Assessing quality of care in oesophago‐gastric cancer surgery in Australia

Background Surgical treatment of gastric cancer in New Zealand is challenging because of a low annual incidence of 400 patients and population dispersal over a wide area with little data on regional treatment trends and outcomes. This investigation was undertaken to evaluate the surgical outcomes of gastric cancer patients presenting to a single upper gastrointestinal centre (WDHB, Waitemata District Health Board) and to compare these to national and international standards. Methods Data on 135 patients with histologically proven gastric adenocarcinoma presenting between January 2010 and December 2014 were reviewed and compared with nationally available procedural volume data. Results Sixty of 135 patients were resected (resection rate 44%) and 75 patients were managed with palliative chemotherapy/symptomatic care alone. Twenty‐six patients (43%) received adjuvant or neoadjuvant chemotherapy and only two patients (3%) underwent laparoscopic resection. In resected patients, 90‐day mortality was 1.6%, and 11 patients (18%) developed complications ≥ Clavien‐Dindo grade 3. Fifty‐two patients (87%) had ≥15 lymph nodes resected and 54 patients (90%) had a histological R0 resection. At median follow‐up of 49 months, 30 patients remain alive and disease‐free with 20 true 5‐year disease‐free survivors. National data between 2010 and 2014 showed WDHB performed 20% (338/1710) of gastric resections for all indications in New Zealand. Conclusion While WDHB is an internationally low volume centre for gastric cancer, surgical outcomes benchmark satisfactorily to international standards. New Zealand's national treatment standards should set aspirational goals for gastric cancer treatment and have a clear strategy to address issues of surgical volume and national service provision.

Section: Discussionsupporting

confidence: 90%

Treatment of gastric adenocarcinoma at a New Zealand centre: meeting the challenges of a low volume country

Saw

Robertson

Walsh

et al. 2019

“…However, in Australia, few high-volume hospitals report similarly high resection volumes, despite reporting mortality rates comparable with those of international 'high-volume' centres. 21 Thus far, Australian population-level studies of oesophagectomy 4,33 and pancreaticoduodenectomy, 19 which use high-volume thresholds similar to those in our study, have not reported significant mortality differences between hospitalvolume groups. This may relate to a lack of statistical power in these studies due to lower numbers of resections and a shorter time-period of assessment as compared with our study, low rates of postoperative mortality following these procedures reported in Australia 22 and the presence, in some low-volume centres, of hospital characteristics including high hospital technology, high-level intensive care, interventional-radiology services, and surgical training programmes which have been reported to be associated with improved post-operative mortality following upper gastrointestinal cancer surgery, independent of hospital-volume.…”

Section: Discussionsupporting

confidence: 57%

“…[15][16][17][18] By comparison, population-level studies in Australia have not reported improved post-operative mortality with higher hospital-volume following pancreaticoduodenectomy, 19 while for oesophagectomy, reports of improved mortality with higher surgical volumes are conflicting. 3,4,20 This may relate to lower resection volumes in Australian centres, including those considered 'high-volume', when compared with the volumes reported by centres in other countries, [10][11][12][13][14]19,21 and to the generally low mortality rates reported by Australian centres performing these procedures. 22 As well, some low-volume centres in Australia offer services including specialist surgeons, advanced endoscopy and interventional-radiology services which have been reported to be associated with lower postoperative mortality following complex upper gastrointestinal procedures such as pancreatic resection, independent of hospital resection volume.…”

Section: Introductionmentioning

confidence: 99%

Assessment of hospital characteristics associated with improved mortality following complex upper gastrointestinal cancer surgery in Queensland

