Background Centralization of care to “centers of excellence” in Europe has led to improved oncologic outcomes; however, little is known regarding the impact of nonmandated regionalization of rectal ...cancer care in the United States. Methods The Statewide Planning and Research Cooperative System (SPARCS) was queried for elective abdominoperineal and low anterior resections for rectal cancer from 2000 to 2011 in New York with the use of International Classification of Diseases, Ninth Revision codes. Surgeon volume and hospital volume were grouped into quartiles, and high-volume surgeons (≥10 resections/year) and hospitals (≥25 resections/year) were defined as the top quartile of annual caseload of rectal cancer resection and compared with the bottom 3 quartiles during analyses. Bivariate and multilevel regression analyses were performed to assess factors associated with restorative procedures, 30-day mortality, and temporal trends in these endpoints. Results Among 7,798 rectal cancer resections, the overall rate of no-restorative proctectomy and 30-day mortality decreased by 7.7% and 1.2%, respectively, from 2000 to 2011. In addition, there was a linear increase in the proportion of cases performed by both high-volume surgeons and high-volume hospitals and a decrease in the number of surgeons and hospitals performing rectal cancer surgery. High-volume surgeons at high-volume hospitals were associated independently with both less nonrestorative proctectomies (odds ratio 0.65, 95% confidence interval 0.48–0.89) and mortality (odds ratio 0.43, 95% confidence interval 0.21–0.87) rates. No patterns of significant improvement within the volume strata of the surgeon and hospitals were observed over time. Conclusion This study suggests that the current trend toward regionalization of rectal cancer care to high-volume surgeons and high-volume centers has led to improved outcomes. These findings have implications regarding the policy of health care delivery in the United States, supporting referral to high-volume centers of excellence.
Background Many rectal cancer patients experience tumor downstaging and some are found to achieve a pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT). Previous data ...suggest that there is an association between the time interval from nCRT completion to surgery and tumor response rates, including pCR. However, these studies have been primarily from single institutions with small sample sizes. The aim of this study was to examine the relationship between a longer interval after nCRT and pCR in a nationally representative cohort of rectal cancer patients. Study Design Clinical stage II to III rectal cancer patients undergoing nCRT with a documented surgical resection were selected from the 2006 to 2011 National Cancer Data Base. Multivariable logistic regression analysis was used to assess the association between the nCRT–surgery interval time (<6 weeks, 6 to 8 weeks, >8 weeks) and the odds of pCR. The relationship between nCRT–surgery interval, surgical morbidity, and tumor downstaging was also examined. Results Overall, 17,255 patients met the inclusion criteria. An nCRT–surgery interval time >8 weeks was associated with higher odds of pCR (odds ratio OR 1.12, 95% CI 1.01 to 1.25) and tumor downstaging (OR 1.11, 95% CI 1.02 to 1.25). The longer time delay was also associated with lower odds of 30-day readmission (OR 0.82, 95% CI 0.70 to 0.92). Conclusions An nCRT–surgery interval time >8 weeks results in increased odds of pCR, with no evidence of associated increased surgical complications compared with an interval of 6 to 8 weeks. These data support implementation of a lengthened interval after nCRT to optimize the chances of pCR and perhaps add to the possibility of ultimate organ preservation (nonoperative management).
Background There is currently little information regarding the impact of procedure volume on outcomes after open inguinal hernia repair in the United States. Our hypothesis was that increasing ...procedure volume is associated with lesser rates of reoperation and resource use. Methods The database of the Statewide Planning and Research Cooperative System was queried for elective open initial inguinal hernia repairs performed in New York State from 2001 to 2008 via the use of International Classification of Diseases, 9th Revision and Current Procedural Terminology codes. Surgeon and hospital procedure volumes were grouped into tertiles based on the number of open inguinal hernia repairs performed per year. Bivariate, hierarchical mixed effects Cox proportional-hazards, and negative binomial regression analyses were performed assessing for factors associated with reoperation for recurrence, procedure time, and downstream total charges. Results Among 151,322 patients who underwent open inguinal hernia repair, the overall rate of reoperation for recurrence within 5 years was 1.7% with a median time to reoperation of 1.9 years. An inverse relationship was seen between surgeon volume and reoperation rate, procedure time, and health care costs ( P < .001). After we controlled for surgeon, facility, operative and patient characteristics, low-volume surgeons (<25 repairs/year) had greater rates of reoperation (hazard ratio 1.23,95% confidence interval 95% CI 1.11–1.36), longer procedure times (incidence rate ratio 1.22, 95% CI 1.21–1.24), and greater downstream costs (incidence rate ratio 1.13,95% CI 1.10–1.17) than high-volume surgeons (≥25 repairs/year). Conclusion Surgeon volume <25 cases per year for open inguinal hernia repair was independently associated with greater rates of reoperation for recurrence, worse operative efficiency, and greater health care costs. Referral to surgeons who perform ≥25 inguinal hernia repairs per year should be considered to decrease reoperation rates and resource use.
