Hospital esophagectomy volume and postoperative length of stay: A systematic review and meta-analysis

Giwa, Femi; Salami, Aitua; Abioye, Ajibola Ibraheem

doi:10.1016/j.amjsurg.2017.03.022

Cited by 47 publications

(23 citation statements)

References 35 publications

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“…In addition to in‐hospital mortality, higher volume hospitals in our study also performed better for other parameters, including shorter operating times, a reduced requirement for ventilation and a lower rate of transfer to another hospital, presumably for post‐operative rehabilitation. These outcomes add support to the contention of better overall performance and more efficient care in higher volume hospitals . Surprisingly, however, the low‐volume hospitals in our study performed at least as well as medium‐volume hospitals, and their mortality rates were lower than the medium‐volume cohort, although neither of these groups performed as well as the high‐volume hospitals.…”

Section: Discussionsupporting

confidence: 56%

Hospital volume versus outcome following oesophagectomy for cancer in Australia and New Zealand

Meng

Bright

Woodman

et al. 2019

ANZ Journal of Surgery

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Background: Volume-outcome relationships for mortality following oesophagectomy have been demonstrated in Europe and the USA, but not in Australia or New Zealand. We determined whether higher volume hospitals achieve better outcomes following oesophagectomy in Australia and New Zealand. Methods: Administrative data for hospitals contributing data to the Health Roundtable were analysed. Hospitals performing oesophagectomy for cancer from July 2008 to June 2015 were grouped according to mean annual caseload: low (1-5), medium (6-11) and high (12+) volume. Univariate and multivariable analyses determined the impact of volume on 30-day and in-hospital mortalities, length of hospital stay and mechanical ventilation following surgery. Results: A total of 2252 patients underwent oesophagectomy in 65 hospitals. Sixty-eight percent (n = 44) were low-, 26% (n = 17) were medium-and 6% (n = 4) were high-volume hospitals. Seven hundred and sixty-two (34%) procedures were performed in low-, 1042 (46%) in medium-and 448 (20%) in high-volume hospitals. Overall in-hospital mortality was 3.1% and 30-day mortality was 2.1%. In-hospital mortality was lowest in high-volume hospitals; 1.6% versus 2.6% and 4.1% for low-and medium-volume hospitals (P = 0.02). Surgery in high-volume hospitals was shorter (32 min, P = 0.001), and patients were less likely to require post-operative ventilation (16.7% versus 25.3% and 28.0%, P < 0.001), although patients requiring ventilation in high-volume hospitals were ventilated for longer. Conclusions: A volume-outcome relationship was demonstrated, with overall better performance in higher volume hospitals. Colocation of oesophagectomies to hospitals that can demonstrate appropriate caseload should be considered.

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Section: Discussionsupporting

confidence: 56%

Hospital volume versus outcome following oesophagectomy for cancer in Australia and New Zealand

Meng

Bright

Woodman

et al. 2019

ANZ Journal of Surgery

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“…After excluding episodes with different characteristics, no single factor influenced the difference in LOS between all volume groups. Post-operative stays at low and medium volume hospitals were shorter versus high volume hospitals, in contrast to the literature [13]. Similarly, after the exclusion of extremely long LOS measures, no statistical differences were observed, and could be a reflection of the unequal distribution of long LOS between all volume groups.…”

Section: Discussioncontrasting

confidence: 72%

“…Variation in the risk-adjusted hospital LOS measures following high risk surgery, has been reported as the resulting impact of hospital volume [10,11]. Shorter mean total LOS and post-operative LOS at high volume hospitals have been reported, yielding to improved outcomes for patients following high risk surgery [12][13][14][15][16]. Similarly, an Irish study investigating LOS among emergency colorectal surgery admissions found total LOS to be significantly shorter among patients admitted to higher volume hospitals, who were older and with co-morbidities [17].…”

Section: Introductionmentioning

confidence: 99%

Variation in Hospital Length of Stay Based on Hospital Volume: A Retrospective Cohort Study of Emergency Abdominal Surgery in Ireland