Narendra

Baade

Aitken

et al. 2019

Background High hospital‐volume and service capability are associated with improved mortality following complex cancer surgery. Using a population‐based study in Queensland, we assessed differences in mortality following oesophagectomy and pancreaticoduodenectomy, comparing high‐ and low‐volume hospitals stratified by service capability. Methods Data on all patients undergoing oesophagectomy and pancreaticoduodenectomy for cancer in Queensland between 2001 and 2015 were obtained from the Queensland Oncology Repository. Hospital service capability was defined using the 2015 Australian Institute of Health and Welfare hospital peer groupings. Hospitals were grouped into ‘high‐volume (≥6 oesophagectomies or pancreaticoduodenectomies annually) with high service capability'; ‘low‐volume (<6) with high service capability' and ‘low‐volume with low service capability'. Multivariate Poisson models were used to estimate differences in 30‐ and 90‐day mortality between hospital groups adjusting for age, sex, socioeconomic status, Charlson and American Society of Anesthesiologists scores, chemotherapy, radiotherapy, stage and time‐period. Results For oesophagectomy, adjusted 90‐day mortality was higher in low‐volume compared with high‐volume hospitals, regardless of service capability (low‐volume, high service: incident rate ratio (IRR) 3.86, 95% confidence interval (CI) 1.74–8.57; low‐volume, low service: IRR 3.40, 95% CI 1.16–10.00). For pancreaticoduodenectomy, mortality was higher in low‐volume compared with high‐volume centres regardless of service capability: 30‐day mortality (low‐volume, high service: IRR 2.32, 95% CI 1.07–5.03; low‐volume, low service: IRR 3.92, 95% CI 1.45–10.61); 90‐day mortality (low‐volume, high service: IRR 2.36, 95% CI 1.29–4.30; low‐volume, low service: IRR 3.32, 95% CI 1.64–6.71). Conclusion High hospital resection volumes are associated with lower post‐operative mortality following oesophagectomy and pancreaticoduodenectomy regardless of hospital service capability. This data supports centralization of these procedures to high‐volume centres.

“…In 2018, gastric cancer was estimated to account for over 700 000 deaths globally and over 1000 deaths in Australia . Surgical resection is the only curative treatment with 30‐day post‐operative mortality rates in western populations reported to be 1.6–16% …”

Section: Introductionmentioning

confidence: 99%

“…These services are reported to be associated with improved post‐operative mortality following other complex upper gastrointestinal surgery, such as pancreatic resection . A high hospital service capability, with appropriately trained surgeons, may explain why some Australian low‐volume centres report post‐operative mortality outcomes equivalent to those reported by centres with much higher resection volumes …”

Section: Introductionmentioning

confidence: 99%

Impact of hospital resection volume and service capability on post‐operative mortality following gastrectomy

Narendra

Baade

Aitken

et al. 2019

Background Improved post‐operative mortality following gastrectomy for cancer in hospitals with higher resection volumes has not been reported in Australia. Using a population‐based study in Queensland, we aimed to compare post‐operative mortality following gastrectomy between high‐ and low‐volume hospitals stratified by their service capability. Methods All patients undergoing gastrectomy for adenocarcinoma in Queensland between 2001 and 2015 were obtained from the Queensland Oncology Repository. Hospital service capability was defined using the 2015 Australian Institute of Health and Welfare hospital peer groupings. Hospitals were grouped into ‘high‐volume (≥5 gastrectomies annually), high service capability’ (HVHS); ‘low‐volume (<5), high service capability’; and ‘low‐volume, low service capability’ (LVLS). Negative binomial regression models were used to compare 30‐ and 90‐day mortality rates between hospital groups adjusting for age, sex, socio‐economic status, Charlson and American Society of Anesthesiologists scores, treatment regimen, stage and time‐period. Potential mediation of mortality differences between hospital groups due to differences in the type of gastrectomy performed was also examined. Results LVLS hospitals have higher adjusted 30‐day (incidence rate ratio (IRR) 2.97, 95% confidence interval (CI) 1.65–5.35) and 90‐day (IRR 1.95, 95% CI 1.23–3.09) mortality rates compared with HVHS hospitals. There is no significant difference in adjusted 30‐day (IRR 1.16, 95% CI 0.48–2.79) and 90‐day (IRR 1.12, 95% CI 0.59–2.13) mortality rates comparing low‐volume, high service capability hospitals with HVHS hospitals. The type of gastrectomy performed did not significantly influence differences in mortality compared between hospital groups. Conclusion In the Australian environment, post‐operative mortality following gastric cancer surgery may be optimized by centralizing gastrectomy away from hospitals characterized by LVLS.