chaeshin Chu
- Managing Editor, Osong Public Health and Research Perspectives, Korea Centers for Disease Control and Prevention, Cheongju, Korea
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18
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Lee JA, Kim SY, Park K, Park EC, Park JH. Analysis of Hospital Volume and Factors Influencing Economic Outcomes in Cancer Surgery: Results from a Population-based Study in Korea. Osong Public Health Res Perspect 2017; 8:34-46. [PMID: 28443222 PMCID: PMC5402846 DOI: 10.24171/j.phrp.2017.8.1.05] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objectives To evaluate associations between hospital volume, costs, and length of stay (LOS), and clinical and demographic outcome factors for five types of cancer resection. The main dependent variables were cost and LOS; the primary independent variable was volume. Methods Data were obtained from claims submitted to the Korean National Health Insurance scheme. We identified patients who underwent the following surgical procedures: pneumonectomy, colectomy, mastectomy, cystectomy, and esophagectomy. Hospital volumes were divided into quartiles. Results Independent predictors of high costs and long LOS included old age, low health insurance contribution, non-metropolitan residents, emergency admission, Charlson score > 2, public hospital ownership, and teaching hospitals. After adjusting for relevant factors, there was an inverse relationship between volume and costs/LOS. The highest volume hospitals had the lowest procedure costs and LOS. However, this was not observed for cystectomy. Conclusion Our findings suggest an association between patient and clinical factors and greater costs and LOS per surgical oncologic procedure, with the exception of cystectomy. Yet, there were no clear associations between hospitals’ cost of care and risk-adjusted mortality.
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Affiliation(s)
- Jung-A Lee
- Department of Health and Medical Information, School of Arts and Health Care, Myongji College, Seoul, Korea
| | - So-Young Kim
- Department of Health Information and Management, Chungbuk National University College of Medicine, Cheongju, Korea.,Graduate School of Health Science Business Convergence, Chungbuk National University, Cheongju, Korea
| | - Keeho Park
- National Cancer Control Research Institute, National Cancer Center, Goyang, Korea
| | - Eun-Cheol Park
- Department of Preventive Medicine and Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea
| | - Jong-Hyock Park
- Department of Health Information and Management, Chungbuk National University College of Medicine, Cheongju, Korea.,Graduate School of Health Science Business Convergence, Chungbuk National University, Cheongju, Korea.,National Cancer Control Research Institute, National Cancer Center, Goyang, Korea
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Sabra MJ, Smotherman C, Kraemer DF, Nussbaum MS, Tepas JJ, Awad ZT. The effects of neoadjuvant therapy on morbidity and mortality of esophagectomy for esophageal cancer: American college of surgeons national surgical quality improvement program (ACS-NSQIP) 2005-2012. J Surg Oncol 2016; 115:296-300. [DOI: 10.1002/jso.24493] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 10/22/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Michel J. Sabra
- Department of Surgery; University of Florida College of Medicine; Jacksonville Florida
| | - Carmen Smotherman
- Center for Health Equity and Quality Research (CHEQR); University of Florida; Jacksonville Florida
| | - Dale F. Kraemer
- Center for Health Equity and Quality Research (CHEQR); University of Florida; Jacksonville Florida
| | - Michael S. Nussbaum
- Department of Surgery; University of Florida College of Medicine; Jacksonville Florida
| | - Joseph J. Tepas
- Department of Surgery; University of Florida College of Medicine; Jacksonville Florida
| | - Ziad T. Awad
- Department of Surgery; University of Florida College of Medicine; Jacksonville Florida
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20
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Turner RB, Valcarlos E, Won R, Chang E, Schwartz J. Impact of Infectious Diseases Consultation on Clinical Outcomes of Patients with Staphylococcus aureus Bacteremia in a Community Health System. Antimicrob Agents Chemother 2016; 60:5682-7. [PMID: 27401580 DOI: 10.1128/AAC.00439-16] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/07/2016] [Indexed: 12/19/2022] Open
Abstract
Staphylococcus aureus bacteremia (SAB) causes high rates of morbidity and death. Several studies in academic health settings have demonstrated that consultations from infectious diseases specialists improve the quality of care and clinical outcomes for SAB. Few data that describe the impact in resource-limited settings such as community hospitals are available. This retrospective cohort study evaluated the adherence to quality-of-care indicators and the clinical outcomes for SAB in a five-hospital community health system (range of 95 to 272 available beds per hospital), for patients with versus without infectious diseases consultation (IDC). IDC was provided if requested by the attending physician. The primary outcome was the incidence of treatment failure, defined as 30-day in-hospital death or 90-day SAB recurrence. Other outcomes included adherence to quality-of-care indicators. A total of 473 adult patients with SAB were included, with 369 (78%) receiving IDC. We identified substantial differences in baseline characteristics between the IDC group and the no-IDC group, including greater incidences of complicated bacteremia and intravenous drug users in the IDC group, with similar rates of severe illness (measured by Pitt bacteremia scores). Adherence to quality-of-care indicators was greater for patients with IDC (P < 0.001). After adjustment for other predicting variables, IDC was associated with a lower rate of treatment failure (adjusted odds ratio, 0.42 [95% confidence interval, 0.20 to 0.86]; P = 0.018). IDC provided better quality of care and better clinical outcomes for patients with SAB who were treated at small, resource-limited, community hospitals.
