Christopher T Aquina1,2, Adan Z Becerra3, Fergal J Fleming2, Jordan M Cloyd1, Allan Tsung1, Timothy M Pawlik1, Aslam Ejaz1. 1. Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio. 2. Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York. 3. Department of Surgery, Rush University Medical Center, Chicago, Illinois.
Abstract
BACKGROUND: A large body of evidence supports regionalization of complex oncologic surgery to high-volume surgeons at high-volume hospitals. However, whether there is heterogeneity of outcomes among high-volume surgeons at high-volume hospitals remains unknown. METHODS: Patients who underwent esophagectomy, lung resection, pancreatectomy, or proctectomy for primary cancer were identified within the Medicare 100% Standard Analytic File (2013-2017). Mixed-effects analyses assessed the association between Leapfrog annual volume standards for surgeons (esophagectomy ≥7, lung resection ≥15, pancreatectomy ≥10, proctectomy ≥6) and hospitals (esophagectomy ≥20, lung resection ≥40, pancreatectomy ≥20, proctectomy ≥16) relative to postoperative complications and 90-day mortality. Additional analyses using New York's all-payer Statewide Planning and Research Cooperative System (2004-2015) were performed. RESULTS: Among 112,154 Medicare beneficiaries, high-volume surgeons at high-volume hospitals were associated with lower adjusted odds of complications (esophagectomy: odds ratio [OR], 0.73 [95% CI, 0.61-0.86]; lung resection: OR, 0.88 [95% CI, 0.82-0.94]; pancreatectomy: OR, 0.73 [95% CI, 0.66-0.80]; proctectomy: OR, 0.92 [95% CI, 0.85-0.99]) and 90-day mortality (esophagectomy: OR, 0.60 [95% CI, 0.44-0.76]; lung resection: OR, 0.82 [95% CI, 0.73-0.93]; pancreatectomy: OR, 0.66 [95% CI, 0.56-0.76]; proctectomy: OR, 0.74 [95% CI, 0.65-0.85]). For the average patient at the average high-volume hospital, there was a 2-fold difference in the adjusted complication rate between the best-performing and worst-performing high-volume surgeon for all operations (esophagectomy, 28%-55%; lung resection, 7%-21%; pancreatectomy, 16%-35%; proctectomy, 16%-28%). Wide variation was also present in adjusted 90-day mortality for esophagectomy (3.5%-9.3%). Results from New York's all-payer database were similar. CONCLUSIONS: Even among high-volume surgeons meeting the Leapfrog volume standards, wide variation in postoperative outcomes exists. These findings suggest that volume alone should not be used as a quality indicator, and quality metrics should be continuously evaluated across all surgeons and hospital systems. LAY SUMMARY: Previous studies have demonstrated a surgical volume-outcome relationship for high-risk operations-that is high-volume surgeons and hospitals that perform a specific surgical procedure more frequently have better outcomes for that operation. Although most high-volume surgeons had better outcomes, this study demonstrated that some high-volume surgeons did not have better outcomes. Therefore, volume is an important factor but should not be the only factor considered when assessing the quality of a surgeon and a hospital for cancer surgery.
BACKGROUND: A large body of evidence supports regionalization of complex oncologic surgery to high-volume surgeons at high-volume hospitals. However, whether there is heterogeneity of outcomes among high-volume surgeons at high-volume hospitals remains unknown. METHODS: Patients who underwent esophagectomy, lung resection, pancreatectomy, or proctectomy for primary cancer were identified within the Medicare 100% Standard Analytic File (2013-2017). Mixed-effects analyses assessed the association between Leapfrog annual volume standards for surgeons (esophagectomy ≥7, lung resection ≥15, pancreatectomy ≥10, proctectomy ≥6) and hospitals (esophagectomy ≥20, lung resection ≥40, pancreatectomy ≥20, proctectomy ≥16) relative to postoperative complications and 90-day mortality. Additional analyses using New York's all-payer Statewide Planning and Research Cooperative System (2004-2015) were performed. RESULTS: Among 112,154 Medicare beneficiaries, high-volume surgeons at high-volume hospitals were associated with lower adjusted odds of complications (esophagectomy: odds ratio [OR], 0.73 [95% CI, 0.61-0.86]; lung resection: OR, 0.88 [95% CI, 0.82-0.94]; pancreatectomy: OR, 0.73 [95% CI, 0.66-0.80]; proctectomy: OR, 0.92 [95% CI, 0.85-0.99]) and 90-day mortality (esophagectomy: OR, 0.60 [95% CI, 0.44-0.76]; lung resection: OR, 0.82 [95% CI, 0.73-0.93]; pancreatectomy: OR, 0.66 [95% CI, 0.56-0.76]; proctectomy: OR, 0.74 [95% CI, 0.65-0.85]). For the average patient at the average high-volume hospital, there was a 2-fold difference in the adjusted complication rate between the best-performing and worst-performing high-volume surgeon for all operations (esophagectomy, 28%-55%; lung resection, 7%-21%; pancreatectomy, 16%-35%; proctectomy, 16%-28%). Wide variation was also present in adjusted 90-day mortality for esophagectomy (3.5%-9.3%). Results from New York's all-payer database were similar. CONCLUSIONS: Even among high-volume surgeons meeting the Leapfrog volume standards, wide variation in postoperative outcomes exists. These findings suggest that volume alone should not be used as a quality indicator, and quality metrics should be continuously evaluated across all surgeons and hospital systems. LAY SUMMARY: Previous studies have demonstrated a surgical volume-outcome relationship for high-risk operations-that is high-volume surgeons and hospitals that perform a specific surgical procedure more frequently have better outcomes for that operation. Although most high-volume surgeons had better outcomes, this study demonstrated that some high-volume surgeons did not have better outcomes. Therefore, volume is an important factor but should not be the only factor considered when assessing the quality of a surgeon and a hospital for cancer surgery.
Authors: Emanuel R Tenorio; Marina F Dias-Neto; Guilherme Baumgardt Barbosa Lima; Anthony L Estrera; Gustavo S Oderich Journal: Ann Cardiothorac Surg Date: 2021-11