Vol. 147 No. 2930 (2017)
Lower hospital volume is associated with higher mortality after oesophageal, gastric, pancreatic and rectal cancer resection
In various countries, the association of lower hospital volume and higher mortality after oesophageal, gastric, pancreatic and rectal cancer resection has been clearly demonstrated. However, scientific evidence regarding the volume-outcomes relationship for high-risk visceral surgical procedures in Switzerland is lacking. The a priori hypothesis of this retrospective population-based cohort study analysis was that low-volume hospitals in Switzerland have a higher rate of postoperative mortality after oesophageal, gastric, pancreatic and rectal cancer resection.
Patients undergoing elective resection of oesophageal, gastric, pancreatic and rectal cancer between 1999 and 2012 were identified in the inpatient database of the Swiss Federal Statistical Office. Nonparametric correlation analyses were used to assess time trends. Mortality was assessed in univariable and risk-adjusted conditional logistic regression analyses with stratification for year of surgery.
A total of 1487 oesophageal, 4404 gastric, 2668 pancreatic and 9743 rectal cancer patients were identified. For all cancer entities, significant treatment centralisation was observed over the time period (all p <0.001). The rate of mortality was inversely related to the annual number of patients treated at a certain hospital. The decrease of postoperative mortality from low-volume to high-volume hospitals was 6.3% to 3.3% for oesophageal cancer (p = 0.019), 4.9% to 3.3% for gastric cancer (p = 0.023), 5.4% to 2.0% for pancreatic cancer (p = 0.037), and 2.4% to 1.6% for rectal cancer (p = 0.008). These results were confirmed in risk-adjusted analyses with a decreased odds of pos-operative death by 49% for oesophageal (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.22–1.18; p = 0.085), 32% for gastric (OR 0.68, 95% CI 0.48–0.98; p = 0.032), 68% for pancreatic (OR 0.32, 95% CI 0.11–0.89; p = 0.011) and 29% for rectal cancer (OR 0.71, 95% CI 0.52–0.98; p = 0.033).
This population-based analysis – the first of its kind in the literature - demonstrates a higher postoperative mortality in low-volume hospitals for patients undergoing oesophageal, gastric, pancreatic and rectal cancer resection in Switzerland. Hence, such operations should preferably be performed in high-volume hospitals.
- Douek M, Taylor I. Good practice and quality assurance in surgical oncology. Lancet Oncol. 2003;4(10):626–30. doi:.https://doi.org/10.1016/S1470-2045(03)01222-1
- Hohenberger W, Merkel S, Hermanek P. Volume and outcome in rectal cancer surgery: the importance of quality management. Int J Colorectal Dis. 2013;28(2):197–206. doi:.https://doi.org/10.1007/s00384-012-1596-2
- Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Kelly KN, Hensley BJ, et al. High volume improves outcomes: The argument for centralization of rectal cancer surgery. Surgery. 2016;159(3):736–48. doi:.https://doi.org/10.1016/j.surg.2015.09.021
- Markar SR, Karthikesalingam A, Thrumurthy S, Low DE. Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000-2011. J Gastrointest Surg. 2012;16(5):1055–63. doi:.https://doi.org/10.1007/s11605-011-1731-3
- Hata T, Motoi F, Ishida M, Naitoh T, Katayose Y, Egawa S, et al. Effect of Hospital Volume on Surgical Outcomes After Pancreaticoduodenectomy: A Systematic Review and Meta-analysis. Ann Surg. 2016;263(4):664–72. doi:.https://doi.org/10.1097/SLA.0000000000001437
- Dikken JL, Dassen AE, Lemmens VE, Putter H, Krijnen P, van der Geest L, et al. Effect of hospital volume on postoperative mortality and survival after oesophageal and gastric cancer surgery in the Netherlands between 1989 and 2009. Eur J Cancer. 2012;48(7):1004–13. doi:.https://doi.org/10.1016/j.ejca.2012.02.064
- Coupland VH, Lagergren J, Lüchtenborg M, Jack RH, Allum W, Holmberg L, et al. Hospital volume, proportion resected and mortality from oesophageal and gastric cancer: a population-based study in England, 2004-2008. Gut. 2013;62(7):961–6. doi:.https://doi.org/10.1136/gutjnl-2012-303008
- Colavita PD, Tsirline VB, Belyansky I, Swan RZ, Walters AL, Lincourt AE, et al. Regionalization and outcomes of hepato-pancreato-biliary cancer surgery in USA. J Gastrointest Surg. 2014;18(3):532–41. doi:.https://doi.org/10.1007/s11605-014-2454-z
- Yoshioka R, Yasunaga H, Hasegawa K, Horiguchi H, Fushimi K, Aoki T, et al. Impact of hospital volume on hospital mortality, length of stay and total costs after pancreaticoduodenectomy. Br J Surg. 2014;101(5):523–9. doi:.https://doi.org/10.1002/bjs.9420
- Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117–27. doi:.https://doi.org/10.1056/NEJMsa035205
- Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128–37. doi:.https://doi.org/10.1056/NEJMsa012337
- Meagher AP. Colorectal cancer: is the surgeon a prognostic factor? A systematic review. Med J Aust. 1999;171(6):308–10.