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Jensen LS, Pilegaard HK, Puho E, Pahle E, Melsen NC. Outcome after Transthoracic Resection of Carcinoma of the Oesophagus and Oesophago-Gastric Junction. Scand J Surg 2016; 94:191-6. [PMID: 16259166 DOI: 10.1177/145749690509400303] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims: To assess the postoperative morbidity and mortality, length of stay and long-term survival after resection of carcinoma of the oesophagus and gastro-oesophageal junction, after establishment of a new surgical team unit between thoracic and gastroenterologic surgeons. Methods: We analysed the prospective collected data of 166 consecutive patients who underwent a transthoracic oesophageal resection between June 1997 and December 2003. Results: There were 119 men and 47 women. The median age was 63 years (range 36–81). Fifty-five patients (33 %) had squamous cell carcinoma and 111 (67 %) had adenocarcinoma. Postoperative complications occurred in a total of 60 patients (36 %). Ten patients (6 %) died postoperatively, eight (4.8 %) due to medical and two (1.2 %) due to surgical complications. The median postoperative length of stay was 11 days (range 6–75). The overall 3- and 5- years survival was 35.6 % and 30.6 % respectively. Survival was adversely affected by patient age and tumor stage. Conclusions: Concentrating resection for carcinoma of the oesophagus and oesophagogastric junction to a dedicated team of specialists, including both gastrointestinal and thoracic surgeons as well as thoracic-anaesthesiological know-how, results in acceptable complication rates as well as low mortality rates especially due to surgical complications.
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Affiliation(s)
- L S Jensen
- Department of Gastrointestinal Surgery, Aarhus University Hospital, Aarhus, Denmark.
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22
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Janowak CF, Blasberg JD, Taylor L, Maloney JD, Macke RA. The Surgical Apgar Score in esophagectomy. J Thorac Cardiovasc Surg 2015; 150:806-12. [DOI: 10.1016/j.jtcvs.2015.07.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 05/12/2015] [Accepted: 07/03/2015] [Indexed: 01/09/2023]
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Handler E, Tavassoli J, Dhaliwal H, Murray M, Haiavy J. A Review of General Cosmetic Surgery Training in Fellowship Programs Offered by the American Academy of Cosmetic Surgery. J Oral Maxillofac Surg 2015; 73:580-6. [DOI: 10.1016/j.joms.2014.11.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/25/2014] [Accepted: 11/25/2014] [Indexed: 11/16/2022]
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Abstract
Esophageal cancer rates have continued to rise in the Western World. Esophageal cancer will be responsible for an estimated 15,450 deaths in the United States in 2014 alone. Esophageal resection with or without preoperative therapy remains the mainstay of treatment. Advances in surgical technique and perioperative care have improved short-term outcomes considerably by decreasing operative mortality. Despite these advances though, esophagectomy remains a procedure associated with considerable morbidity from a wide range of complications. Prompt recognition and treatment of complications can lower overall morbidity and mortality. Unfortunately, long-term outcomes remain poor as the vast majority of patients present with loco-regionally advanced or metastatic disease. Surgery by itself provides poor loco-regional control and fails to address micrometastatic disease. Neoadjuvant chemotherapy or chemoradiation provides a modest survival advantage compared to surgical resection alone. Future gains in understanding the molecular biology of esophageal cancer will hopefully lead to improved therapeutics and resultant outcomes.
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Affiliation(s)
- Subroto Paul
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY
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25
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Koo JJ, Wang J, Thompson CB, Merbs SL, Grant MP. Impact of Hospital Volume and Specialization on the Cost of Orbital Trauma Care. Ophthalmology 2013; 120:2741-2746. [DOI: 10.1016/j.ophtha.2013.07.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 07/15/2013] [Accepted: 07/19/2013] [Indexed: 11/15/2022] Open
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Murphy CC, Incalcaterra JR, Albright HW, Correa AM, Swisher SG, Hofstetter WL. Pretreatment Patient Comorbidity and Tobacco Use Increase Cost and Risk of Postoperative Complications After Esophagectomy at a High-Volume Cancer Center. J Oncol Pract 2013; 9:233-9. [DOI: 10.1200/jop.2013.001047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Although direct cost comparisons between institutions may not yet be possible, the model and methods the authors used to assess variance in cost of esophagectomy could be adopted for use in different clinical settings.
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Affiliation(s)
- Caitlin C. Murphy
- The University of Texas MD Anderson Cancer Center; and The University of Texas School of Public Health, Houston, TX
| | - James R. Incalcaterra
- The University of Texas MD Anderson Cancer Center; and The University of Texas School of Public Health, Houston, TX
| | - Heidi W. Albright
- The University of Texas MD Anderson Cancer Center; and The University of Texas School of Public Health, Houston, TX
| | - Arlene M. Correa
- The University of Texas MD Anderson Cancer Center; and The University of Texas School of Public Health, Houston, TX
| | - Stephen G. Swisher
- The University of Texas MD Anderson Cancer Center; and The University of Texas School of Public Health, Houston, TX
| | - Wayne L. Hofstetter
- The University of Texas MD Anderson Cancer Center; and The University of Texas School of Public Health, Houston, TX
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Arnaoutakis GJ, George TJ, Allen JG, Russell SD, Shah AS, Conte JV, Weiss ES. Institutional volume and the effect of recipient risk on short-term mortality after orthotopic heart transplant. J Thorac Cardiovasc Surg 2012; 143:157-67, 167.e1. [PMID: 22172752 DOI: 10.1016/j.jtcvs.2011.09.040] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 08/17/2011] [Accepted: 09/26/2011] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We developed a validated 50-point recipient risk index predicting short-term mortality after orthotopic heart transplant (OHT). This study examined the relationship between institutional volume and recipient risk on post-OHT mortality. METHODS We used United Network for Organ Sharing (UNOS) data to identify primary OHT recipients between January 2000 and April 2010. Centers were stratified by mean annual volume. Preoperative Index for Mortality Prediction After Cardiac Transplantation risk scores were calculated for each patient with our validated 50-point system. Primary outcomes were 30-day and 1-year survivals. Multivariable logistic regression analysis included interaction terms to examine effect modification of risk and volume on mortality. RESULTS In all, 18,226 patients underwent transplant at 141 centers: 1173 (6.4%) recipients at low-volume centers (<7 procedures/y), 5353 (29.4%) at medium-volume centers (7-15 procedures/y), and 11,700 (64.2%) at high-volume centers (>15 procedures/y). Low center volume was associated with worse 1-year mortality (odds ratio, 1.58; 95% confidence interval, 1.30-1.92; P < .001). For 1-year survival, there was significant positive interaction between center volume and recipient risk score (odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P = .02), indicating effect of risk on mortality at low-volume centers greater than from either variable analyzed individually. Among high-risk recipients (score ≥10), 1-year survival was improved at high-volume centers (high, 79%; medium, 75%; low, 64%). CONCLUSIONS In analysis of UNOS data with our validated recipient risk index, institutional volume acted as an effect modifier on association between risk and mortality. High-risk patients had higher mortality at low-volume centers; differences dissipated among lower-risk recipients. These data support a mandate for high-risk transplants at higher-volume centers.
