High volume improves outcomes: The argument for centralization of rectal cancer surgery

Aquina, Christopher T.; Probst, Christian; Becerra, Adan Z.; Iannuzzi, James C.; Kelly, Kristin N.; Hensley, Bradley J.; Rickles, Aaron S.; Noyes, Katia; Fleming, Fergal J.; Monson, J. R. T.

doi:10.1016/j.surg.2015.09.021

Cited by 160 publications

(107 citation statements)

References 46 publications

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“…This has been supported by evidence that treatment at a high-volume center results in improved overall survival when compared to that at low-volume centers. 1–3 This centralization of care has led to an increase in the distance that many patients must travel to receive care. Stitenberg et al have demonstrated a 70% increase in travel distance for surgery through the 1900s–2000s.…”

Section: Introductionmentioning

confidence: 99%

The Effects of Travel Burden on Outcomes After Resection of Extrahepatic Biliary Malignancies: Results from the US Extrahepatic Biliary Consortium

O’Connor

Mogal

Russell

et al. 2017

Journal of Gastrointestinal Surgery

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Background Surgical resection of extrahepatic biliary malignancies has been increasingly centralized at high-volume tertiary care centers. While this has improved outcomes overall, increased travel burden has been associated with worse survival for many other malignancies. We hypothesized that longer travel distances are associated with worse outcomes for these patients as well. Study Design Data was analyzed from the US Extrahepatic Biliary Consortium database, which retrospectively reviewed patients who received resection of extrahepatic biliary malignancies at 10 high-volume centers. Driving distance to the patient's treatment center was measured for 1025 patients. These were divided into four quartiles for analysis: < 24.5, 24.5–57.2, 57.2–117, and < 117 mi. Cox proportional hazard models were then used to measure differences in overall survival. Results No difference was found between the groups in severity of disease or post-operative complications. The median overall survival in each quartile was as follows: 1st = 1.91, 2nd = 1.60, 3rd = 1.30, and 4th = 1.39 years. Patients in the 3rd and 4th quartile had a significantly lower median household income (p = 0.0001) and a greater proportion Caucasian race (p = 0.0001). However, neither of these was independently associated with overall survival. The two furthest quartiles were found to have decreased overall survival (HR = 1.39, CI = 1.12–1.73 and HR = 1.3, CI = 1.04–1.62), with quartile 3 remaining significant after multivariate analysis (HR = 1.45, CI = 1.04–2.0, p = 0.028). Conclusions Longer travel distances were associated with decreased overall survival, especially in the 3rd quartile of our study. Patients traveling longer distances also had a lower household income, suggesting that these patients have significant barriers to care.

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Section: Introductionmentioning

confidence: 99%

The Effects of Travel Burden on Outcomes After Resection of Extrahepatic Biliary Malignancies: Results from the US Extrahepatic Biliary Consortium

O’Connor

Mogal

Russell

et al. 2017

Journal of Gastrointestinal Surgery

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“…[15][16][17] This heterogeneity of surgical volume measurements may affect the external validity of study results. 4 Patient outcomes used in previous studies have also varied; these include 5-year survival, 7,18 postoperative mortality, 19,20 procedure-related complications 11,21 and recurrence of cancer. 16,22 Although a number of studies have demonstrated that patients treated at high-volume hospitals have better outcomes, patient characteristics are critical confounders to the choice of hospital and patient outcomes.…”

