Hospital characteristics associated with better ‘quality of surgery’ and survival following oesophagogastric cancer surgery in Queensland: a population‐level study

Abstract

Background The impact of hospital characteristics on the quality of surgery and survival following oesophagogastric cancer surgery has not been well established in Australia. We assessed the interaction between hospital volume, service capability and surgical outcomes, with the hypothesis that both the quality of surgery and survival are better following treatment in high‐volume, high service capability hospitals. Methods All patients undergoing oesophagectomy and gastrectomy for cancer in Queensland, between 2001 and 2015, were included. Demographic, pathology and outcome data were collected. Hospitals were categorized into high (HV) (≥5 gastrectomies; ≥6 oesophagectomies) and low volume (LV). Hospital service capability was defined as high (HS) and low (LS), and then linked to hospital volume: HVHS, LVHS and LVLS. Higher quality surgery was defined using six perioperative parameters. Univariable comparisons of quality of surgery between hospital groups used chi‐squared tests. The 5‐year overall survival was compared using log‐rank tests and Cox proportional hazard models. Results For both gastrectomy and oesophagectomy, higher quality surgery occurred more frequently in HVHS hospitals (gastrectomy: HVHS = 44.2%, LVHS = 23.1%, LVLS = 29.1% (P < 0.01); oesophagectomy: HVHS = 34.5%, LVHS = 24.4%, LVLS = 21.7% (P = 0.01)). Following oesophagectomy, the 3‐ and 5‐year overall survival was better following treatment in HVHS (P < 0.01). There was no difference between the groups following gastrectomy. Conclusion In Queensland, the quality of surgery was higher in HVHS hospitals performing gastrectomy and oesophagectomy; however, the impact on cancer survival was only seen following oesophagectomy.

Procedure‐specific outcomes following gastrectomy for cancer compared by hospital volume and service capability

“…This threshold approximated the lowest median annual average resection volume in our cohort and has previously been shown to be a valid cut-off, published in the Australian literature. 8,10,11,15 Hospitals were considered to have a high service capability if classified as a Principal Referral hospital or Private Group A hospital, as defined by the 2015 Australian Institute of Health and Welfare's (AIHW) Australian Hospital Peer Groupings. 16 These acute hospitals are defined by the presence of 24-h emergency departments, accredited intensive care units (ICUs) and specialised units including oncology, interventional radiology, advanced endoscopy and surgical units staffed by surgeons with specialist training in upper gastrointestinal surgery.…”

“…Higher quality surgery was registered if patients received an R0 resection, with ≥15 lymph node yield, uncomplicated post-operative course and no readmission or death within 30 days. 11 This composite variable is based on the previously published definition of 'textbook post-operative outcome'. 18 Univariate comparisons of demographics, mortality, morbidity and quality parameters between hospital groups were stratified by the type of gastrectomy (PG and TG).…”

“…5,6,10 In Queensland, using a volume threshold of five or more annual gastrectomies, we have reported similar improvements in mortality but no difference in survival, following gastrectomy for cancer, when performed in hospitals with high-volume and high service capability (HVHS), compared with low-volume and low service capability centres (LVLS). 11 We have also reported that patients who did not receive high-quality surgery (HQS) had a higher adjusted risk of death at 5 years. 11 It is unclear whether better outcomes following gastrectomy in HV centres are also applicable when assessing short-term post-operative outcomes of PG and TG separately, given the different complication profiles of these two procedures.…”

“…11 We have also reported that patients who did not receive high-quality surgery (HQS) had a higher adjusted risk of death at 5 years. 11 It is unclear whether better outcomes following gastrectomy in HV centres are also applicable when assessing short-term post-operative outcomes of PG and TG separately, given the different complication profiles of these two procedures. To date, there has been no study that compares short-term post-operative outcomes of gastrectomy between HV and LV centres and stratifies results by the type of gastrectomy performed.…”

RAMIE for T4b Esophageal Cancer: A Study of Salvage Surgery or Superior Selection?

“…Also, as the authors mention, their meticulous process of staging, restaging, and the remainder of their patient selection process cannot be overlooked or underemphasized and is a Given this, and the recognized association of volume and outcomes in complex esophageal cancer surgery, it is not overly surprising that the surgeons from this highly experienced esophageal center of excellence, credited as being among the initial innovators in RAMIE, have demonstrated the technical feasibility of RAMIE for T4b esophageal tumors with superior outcomes. 6 With regards to the robotic platform, which is increasingly lauded as a superior technical instrument, we humbly remind the reader it can only augment existing surgical experience and wisdom, not create it. This caution must accompany any new technology advocated to potentially ''improve outcomes.''…”