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Affiliation(s)
- George J Arnaoutakis
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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28
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Abstract
We report our initial experience with minimally-invasive esophagectomy in 32 patients at Carolinas Medical Center, a community academic medical center. Indications for surgery were adenocarcinoma in 27, squamous cell carcinoma in 3, and benign stricture in 2. Transthoracic Ivor-Lewis esophagectomy with laparoscopy and thoracoscopy was performed in 28, a 3-stage esophagectomy in 3, and transhaital esophagectomy in 1. There was no operative mortality and median hospital stay was 10.5 days for patients treated with minimally invasive esophagectomy. This compares with an operative mortality of 8.9% and median hospital stay of 17 days for open esophagectomy in our institution.
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Affiliation(s)
- Erin M Hanna
- Department of General Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, PO Box 32861, Charlotte, NC 28232-2861, USA
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Wouters MWJM, Gooiker GA, van Sandick JW, Tollenaar RAEM. The volume-outcome relation in the surgical treatment of esophageal cancer: a systematic review and meta-analysis. Cancer 2011; 118:1754-63. [PMID: 22009562 DOI: 10.1002/cncr.26383] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 04/06/2011] [Accepted: 04/26/2011] [Indexed: 01/16/2023]
Abstract
This study was undertaken to conduct a systematic review and meta-analysis of the literature on the relation between procedural volume and outcome of esophagectomies. A systematic search was carried out to identify articles investigating effects of hospital or surgeon volume on short-term and long-term outcomes published between 1995 and 2010. Articles were scrutinized for methodological quality, and after inclusion of only high-quality studies, a meta-analysis assuming a random effects model was done to estimate the effect of higher volume on patient outcome. Heterogeneity in study results was evaluated with an I(2) -test and risk of publication bias with an Egger regression intercept. Forty-three studies were found. Sixteen studies met the strict inclusion criteria for the meta-analysis on hospital volume and postoperative mortality and 4 studies on hospital volume and survival. The pooled estimated effect size was significant for high-volume providers in the analysis of postoperative mortality (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.89-2.80) and in the survival analysis (OR, 1.17; 95% CI, 1.05-1.30). The meta-analysis of surgical volume and outcome showed no significant results. Studies in which the results were adjusted not only for patient characteristics but also for tumor characteristics and urgency of the operation showed a stronger correlation between hospital volume and mortality. Also, studies performed on data from the United States showed higher effect sizes. The evidence for hospital volume as an important determinant of outcome in esophageal cancer surgery is strong. Concentration of procedures in high-volume hospitals with a dedicated setting for the treatment of esophageal cancer might lead to an overall improvement in patient outcome.
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Affiliation(s)
- Michel W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands.
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Rubiano S, Gil F, Celis-Rodriguez E, Oliveros H, Carrasquilla G. Critical care in Colombia: differences between teaching and nonteaching intensive care units. A prospective cohort observational study. J Crit Care 2011; 27:104.e9-17. [PMID: 21703811 DOI: 10.1016/j.jcrc.2011.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 03/01/2011] [Accepted: 03/05/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this study was to determine the differences in the efficacy and efficiency in providing critical care to hospitalized patients in teaching vs nonteaching intensive care units (ICUs) in Colombia. METHODS A prospective cohort observational study was conducted. LOCATION This study was conducted in 11 teaching and 8 nonteaching ICUs. From June 1 until December 31, 2005, data on 826 patients admitted consecutively to teaching ICUs and 825 patients admitted to nonteaching ICUs were analyzed. MEASUREMENTS Acute Physiology and Chronic Health Evaluation II, Simplified Therapeutic Intervention Scoring System, ICU discharge status (dead or alive) and ICU length of stay, and standardized mortality ratios were considered in this study. A logistic regression and robust linear regression were performed. RESULTS There were no differences in mortality (P = .25). Standardized mortality was less than 1 for both types of units. The teaching ICUs length of stay was 1 day longer (P < .01). Resource use is 25% higher in teaching units (P = .01). When the Simplified Therapeutic Intervention Scoring System score on the last day was from 21 to 35, a higher ratio of patients from the nonteaching ICUs was observed going floor or home when discharged from the ICU (P < .01). CONCLUSIONS Nonteaching ICUs discharge patients earlier than do teaching ICUs, but the effect of it remains to be clarified with further studies addressing questions as what happens after ICU discharge.
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Affiliation(s)
- Sandra Rubiano
- Clinical Studies Department, Centro de Estudios e Investigación en Salud, CEIS; Health Research and Studies Center-CEIS, Fundacion Santa Fe de Bogota, Bogota, Colombia.