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confidence: 99%

Hospital volume and postoperative 5‐year survival for five different cancer sites: A population‐based study in Japan

et al. 2020

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The relationship between hospital volume and patient outcome is globally known; thus, hospital volume is widely used as a quality indicator. In Japan, however, recent studies on this topic are scarce. The present study examined whether hospital surgery volume is associated with postoperative 5‐year survival among cancer patients. Using the Osaka Cancer Registry, we identified a sample of 86 145 patients who were diagnosed with cancer at any of five different sites (stomach, colorectum, lung, breast and uterus) and underwent surgeries between 2007 and 2011 in Osaka. We ranked hospitals by annual surgical volume, sorted patients in descending order by hospital volume, and assigned them into quartiles (high, medium, low and very low volume). We analyzed the association between hospital volume and 5‐year survival among 80 959 patients aged between 15 and 84 years using Cox proportional hazard models. Adjustments were made for characteristics of patients, type of surgery and adjuvant treatment received. The mortality hazard of patients treated at very low‐volume hospitals was 1.36‐1.82‐fold higher than that of patients treated at high‐volume hospitals. Absolute differences in adjusted survival rates between high‐volume and very low‐volume hospitals varied with the cancer site: 14.9 in stomach, 11.5 in colorectal, 10.8 in lung, 2.4 in breast and 3.3 in uterine cancers. Hospitals with lower surgery volumes showed higher mortality risks after cancer surgery than those with higher volumes. Monitoring site‐specific surgery volumes and referring patients from low‐volume to high‐volume hospitals may be beneficial for improving the long‐term survival of cancer patients.

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“…(6, 7, 10, 11) This finding echoes recent analyses showing persistent variability in rectal cancer clinical outcomes as well. (12, 13) In fact, the high degree of variability we note among surgeons is precisely why the checklist was created – to provide a tool for rectal cancer care standardization. (8) Therefore, proponents of centralized rectal cancer centers must recognize that simply referring patients to specialty centers – such as the site of this study – will not alone improve treatment variability.…”

Section: Discussionmentioning

confidence: 99%

Benchmarking rectal cancer care: institutional compliance with a longitudinal checklist

Chapman

Choi

Hawkins

et al. 2018

Journal of Surgical Research

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Background In 2012, the American Society of Colon and Rectal Surgeons published the Rectal Cancer Surgery Checklist, a consensus document listing 25 essential elements of care for all patients undergoing radical surgery for rectal cancer. The authors herein examine checklist adherence among a mature, multi-surgeon specialty academic practice. Materials and Methods A retrospective medical record review of patients undergoing elective radical resection for rectal adenocarcinoma over a 23-month period was conducted. Checklists were completed post hoc for each patient, and these results were tabulated to determine levels of compliance. Subgroup analyses by compliance levels and experience level of the treating surgeon were performed. Results 161 patients underwent resection, demonstrating a median completion rate of 84% per patient. Poor compliance was noted consistently in documenting baseline sexual function (0%), multidisciplinary discussion of treatment plans (16.8%), pelvic nerve identification (8.7%) and leak testing (52.9%), and radial margin status reporting (57.5%). Junior surgeons achieved higher rates of compliance and were more likely to restage following neoadjuvant therapy (67.9% vs 29.4%, p < 0.001), discuss patients at tumor board (31.3% vs 13.2%, p=0.014), and document leak testing (86.7% vs 47.2%, p=0.005) compared to senior surgeons. Conclusions Checklist compliance within a high-volume, specialty academic practice remains varied. Only surgeon experience level was significantly associated with high checklist compliance. Junior surgeons achieved greater compliance with certain items, particularly those that reinforce decision-making. Further efforts to standardize rectal cancer care should focus on checklist implementation, targeted surgeon outreach, and assessment of checklist compliance correlation to clinical outcomes.

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High volume improves outcomes: The argument for centralization of rectal cancer surgery

Cited by 160 publications

References 46 publications

The Effects of Travel Burden on Outcomes After Resection of Extrahepatic Biliary Malignancies: Results from the US Extrahepatic Biliary Consortium

The Effects of Travel Burden on Outcomes After Resection of Extrahepatic Biliary Malignancies: Results from the US Extrahepatic Biliary Consortium

Hospital volume and postoperative 5‐year survival for five different cancer sites: A population‐based study in Japan

Benchmarking rectal cancer care: institutional compliance with a longitudinal checklist

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