Do the 2018 Leapfrog Group Minimal Hospital and Surgeon Volume Thresholds for Esophagectomy Favor Specific Patient Demographics?

Abstract

Objective: We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. Summary Background Data: Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. Methods: Patients undergoing esophagectomy for cancer were identified from the 2007-2013 New York and Florida Healthcare Cost and Utilization Project's State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18-57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age !71, ECI >4). Results: Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58-71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). Formortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. Conclusions: Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities.

Variation in outcomes across surgeons meeting the Leapfrog volume standard for complex oncologic surgery

“…However, their study did not evaluate the surgeon volume standard. Similar to the current findings, 2 previous studies by Clark et al noted that high‐volume surgeons at high‐volume hospitals in New York and Florida had lower complication and mortality rates after esophageal or lung cancer resection from 2007 to 2013 32,33 . With respect to variation in outcomes, a previous study by Varghese et al investigated variation in postoperative outcomes across high‐volume hospitals meeting the Leapfrog volume standard for esophagectomy 24 .…”

“…Although the volume‐outcome relationship remains important and does contribute to improvements in postoperative outcomes, the current data suggest that regionalization or selective referral to any high‐volume surgeon may not necessarily lead to better perioperative outcomes in all instances 7,32‐35 . In addition, whereas wide variation in 90‐day mortality across high‐volume surgeons was only present for esophagectomy and pancreatectomy, postoperative complications, especially infectious complications, have a detrimental effect on long‐term disease‐specific and overall survival after oncologic resection 36‐39 .…”

The Academic Facility Is Associated with Higher Utilization of Esophagectomy and Improved Overall Survival for Esophageal Carcinoma

“…15 A recent report by Clark and colleagues suggest that the Leapfrog volume thresholds may not be uniformly valid when managing a cohort of older patients with multiple medical comorbidities. 16 We determined from our analysis that the utilization rate of esophagectomy was significantly higher at academic facilities, and we observed a higher overall survival rate for patients who underwent esophagectomy for esophageal cancer at academic facilities. The underutilization of esophagectomy and the associated negative impact on overall survival for 17 In an analysis of the National Cancer Database, Taylor and colleagues demonstrated an overall esophagectomy rate of 36.5% but did see a gradual increase in the utilization of esophagectomy over time.…”

Effect of surgeon case volume on major surgical complications for abdominal and laparoscopic radical hysterectomy for cervical cancer in China, 2004-2016: A retrospective cohort study

“…Accumulative evidence to date has suggested that higher surgeon volume leads to improved perioperative outcomes for oncologic surgery, such as surgery for esophageal cancer 6 , brain tumors 7 , pancreatic cancer 8 , bladder cancer 9 , endometrial cancer 10 , rectal cancer 11 and lung cancer 12 . However, some scholars argue that surgeon volume is not associated with complications 13,14 .…”