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SPECHLER STUARTJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American Gastroenterological Association technical review on the management of Barrett's esophagus. Gastroenterology 2011; 140:e18-52; quiz e13. [PMID: 21376939 PMCID: PMC3258495 DOI: 10.1053/j.gastro.2011.01.031] [Citation(s) in RCA: 773] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Morita M, Nakanoko T, Fujinaka Y, Kubo N, Yamashita N, Yoshinaga K, Saeki H, Emi Y, Kakeji Y, Shirabe K, Maehara Y. In-hospital mortality after a surgical resection for esophageal cancer: analyses of the associated factors and historical changes. Ann Surg Oncol 2011; 18:1757-65. [PMID: 21207167 DOI: 10.1245/s10434-010-1502-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Resections for esophageal cancer are invasive, with high mortality and morbidity rates. The object of this study was to clarify the factors associated with in-hospital death while also evaluating any associated historical changes in the characteristics of such deaths. METHODS The factors associated with mortality were examined by logistic regression analysis in 1106 patients who underwent an esophagectomy for esophageal cancer. The historical changes in the characteristics of in-hospital deaths were also evaluated. RESULTS A multivariate analysis revealed that not only undergoing an esophagectomy before 1979, but also a patient's age (odds ratio 1.070 for every increase in age by year) and an incomplete resection (odds ratio 2.265) were independent factors associated with in-hospital death. The in-hospital mortality rates were 16.1%, 5.8%, 2.5%, and 3.1%, while the 30-day mortality rates were 9.2%, 2.2%, 0.8%, and 0.3% during 1964-1979, the 1980s, the 1990s, and the 2000s, respectively. Eight patients had preoperative comorbidities among 11 patients who died in the hospital after 1997. The mortality rate was 5.5% in patients with any comorbidities, while it was 1.3% in patients without any comorbidities (P = 0.026). The most common direct cause of in-hospital death was previous pulmonary complications; however, cancer progression has recently become the most common cause. CONCLUSIONS To prevent in-hospital mortality after an esophagectomy, strict indications for surgery and careful perioperative management are important, especially in high-risk patients with advanced esophageal cancer.
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Affiliation(s)
- Masaru Morita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Lauder CIW, Marlow NE, Maddern GJ, Barraclough B, Collier NA, Dickinson IC, Fawcett J, Graham JC. Systematic review of the impact of volume of oesophagectomy on patient outcome. ANZ J Surg 2010; 80:317-23. [PMID: 20557504 DOI: 10.1111/j.1445-2197.2010.05276.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE This systematic review aims to assess whether overall survival, mortality, morbidity, length of stay and cost of performing oesophagectomy are related to surgical volume. METHODS A systematic search strategy from 1997 until December 2006 was used to retrieve relevant studies. Inclusion of articles was established through application of a predetermined protocol, independent assessment by two reviewers and a final consensus decision. RESULTS A total of 55 studies were identified of which 27 studies, representing 68 882 patients, met the inclusion criteria. Twenty-one of these solely examined hospital volume, 5 examined both hospital and surgeon volume, and 1 examined surgeon volume in isolation. All but one of the studies were retrospective in nature, and because of the heterogeneity of the literature, no meta-analysis could be performed. Of the studies exploring the relationship between hospital volume and mortality, 20 reported a statistically significant benefit to large volume centres. Five of six included studies showed significant evidence for a reduced mortality risk with greater surgeon volume. CONCLUSIONS Based on the evidence from these retrospective studies, oesophagectomy performed in high volume centres would appear to be associated with better outcome compared with low volume centres.
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Affiliation(s)
- Christopher I W Lauder
- University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Woodville South, SA 5011, Australia
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Wouters M, Jansen-Landheer M, van de Velde C. The quality of cancer care initiative in the Netherlands. Eur J Surg Oncol 2010; 36 Suppl 1:S3-S13. [DOI: 10.1016/j.ejso.2010.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Accepted: 06/01/2010] [Indexed: 01/08/2023] Open
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Fujita H, Ozawa S, Kuwano H, Ueda Y, Hattori S, Yanagawa T. Esophagectomy for cancer: clinical concerns support centralizing operations within the larger hospitals. Dis Esophagus 2010; 23:145-52. [PMID: 19515188 DOI: 10.1111/j.1442-2050.2009.00986.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophagectomy needs experienced surgical techniques and a well-trained perioperative care team. There are now many reports that the mortality rate after esophagectomy is higher in those hospitals with a low volume of esophagectomy and/or low surgeon's volume. The purpose of this study is to decide the respective numbers of esophagectomy operations per year to define low-volume and high-volume hospitals in Japan. If medical policy aims to further reduce mortality and morbidity associated with esophagectomy, then esophagectomy operations should be further centralized, away from low-volume hospitals, into high-volume hospitals. The Japanese Association for Thoracic Surgery has accumulated the surgical outcomes from 31 380 esophagectomy operations, registered from 709 institutes during the period from 2001 to 2006. These institutes are here classified into six groups according to the number of esophagectomy operations per year as 4 or less, 5-9, 10-19, 20-39, 40-79, and 80 or more. Using a statistical model-selection procedure by information criteria, these six groups are then classified into three categories as low-volume, medium-volume, and as high-volume hospitals. Among the 31 380 patients registered, overall, 390 patients (1.2%) died within 30 days, and 1187 patients (3.8%) died during the primary hospital stay. The odds ratio of the greatest volume group to the minimum volume group was 0.307 for the 30-day mortality rate, and 0.288 for the in-hospital mortality rate. For both the 30-day mortality rate and the in-hospital mortality rate, a hospital with less than five esophagectomy operations per year was classified as a low-volume hospital. A hospital with 40 or more esophagectomy operations per year was classified as a high-volume hospital. Concerning the number of esophagectomy operations performed per year in Japan, low-volume hospitals are defined as those where esophagectomy is performed less than five times per year, and high-volume hospitals are defined as those where esophagectomy is performed 40 or more times per year. If medical policy in Japan aims to further decrease the mortality after esophagectomy, then esophagectomy operations should be limited in these identified low-volume hospitals.
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Affiliation(s)
- H Fujita
- Department of Surgery, School of Medicine, Kurume University, Kurume, Fukuoka 830-0011, Japan.