Background No study has evaluated the relative importance of patient, surgeon, and hospital-level factors on surgeon and hospital variation in hernia reoperation rates. This population-based ...retrospective cohort study evaluated factors associated with variation in reoperation rates for recurrence after initial ventral hernia repair and inguinal hernia repair. Methods The Statewide Planning and Research Cooperative System identified initial ventral hernia repairs and inguinal hernia repairs in New York state from 2003–2009. Mixed-effects Cox proportional hazards analyses were performed assessing factors associated with surgeon/hospital variation in 5-year reoperation rates for hernia recurrence. Results Among 78,267 ventral hernia repairs and 124,416 inguinal hernia repairs, the proportion of total variation in reoperation rates attributable to individual surgeons compared with hospitals was 87% for ventral hernia repairs and 92% for inguinal hernia repairs. In explaining variation in ventral hernia repair reoperation between surgeons, 19% was attributable to patient-level factors, 4% attributable to mesh placement, and 10% attributable to surgeon volume and type of board certification. In explaining variation in inguinal hernia repair reoperation between surgeons, 1.1% was attributable to mesh placement and 10% was attributable to surgeon volume and years of experience. However, 67% of the variation between surgeons for ventral hernia repair and 89% of the variation between surgeons for inguinal hernia repair remained unexplained by factors in the models. Conclusion The majority of variation in hernia reoperation rates is attributable to surgeon-level variation. This suggests that hernia recurrence may be an appropriate surgeon quality metric. While modifiable factors such as mesh placement and surgeon characteristics play roles in surgeon variation, future research should focus on identifying additional surgeon attributes responsible for this variation.
Background Colostomy reversal after Hartmann's procedure for diverticulitis is a morbid procedure, and studies investigating factors associated with outcomes are lacking. This study identifies ...patient, surgeon, and hospital-level factors associated with perioperative outcomes after stoma reversal. Methods The Statewide Planning and Research Cooperative System was queried for urgent/emergency Hartmann's procedures for diverticulitis between 2000–2012 in New York State and subsequent colostomy reversal within 1 year of the procedure. Surgeon and hospital volume were categorized into tertiles based on the annual number of colorectal resections performed each year. Bivariate and mixed-effects analyses were used to assess the association between patient, surgeon, and hospital-level factors and perioperative outcomes after colostomy reversal, including a laparoscopic approach; duration of stay; intensive care unit admission; complications; mortality; and 30-day, unscheduled readmission. Results Among 10,487 patients who underwent Hartmann's procedure and survived to discharge, 63% had the colostomy reversed within 1 year. After controlling for patient, surgeon, and hospital-level factors, high-volume surgeons (≥40 colorectal resections/yr) were independently associated with higher odds of a laparoscopic approach (unadjusted rates: 14% vs 7.6%; adjusted odds ratio = 1.84, 95% confidence interval = 1.12, 3.00), shorter duration of stay (median: 6 versus 7 days; adjusted incidence rate ratio = 0.87, 95% confidence interval = 0.81, 0.95), and lower odds of 90-day mortality (unadjusted rates: 0.4% vs 1.0%; adjusted odds ratio = 0.30, 95% confidence interval = 0.10, 0.88) compared with low-volume surgeons (1–15 colorectal resections/yr). Conclusion High-volume surgeons are associated with better perioperative outcomes and lower health care utilization after Hartmann's reversal for diverticulitis. These findings support referral to high-volume surgeons for colostomy reversal.
Introduction There is strong evidence supporting the efficacy of adjuvant chemotherapy for patients with pathologic, stage III colon cancer. This study examines differences in adherence to ...evidence-based adjuvant chemotherapy guidelines for pathologic, stage III colon cancer cases across hospital and patient subgroups. Methods Patients with stage III colon cancer were identified from the 2003 to 2011 National Cancer Data Base (NCDB). A logistic regression model was used to estimate the odds of receipt of adjuvant chemotherapy across varying hospital and patient characteristics. A multivariable Cox proportional hazards model was used to estimate the association between receipt of adjuvant chemotherapy and 5-year survival. Risk adjusted observed/expected (O/E) outcome ratios were calculated for each hospital to compare hospital-specific quality of care during the study period. Results A total of 124,008 patients met the inclusion criteria. Adjuvant chemotherapy was not administered to 34%. The rates of adjuvant chemotherapy have shown little improvement over time (63% in 2003 vs 66% in 2011). The Cox model indicates that patients receiving adjuvant chemotherapy had better survival (hazard ratio = 0.48, 95% confidence interval 0.47–0.49). Analysis of risk adjusted O/E ratios indicated no consistent pattern as to which hospitals were performing optimally or subopitmally over time. Conclusion There has been no meaningful improvement in receipt of chemotherapy in patients with stage III colon cancer. The fact that chemotherapy is not being considered or offered to more than 20% of patients with node-positive colon cancer suggests that there are substantial process failures across many institutions and regions in the United States.