Kavanagh¹,

Nally²,

Valentelyte³

et al. 2019

SCR

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Objectives: Emergency abdominal surgery (EAS) refers to high risk intra-abdominal surgical procedures associated with increased mortality risk and long length of hospital stay. The variation between hospital volume and hospital length of stay (LOS) of patients undergoing EAS is poorly understood. Our objective was to explore this relationship across public hospitals in Ireland. Methods: Data for all adult episode discharges from public Irish hospitals in 2014-2017 were obtained from National Quality Assurance Improvement System (NQAIS) Clinical with EAS identified by primary procedure codes. Hospitals were categorised into low (n<200), medium (n=200-400), and high (n>400) volume groups based on the number of EAS episodes during the study period. Negative binomial regression models were applied to standardise for patient case mix. Several adjusted LOS measures were compared across the three volume groups. Sensitivity analysis was conducted to test the robustness of our findings. Results: 8120 hospital episodes across 24 public hospitals providing EAS services were analysed. 7 were categorised as low, 9 as medium, and 8 as high-volume hospitals. High volume hospitals had a significantly longer adjusted LOS (24.7 days) relative to low and medium volume hospitals (18.2 and 18.6 days). Sensitivity analysis consisted of the exclusion of the following hospital episodes: in-hospital death, cancer diagnosis, Charlson comorbidity index (CCI) >0, admission from other hospitals, and discharge to other hospitals. No single variable influenced the observed LOS variation, although when the more complex episodes were excluded, the post-operative LOS at low and medium volume hospitals was significantly shorter compared to high volume hospitals (by 1.1-6.1 days). Intensive care unit (ICU) LOS was similar in all three hospital volume groups although low volume hospitals appeared to have more ICU admissions and longer stay (by up to 1.6 days). Conclusions: Our findings indicate that patients treated at low volume hospitals have shorter LOS and may be discharged earlier than from high volume hospitals. This finding is surprising, suggesting that concentration of services to larger clinical departments may not necessarily reduce LOS and improve the efficiency of resource utilisation and service delivery.

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“…Treatment simulations were performed for both immediate and delayed resection via minimally invasive or open transhiatal esophagectomy. Assumptions for patients undergoing immediate surgery were a 7–10 days hospitalization [ 17 – 20 ], during which time the patient would be at risk for a COVID-19 infection.…”

Section: Methodsmentioning

confidence: 99%

Modeling the impact of delaying surgery for early esophageal cancer in the era of COVID-19

et al. 2020

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Background Surgical society guidelines have recommended changing the treatment strategy for early esophageal cancer during the novel coronavirus (COVID-19) pandemic. Delaying resection can allow for interim disease progression, but the impact of this delay on mortality is unknown. The COVID-19 infection rate at which immediate operative risk exceeds benefit is unknown. We sought to model immediate versus delayed surgical resection in a T1b esophageal adenocarcinoma. Methods A decision analysis model was developed, and sensitivity analyses performed. The base case was a 65-year-old male smoker presenting with cT1b esophageal adenocarcinoma scheduled for esophagectomy during the COVID-19 pandemic. We compared immediate surgical resection to delayed resection after 3 months. The likelihood of key outcomes was derived from the literature where available. The outcome was 5-year overall survival. Results Proceeding with immediate esophagectomy for the base case scenario resulted in slightly improved 5-year overall survival when compared to delaying surgery by 3 months (5-year overall survival 0.74 for immediate and 0.73 for delayed resection). In sensitivity analyses, a delayed approach became preferred when the probability of perioperative COVID-19 infection increased above 7%. Conclusions Immediate resection of early esophageal cancer during the COVID-19 pandemic did not decrease 5-year survival when compared to resection after 3 months for the base case scenario. However, as the risk of perioperative COVID-19 infection increases above 7%, a delayed approach has improved 5-year survival. This balance should be frequently re-examined by surgeons as infection risk changes in each hospital and community throughout the COVID-19 pandemic.

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Hospital esophagectomy volume and postoperative length of stay: A systematic review and meta-analysis

Cited by 47 publications

References 35 publications

Hospital volume versus outcome following oesophagectomy for cancer in Australia and New Zealand

Hospital volume versus outcome following oesophagectomy for cancer in Australia and New Zealand

Variation in Hospital Length of Stay Based on Hospital Volume: A Retrospective Cohort Study of Emergency Abdominal Surgery in Ireland

Modeling the impact of delaying surgery for early esophageal cancer in the era of COVID-19

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