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Nicholson WK, Witter F, Powe NR. Effect of hospital setting and volume on clinical outcomes in women with gestational and type 2 diabetes mellitus. J Womens Health (Larchmt) 2010; 18:1567-76. [PMID: 19764843 DOI: 10.1089/jwh.2008.1114] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Efforts to improve health care outcomes in the United States have led some organizations to recommend specific hospital settings or case volumes for complex medical diagnoses and procedures. But there are few studies of the effect of setting and volume on maternal outcomes, particularly in complicated conditions, such as diabetes. Our objective was to estimate the effect of hospital setting and volume on childbirth morbidity and length of stay in pregnancies complicated by type 2 and gestational diabetes. METHODS We analyzed Maryland hospital discharge data during 1999-2004. The dependent variables were primary cesarean delivery, episiotomy, a composite variable for severe maternal morbidity, and hospital length of stay. The independent variables were hospital setting (community, non-teaching hospitals, community, teaching hospitals, and academic medical centers) and tertiles of annual hospital diabetes delivery volume. Multivariable regression analysis was used to assess the relation of hospital setting with each outcome, adjusting for hospital volume and maternal case mix. RESULTS 5,507 deliveries with type 2 (15%) and gestational (85%) diabetes were analyzed. Primary cesarean delivery rates among women with any diabetes did not vary across settings. After adjustment for volume and patient case mix, the likelihood of severe maternal morbidity was higher among deliveries at academic centers compared to community, non-teaching hospitals (odds ratio [OR], 2.1; 95% confidence interval: 1.0, 4.2). Academic centers had a protective effect (OR, 0.3; 95% CI: 0.2, 0.7) and community teaching hospitals had a borderline protective effect (OR, 0.8; 95% CI: 0.7, 1.0) on episiotomy, compared to community, non-teaching hospitals. Length of stay was greater at academic centers and community, teaching hospitals compared to community, non-teaching hospitals (5.4 days, 3.5 days vs. 2.8 days, respectively). We did not identify an independent association between hospital diabetes volume and clinical outcomes after adjustment for case mix. CONCLUSIONS Among women with type 2 and gestational diabetes, hospital setting is associated with a higher likelihood of severe maternal morbidity and length of stay, independent of volume. Patient case mix accounts for some of the variation across settings. The volume-outcome relationship found with other complex medical conditions or procedures was not found among diabetic pregnancies. Further investigations are needed to explain variations in outcomes across hospital settings and volumes.
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Affiliation(s)
- W K Nicholson
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA.
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Abstract
Barrett's esophagus is a condition in which the stratified squamous epithelium of the distal esophagus is replaced by specialized intestinal metaplasia. Clinical management of Barrett's esophagus, like many other "premalignant" conditions, is characterized by overdiagnosis of benign early changes that will not cause death or suffering during the lifetime of an individual and underdiagnosis of life-threatening early disease. Recent studies of a number of different types of cancer have revealed much greater genomic complexity than was previously suspected. This genomic complexity could create challenges for early detection and prevention if it develops in premalignant epithelia prior to cancer. Neoplastic progression unfolds in space and time, and Barrett's esophagus provides one of the best models for rapid advances, including "gold standard" cohort studies, to distinguish individuals who do and do not progress to cancer. Specialized intestinal metaplasia has many properties that appear to be protective adaptations to the abnormal environment of gastroesophageal reflux. A large body of evidence accumulated over several decades implicates chromosome instability in neoplastic progression from Barrett's esophagus to esophageal adenocarcinoma. Small, spatial scale studies have been used to infer the temporal order in which genomic abnormalities develop during neoplastic progression in Barrett's esophagus. These spatial studies have provided the basis for prospective cohort studies of biomarkers, including DNA content abnormalities (tetraploidy, aneuploidy) and a biomarker panel of 9p LOH, 17p LOH and DNA content abnormalities. Recent advances in SNP array technology provide a uniform platform to assess chromosome instability.
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Affiliation(s)
- Brian J Reid
- Fred Hutchinson Cancer Research Center, Divisions of Human Biology and Public Health Sciences, Department of Genome Sciences, University of Washington, Seattle, WA, USA.
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Kohn GP, Galanko JA, Meyers MO, Feins RH, Farrell TM. National trends in esophageal surgery--are outcomes as good as we believe? J Gastrointest Surg 2009; 13:1900-10; discussion 1910-2. [PMID: 19760305 DOI: 10.1007/s11605-009-1008-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Accepted: 08/25/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Positive volume-outcome relationships in esophagectomy have prompted support for regionalization of care; however, outcomes have not recently been analyzed. This study examines national trends in provision of esophagectomy and reassesses the volume-outcome relationship in light of changing practice patterns and training paradigms. METHODS The Nationwide Inpatient Sample was queried from 1998 to 2006. Quantification of patients' comorbidities was made using the Charlson Index. Using logistic regression modeling, institutions' annual case volumes were correlated with risk-adjusted outcomes over time, as well as presence or absence of fellowship and residency training programs. RESULTS A nationwide total of 57,676 esophagectomies were recorded. In-hospital unadjusted mortality fell from 12% to 7%. Adjusting for comorbidities, greater esophagectomy volume was associated with improvements in the incidence of most measured complications, though mortality increased once greater than 100 cases were performed. Hospitals supporting fellowship training or a surgical residency program did not have higher rates of mortality or total complications. CONCLUSIONS The current national mortality rate of 7% following esophagectomy is higher than is reported in most contemporary case series. A greater annual esophagectomy volume improves outcomes, but only up to a point. Current training paradigms are safe.
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Affiliation(s)
- Geoffrey Paul Kohn
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27599-7081, USA.