Background Little is known regarding recent trends in the rate of nonelective colon cancer resection in the United States and its impact on both short-term and long-term outcomes. Methods The New ...York State Cancer Registry and Statewide Planning & Research Cooperative System identified stage I–III colon cancer resections from 2004–2011. Propensity-matched analyses assessed differences in short-term adverse outcomes and 5-year disease-specific and overall survival between elective and nonelective colon cancer operations. Further analyses assessed the association among patient, surgeon, and hospital-level factors and outcomes within the nonelective operation group. Results Among 26,420 patients, 26.5% underwent nonelective operations. There was no significant change in the rate of nonelective resection from 2004–2011 ( P = .25). Nonelective operations were independently associated with greater odds of 30-day mortality (odds ratio OR = 3.42, 95% confidence interval CI = 2.87–4.06), stoma creation (OR = 4.49, 95% CI = 3.95–5.09), intensive care unit admission (OR = 1.68, 95% CI = 1.53–1.84), complications (OR = 2.34, 95% CI = 2.18–2.52), and discharge to another health care facility (OR = 2.46, 95% CI = 2.26–2.68), longer duration of stay (incidence rate ratio = 1.79, 95% CI = 1.76–1.83), and worse disease-specific (hazard ratio = 1.74, 95% CI = 1.61–1.88) and overall survival (hazard ratio = 1.64, 95% CI = 1.55–1.75). Other than an association among high-volume surgeons, adequate lymph node yield, and receipt of adjuvant chemotherapy and lower mortality, no other potentially modifiable factors were associated with survival after nonelective operations. Conclusion Nonelective colon cancer resection remains a concerning public health issue with >25% of cases being performed on a nonelective basis and an independent association with poor short-term and long-term survival compared with elective operations. Given that few potentially modifiable factors appear to have an impact on survival after nonelective operations, these findings highlight the importance of adherence to colon cancer screening guidelines to limit the number of nonelective colon cancer resections.
Background The goals of this study were to characterize the variation in suboptimal lymph node examination for patients with colon cancer across individual surgeons, pathologists, and hospitals and ...to examine if this variation affects 5-year, disease-specific survival. Methods A retrospective cohort study was conducted by merging the New York State Cancer Registry with the Statewide Planning & Research Cooperative System, Medicaid, and Medicare claims to identify resections for stages I–III colon cancer from 2004–2011. Multilevel logistic regression models characterized variation in suboptimal lymph node examination (<12 lymph nodes). Multilevel competing-risks Cox models were used for survival analyses. Results The overall rate of suboptimal lymph node examination was 32% in 12,332 patients treated by 1,503 surgeons and 814 pathologists at 187 hospitals. Patient-level predictors of suboptimal lymph node examination were older age, male sex, nonscheduled admission, lesser stage, and left colectomy procedure. Hospital-level predictors of suboptimal lymph node examination were a nonacademic status, a rural setting, and a low annual number of resections for colon cancer. The percent of the total clustering variance attributed to surgeons, pathologists, and hospitals was 8%, 23%, and 70%, respectively. Increasing the pathologist and hospital-specific rates of suboptimal lymph node examination were associated with worse 5-year, disease-specific survival. Conclusion There was a large variation in suboptimal lymph node examination between surgeons, pathologists, and hospitals. Collaborative efforts that promote optimal examination of lymph nodes may improve prognosis for colon cancer patients. Given that 93% of the variation was attributable to pathologists and hospitals, endeavors in quality improvement should focus on these 2 settings.
Background Hospitals and surgeons simultaneously are pressured to decrease readmissions and duration of stay. We hypothesized that readmissions after endocrine surgery could be predicted by using a ...novel risk-score. Methods The National Surgical Quality Improvement Program database was queried for cervical endocrine operations performed during 2011 and 2012. The primary end point was unplanned readmission within 30 days. Multivariable logistic regression was used to create and validate a scoring system to predict unplanned readmissions. Results Overall, 34,046 cases were included with a readmission rate of 2.8% ( n = 947). The most frequent reasons for readmission were hypocalcemia (32.4%) surgical-site infection (8.4%), and hematoma (8.0%) (2012 data only). The readmission risk score was created using the following factors: thyroid malignancy, hypoalbuminemia, renal insufficiency, American Society of Anesthesiologists class, and duration of stay >1 day. Predicted readmission rate by number of risk factors was 1.7 % for 0 risk factors, 3.2% for 1 risk factor (5–11 points), 5.8% for 2 risk factors, 10.5% for 3 risk factors, and 18.0% for 4 risk factors. The model had good predictive ability with c = 0.646. Conclusion Readmissions after cervical endocrine operations can be predicted. This risk score could be used to direct resource use for preoperative, inpatient, and outpatient care delivery to reduce readmissions.
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