- Guller U, Safford S, Pietrobon R, Heberer M, Oertli D, Jain NB. High hospital volume is associated with better outcomes for breast cancer surgery: analysis of 233,247 patients. World J Surg. 2005;29(8):994–9, discussion 999–1000. doi:.https://doi.org/10.1007/s00268-005-7831-z
- Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011;364(22):2128–37. doi:.https://doi.org/10.1056/NEJMsa1010705
- Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA. 1998;280(20):1747–51. doi:.https://doi.org/10.1001/jama.280.20.1747
- Derogar M, Sadr-Azodi O, Johar A, Lagergren P, Lagergren J. Hospital and surgeon volume in relation to survival after esophageal cancer surgery in a population-based study. J Clin Oncol. 2013;31(5):551–7. doi:.https://doi.org/10.1200/JCO.2012.46.1517
- Pecorelli N, Balzano G, Capretti G, Zerbi A, Di Carlo V, Braga M. Effect of surgeon volume on outcome following pancreaticoduodenectomy in a high-volume hospital. J Gastrointest Surg. 2012;16(3):518–23. doi:.https://doi.org/10.1007/s11605-011-1777-2
- Yeo HL, Abelson JS, Mao J, O’Mahoney PR, Milsom JW, Sedrakyan A. Surgeon Annual and Cumulative Volumes Predict Early Postoperative Outcomes after Rectal Cancer Resection. Ann Surg. 2017;265(1):151–7.
- Liu CJ, Chou YJ, Teng CJ, Lin CC, Lee YT, Hu YW, et al. Association of surgeon volume and hospital volume with the outcome of patients receiving definitive surgery for colorectal cancer: A nationwide population-based study. Cancer. 2015;121(16):2782–90. doi:.https://doi.org/10.1002/cncr.29356
- Mamidanna R, Ni Z, Anderson O, Spiegelhalter SD, Bottle A, Aylin P, et al. Surgeon Volume and Cancer Esophagectomy, Gastrectomy, and Pancreatectomy: A Population-based Study in England. Ann Surg. 2016;263(4):727–32. doi:.https://doi.org/10.1097/SLA.0000000000001490
- Derogar M, Blomberg J, Sadr-Azodi O. Hospital teaching status and volume related to mortality after pancreatic cancer surgery in a national cohort. Br J Surg. 2015;102(5):548–57, discussion 557. doi:.https://doi.org/10.1002/bjs.9754
- Sutton JM, Wilson GC, Wima K, Hoehn RS, Cutler Quillin R, 3rd, Hanseman DJ, et al. Readmission After Pancreaticoduodenectomy: The Influence of the Volume Effect Beyond Mortality. Ann Surg Oncol. 2015;22(12):3785–92. doi:.https://doi.org/10.1245/s10434-015-4451-1
- Ess S, Joerger M, Frick H, Probst-Hensch N, Vlastos G, Rageth C, et al. Predictors of state-of-the-art management of early breast cancer in Switzerland. Ann Oncol. 2011;22(3):618–24. doi:.https://doi.org/10.1093/annonc/mdq404
- Munasinghe A, Markar SR, Mamidanna R, Darzi AW, Faiz OD, Hanna GB, et al. Is It Time to Centralize High-risk Cancer Care in the United States? Comparison of Outcomes of Esophagectomy Between England and the United States. Ann Surg. 2015;262(1):79–85. doi:.https://doi.org/10.1097/SLA.0000000000000805
- Brusselaers N, Mattsson F, Lagergren J. Hospital and surgeon volume in relation to long-term survival after oesophagectomy: systematic review and meta-analysis. Gut. 2014;63(9):1393–400. doi:.https://doi.org/10.1136/gutjnl-2013-306074
- Rosenbaum PR. Model-Based Direct Adjustment. J Am Stat Assoc. 1987;82(398):387–94. doi:.https://doi.org/10.1080/01621459.1987.10478441
- Ho DE, Imai K, King G, Stuart EA. MatchIt: Nonparametric preprocessing for parametric causal inference. J Stat Softw. 2011;42(8):1–28. doi:.https://doi.org/10.18637/jss.v042.i08
- Hansen BB, Klopfer SO. Optimal full matching and related designs via network flows. J Comput Graph Stat. 2006;15(3):609–27. doi:.https://doi.org/10.1198/106186006X137047
- Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK, Andersen DK, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236(4):458–63, discussion 463–4. doi:.https://doi.org/10.1097/00000658-200210000-00008
- Hall GM, Shanmugan S, Bleier JI, Jeganathan AN, Epstein AJ, Paulson EC. Colorectal specialization and survival in colorectal cancer. Colorectal Dis. 2016;18(2):O51–60. doi:.https://doi.org/10.1111/codi.13246
- Henneman D, Dikken JL, Putter H, Lemmens VE, Van der Geest LG, van Hillegersberg R, et al. Centralization of esophagectomy: how far should we go? Ann Surg Oncol. 2014;21(13):4068–74. doi:.https://doi.org/10.1245/s10434-014-3873-5
- Gronnier C, Pasquer A, Renaud F, Hec F, Gandon A, Vanderbeken M, et al. Is centralization needed for esophago-gastric cancer patients with low operative risk? a nationwide study, in ESMO 2016, oral presentation. 2016: Copenhagen.