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Weiss ES, Allen JG, Meguid RA, Patel ND, Merlo CA, Orens JB, Baumgartner WA, Conte JV, Shah AS. The impact of center volume on survival in lung transplantation: an analysis of more than 10,000 cases. Ann Thorac Surg 2009; 88:1062-70. [PMID: 19766782 DOI: 10.1016/j.athoracsur.2009.06.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 05/28/2009] [Accepted: 06/01/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND Whether center volume influences outcomes in lung transplantation is unknown. We reviewed United Network for Organ Sharing data to examine the effect of center volume on short-term mortality. METHODS We reviewed United Network for Organ Sharing data (1998 through 2007) to identify 10,496 first-time adult lung transplantation recipients at 79 centers. Centers were stratified by quartiles of mean annual volume. Risk of 30-day mortality and 1- and 5-year mortality (censored for 30-day death) were assessed by multivariable Cox proportional hazards regression. RESULTS Mean center volume ranged from less than 1 to 58.2 (median, 9.4 cases/year; volume quartiles: 0 to 2.1, 2.2 to 9.4, 9.5 to 19.9, and 20 to 58.2 cases). Each 1 case/year decrease led to a 2% increase in 30-day mortality (hazard ratio, 1.02; 95% confidence interval, 1.01 to 1.02; p < 0.001). Centers of lowest quartile (performing <or=2.1 lung transplantations/year) had a 30-day cumulative mortality of 9.6% or 89% increase in the risk of death (hazard ratio, 1.89; 95% confidence interval, 1.01 to 3.44; p = 0.05) compared with the highest quartile centers despite fewer idiopathic pulmonary fibrosis patients (15.6% versus 25.8%; p < 0.001) and younger age (40.9 versus 51.5 years; p < 0.001). Low-volume centers had double the risk of 30-day censored 1-year mortality (hazard ratio, 1.95; 95% confidence interval, 1.30 to 2.92; p = 0.001). High-volume centers (>or=20 lung transplantations/year) had the lowest 30-day mortality (4.1%). CONCLUSIONS We provide an initial examination of the relationship of volume and lung allocation score to outcomes for lung transplantation. Low center volume is associated with increased short-term and cumulative mortality despite fewer idiopathic pulmonary fibrosis patients and younger patients.
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Affiliation(s)
- Eric S Weiss
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA
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Hastan D, Vandenbroucke JP, van der Mey AGL. A Meta-Analysis of Surgical Treatment for Vestibular Schwannoma: Is Hospital Volume Related to Preservation of Facial Function? Otol Neurotol 2009; 30:975-80. [DOI: 10.1097/mao.0b013e3181b0d04a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Slim K, Blay JY, Brouquet A, Chatelain D, Comy M, Delpero JR, Denet C, Elias D, Fléjou JF, Fourquier P, Fuks D, Glehen O, Karoui M, Kohneh-Shahri N, Lesurtel M, Mariette C, Mauvais F, Nicolet J, Perniceni T, Piessen G, Regimbeau JM, Rouanet P, sauvanet A, Schmitt G, Vons C, Lasser P, Belghiti J, Berdah S, Champault G, Chiche L, Chipponi J, Chollet P, De Baère T, Déchelotte P, Garcier JM, Gayet B, Gouillat C, Kianmanesh R, Laurent C, Meyer C, Millat B, Msika S, Nordlinger B, Paraf F, Partensky C, Peschaud F, Pocard M, Sastre B, Scoazec JY, Scotté M, Triboulet JP, Trillaud H, Valleur P. [Digestive oncology: surgical practices]. ACTA ACUST UNITED AC 2009; 146 Suppl 2:S11-80. [PMID: 19435621 DOI: 10.1016/s0021-7697(09)72398-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- K Slim
- Chirurgien Clermont-Ferrand.
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Yasunaga H, Matsuyama Y, Ohe K; Japan Surgical Society. Effects of hospital and surgeon case-volumes on postoperative complications and length of stay after esophagectomy in Japan. Surg Today 2009; 39:566-71. [PMID: 19562442 DOI: 10.1007/s00595-008-3832-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2008] [Accepted: 06/09/2008] [Indexed: 02/06/2023]
Abstract
PURPOSE The exact relationship between larger caseload volume and lower morbidity following esophagectomy has not been established. This study investigates the effect of surgical volumes on reducing postoperative complications and length of stay after esophagectomy. METHODS Patient and hospital data were collected electronically via a web-based questionnaire sent to surgeons in the Japan Surgical Society. Data were based on 642 patients treated with esophagectomy at 183 hospitals between November 1, 2006 and February 28, 2007. Multivariate analysis revealed that postoperative morbidity and length of stay regressed against hospital and surgeon volumes, patient characteristics, and details of the procedures. RESULTS In a logistic regression model, esophagectomies by surgeons performing a high volume of operations (>100 cases; "high case-volume surgeons") were followed by a significantly lower rate of postoperative complications (odds ratio [OR], 0.49; 95% confidence interval (CI), 0.24-0.98, P = 0.04). In a proportional hazard model, high-volume surgeons reduced the length of stay significantly: the hazard ratio for medium casevolume surgeons (50-99 cases) was 1.53 [95% CI, 1.14-2.06, P = 0.00], whereas that for the highest case-volume surgeons was 1.34 [95% CI, 1.00-1.79, P = 0.05] vs the lowest case-volume surgeons. Neither postoperative complications nor length of stay were significantly associated with hospital volume. CONCLUSION These findings indicate that morbidity after esophagectomy is more dependent on individual surgeon-specific skill than on hospital-based factors.
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Wouters M, Krijnen P, Le Cessie S, Gooiker G, Guicherit O, Marinelli A, Kievit J, Tollenaar R. Volume- or outcome-based referral to improve quality of care for esophageal cancer surgery in The Netherlands. J Surg Oncol 2009; 99:481-7. [DOI: 10.1002/jso.21191] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Pennathur A, Farkas A, Krasinskas AM, Ferson PF, Gooding WE, Gibson MK, Schuchert MJ, Landreneau RJ, Luketich JD. Esophagectomy for T1 esophageal cancer: outcomes in 100 patients and implications for endoscopic therapy. Ann Thorac Surg 2009; 87:1048-54; discussion 1054-5. [PMID: 19324126 DOI: 10.1016/j.athoracsur.2008.12.060] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Revised: 12/15/2008] [Accepted: 12/17/2008] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Esophagectomy is the standard treatment for T1 esophageal cancer (EC). Interest in endoscopic therapies, particularly for T1 EC, is increasing. We evaluated the long-term outcomes after esophagectomy and examined the pathologic features of T1 cancer to determine the suitability for potential endoscopic therapy. METHODS We reviewed the outcomes of esophagectomy in 100 consecutive patients with T1 EC. The primary end points studied were overall survival (OS) and disease-free survival (DFS). In addition to detailed pathology review, we evaluated prognostic variables associated with survival. RESULTS Esophagectomy was performed in 100 patients (79 men, 21 women; median age, 68 years) for T1 EC, comprising adenocarcinoma, 91; squamous, 9; intramucosal (T1a), 29; and submucosal (T1b), 71. The 30-day mortality was 0%. Resection margins were microscopically negative in 99 patients (99%). N1 disease was present in 21 (T1a, 2 of 29 [7%]; T1b, 19 of 71 [27%]), associated high-grade dysplasia in 64 (64%), and angiolymphatic invasion in 19 (19%). At a median follow-up of 66 months, estimated 5-year OS was 62% and 3-year DFS was 80% for all patients (including N1). Nodal status and tumor size were significantly associated with OS and DFS, respectively. CONCLUSIONS Esophagectomy can be performed safely in patients with T1 EC with good long-term results. Many patients with T1 EC have several risk factors that may preclude adequate treatment with endoscopic therapy. Further prospective studies are required to evaluate endoscopic therapies. Esophagectomy should continue to remain the standard treatment in patients with T1 EC.
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Affiliation(s)
- Arjun Pennathur
- Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Meguid RA, Weiss ES, Chang DC, Brock MV, Yang SC. The effect of volume on esophageal cancer resections: what constitutes acceptable resection volumes for centers of excellence? J Thorac Cardiovasc Surg 2009; 137:23-9. [PMID: 19154895 DOI: 10.1016/j.jtcvs.2008.09.040] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2007] [Revised: 06/20/2008] [Accepted: 09/16/2008] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Volume-outcome relationships for esophageal cancer resection have been well described with centers of excellence defined by volume. No consensus exists for what constitutes a "high-volume" center. We aim to determine if an objective evidence-based threshold of operative volume associated with improvement in operative outcome for esophageal resections can be defined. METHODS Retrospective analysis was performed on patients undergoing esophageal resection for cancer in the 1998 to 2005 Nationwide Inpatient Sample. A series of multivariable analyses were performed, changing the resection volume cutoff to account for the range of annual hospital resections. The goodness of fit of each model was compared by pseudo r(2), the amount of data variance explained by each model. RESULTS A total of 4080 patients underwent esophageal resection. The median annual hospital resection volume was 4 (range: 1-34). The mortality rate of "high-volume" centers ranged from 9.94% (>or=2 resection/year) to 1.56% (>or=30 resections/year). The best model was with an annual hospital resection volume greater than or equal to 15 (3.87% of data variance explained). The difference in goodness of fit between the best model and other models with different volume cutoffs was 0.64%, suggesting that volume explains less than 1% of variance in perioperative death. CONCLUSION Our data do not support the use of volume cutoffs for defining centers of excellence for esophageal cancer resections. Although volume has an incremental impact on mortality, volume alone is insufficient for defining centers of excellence. Volume seems to function as an imperfect surrogate for other variables, which may better define centers of excellence. Additional work is needed to identify these variables.
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Affiliation(s)
- Robert A Meguid
- Division of Thoracic Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
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Abstract
OBJECTIVES Dysplasia in a Barrett's esophagus (BE) is associated with an increased risk for developing esophageal adenocarcinoma. Ablation using the HALO system has shown promise for the treatment of BE with dysplasia. The objective of this study was to assess the safety and efficacy of a stepwise regimen of circumferential and focal ablation using the HALO system for the treatment of BE with dysplasia. METHODS BE patients with low-grade dysplasia (LGD) or high-grade dysplasia (HGD) were enrolled. Primary circumferential ablation was followed every 3 months by further circumferential ablation or focal ablation until complete endoscopic eradication of BE was achieved. At 3- or 6-month intervals, depending on baseline grade, targeted and four quadrant random biopsies were obtained to assess the histological response to ablation. A complete response (CR) is defined as all biopsies negative for intestinal metaplasia (IM) (CR-IM) or dysplasia (CR-D) at last available follow-up. RESULTS A total of 63 patients were treated (57 men; median age 71 years; median BE length 5 cm), with worst grade of dysplasia being LGD (n=39) and HGD (n=24). Follow-up is available for 62 patients (median 24 months). Overall, CR-IM is 79% and CR-D is 89%. For the LGD cohort, CR-IM is 87% and CR-D is 95%. For the HGD cohort, CR-IM is 67% and CR-D is 79%. CONCLUSIONS Stepwise circumferential and focal ablation of BE containing dysplasia appears to be a safe and effective intervention, achieving a CR for dysplasia in 95% and 79% of LGD and HGD patients, respectively.
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Affiliation(s)
- Virender K Sharma
- 1Esophageal Clinic, Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona 85259, USA.
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Abstract
In patients with esophageal cancer, radical surgical resection of the esophagus and surrounding lymph nodes is the only curative treatment option. Nevertheless, no standard surgical procedure exists. The aims of the present study were to gain insight into the frequencies of the various surgical techniques in esophageal cancer surgery as applied by surgeons throughout the world and to identify intercontinental differences regarding surgical techniques. Surgeons with particular interest in esophageal surgery, including members of the International Society for Diseases of the Esophagus, the European Society of Esophagology Group d'Etude Européen des Maladies de l'Oesophage and the OESO, were invited to participate in an online questionnaire. Questions were asked regarding approach to esophagectomy, extent of lymphadenectomy (LND), type of reconstruction, and anastomotic techniques. Subanalyses were performed for the surgeons' case volume per year, years of experience in esophageal cancer surgery, and continent. Of 567 invited surgeons, 269 participated, resulting in an overall response rate of 47%. The responders currently performing esophagectomies (n= 250; 44%), represented 41 countries across the six continents. Fifty-two percent of responders favor open transthoracic esophagectomy (TTE) over transhiatal esophagectomy (THE) or minimally invasive esophagectomy (MIE). THE is preferred by 26%, whereas MIE is favored by 14%. Eight percent have no preference for one approach to esophagectomy over the other. The extent of LND is most frequently the 2-field, routinely performed by 73% of surgeons. The continuity of the digestive tract is most frequently restored with a gastric conduit (85%). In open TTE, the anastomosis is routinely created in the neck by 56% of responders and in the chest by 40%. Cervical anastomoses are routinely fashioned by means of a handsewn technique by 65% of responders, while 35% favor the stapled technique. The cervical incision is predominantly performed vertically on the left side of the neck (routinely by 66%). A horizontal neck incision is routinely carried out by 19% of responders and a vertical right-sided incision by 11%. Significant differences in surgical techniques could be detected between low- and high-volume surgeons, between surgeons with <or=10 versus >or=21 years of experience, and between surgeons from different continents. In conclusion, currently the most commonly applied surgical procedure is the open right-sided transthoracic approach with a two-field lymphadenectomy, using a gastric tube anastomosed at the left side of the neck by means of a handsewn, end-to-side technique. The results of this survey provide baseline data for future research and for the development of international guidelines.
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Affiliation(s)
- Judith Boone
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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Weiss ES, Meguid RA, Patel ND, Russell SD, Shah AS, Baumgartner WA, Conte JV. Increased mortality at low-volume orthotopic heart transplantation centers: should current standards change? Ann Thorac Surg 2008; 86:1250-9; discussion 1259-60. [PMID: 18805171 DOI: 10.1016/j.athoracsur.2008.06.071] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 06/11/2008] [Accepted: 06/13/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) mandate that orthotopic heart transplantation (OHT) centers perform 10 transplants per year to qualify for funding. We sought to determine whether this cutoff is meaningful and establish recommendations for optimal center volume using the United Network for Organ Sharing (UNOS) registry. METHODS We reviewed UNOS data (years 1999 to 2006) identifying 14,401 first-time adult OHTs conducted at 143 centers. Stratification was by mean annual institution volume. Primary outcomes of 30-day and 1-year mortality were assessed by multivariable logistic regression (adjusted for comorbidities and risk factors for death). Sequential volume cutoffs were examined to determine if current CMS standards are optimal. Pseudo R2 and area under the receiver operating curve assessed goodness of fit. RESULTS Mean annual volume ranged from 1 to 90. One-year mortality was 12.6% (n = 1,800). Increased center volume was associated with decreased 30-day mortality (p < 0.001). Decreased center volume was associated with increases in 30-day (odds ratio [OR] 1.03, 95% confidence interval [CI]: 1.02 to 1.03, p < 0.001) and 1-year mortality (OR 1.01, 95% CI: 1.01 to 1.02, p = 0.03--censored for 30-day death). The greatest mortality risk occurred at very low volume centers (<or= 2 cases = 2.15 times increase in death, p = 0.03). Annual institutional volume of fewer than 10 cases per year increased 30-day mortality by more than 100% (OR 2.02, 95%CI: 1.46 to 2.80, p < 0.001) and each decrease in mean center volume by one case per year increased the odds of 30-day mortality by 2% (OR 1.02, 95% CI: 1.01 to 1.03, p < 0.001]. Additionally, centers performing fewer than 10 OHTs per year had increased cumulative mortality by Cox proportional hazards regression (hazard ratio 1.35, 95% CI: 1.14 to 1.60, p < 0.001). Sequential multivariable analyses suggested that current CMS standards may not be optimal, as all centers performing more than 40 transplants per year demonstrated less than 5% 30-day mortality. CONCLUSIONS Annual center volume is an independent predictor of short-term mortality in OHT. These data support reevaluation of the current CMS volume cutoff for OHT, as high-volume centers achieve lower mortality.
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50
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McPhee JT, Schanzer A, Messina LM, Eslami MH. Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005. J Vasc Surg 2008; 48:1442-50, 1450.e1. [PMID: 18829236 DOI: 10.1016/j.jvs.2008.07.017] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 07/10/2008] [Accepted: 07/10/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) remains the procedure of choice for treatment of patients with severe carotid artery stenosis. The role of carotid artery stenting (CAS) in this patient group is still being defined. Prior single and multicenter studies have demonstrated economic savings associated with CEA compared with CAS. The purpose of this study was to compare surgical outcomes and resource utilization associated with these two procedures at the national level in 2005, the first year in which a specific ICD-9 procedure code for CAS was available. METHODS All patient discharges for carotid revascularization for the year 2005 were identified in the Nationwide Inpatient Sample based on ICD9-CM procedure codes for CEA (38.12) and CAS (00.63). The primary outcome measures of interest were in-hospital mortality and postoperative stroke; secondary outcome measures included total hospital charges and length of stay (LOS). All statistical analyses were performed using SAS version 9.1 (Cary, NC), and data are weighted according to the Nationwide Inpatient Sample (NIS) design to draw national estimates. Univariate analyses of categorical variables were performed using Rao-Scott chi(2), and continuous variables were analyzed by survey weighted analysis of variance (ANOVA). Multivariate logistic regression was performed to evaluate independent predictors of postoperative stroke and mortality. RESULTS During 2005, an estimated 135,701 patients underwent either CEA or CAS nationally. Overall, 91% of patients underwent CEA. The mean age overall was 71 years. Postoperative stroke rates were increased for CAS compared with CEA (1.8% vs 1.1%, P < .05), odds ratio (OR) 1.7; (95% confidence interval [CI] 1.2-2.3). Overall, mortality rates were higher for CAS compared with CEA (1.1% vs 0.57%, P < .05) this difference was substantially increased in regard to patients with symptomatic disease (4.6% vs 1.4%, P < .05). By logistic regression, CAS trended toward increased mortality, OR 1.5; (95% CI .96-2.5). Overall, the median total hospital charges for patients that underwent CAS were significantly greater than those that underwent CEA ($30,396 vs $17,658 P < .05). CONCLUSIONS Based on a large representative sample during the year 2005, CEA was performed with significantly lower in-hospital mortality, postoperative stroke rates, and lower median total hospital charges than CAS in US hospitals. As the role for CAS becomes defined for the management of patients with carotid artery stenosis, clinical as well as economic outcomes must be continually evaluated.
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Affiliation(s)
- James T McPhee
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA
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