Centralization of Esophageal Cancer Treatment Peter D. Siersema Dept. of Gastroenterology and Hepatology
Factors affecting outcome of esophageal cancer treatment <ul><li>5-year survival rate of esophageal cancer is still poor, ...
Factors affecting outcome of esophageal cancer treatment <ul><li>5-year survival rate of esophageal cancer is still poor, ...
Factors affecting outcome of esophageal cancer treatment <ul><li>5-year survival rate of esophageal cancer is still poor, ...
Outcome of esophagectomy Practice makes perfect …..
Hospital volume and esophagectomy <ul><li>Period 1993-1998 in The Netherlands </li></ul><ul><li>Prismant (DNMR):  </li></u...
<ul><li>Distribution of resections: </li></ul>Hospital volume and esophagectomy van Lanschot et al. Cancer 2001; 91: 1574-8
<ul><li>Hospital mortality (%) in hospital categories: </li></ul>Hospital volume and esophagectomy van Lanschot et al. Can...
<ul><li>Period 1998-1999 in the USA </li></ul><ul><li>Medicare claims:  </li></ul><ul><ul><li>Operative mortality after 4 ...
<ul><li>Adjusted operative mortality according to surgeon volume </li></ul>Surgeon volume and esophagectomy Birkmeyer et a...
<ul><li>Adjusted operative mortality according to surgeon volume and hospital volume  </li></ul>Surgeon volume and esophag...
Dutch guidelines on esophageal cancer (2005)
Dutch guidelines on esophageal cancer (2005) “ At least 10 times per year” “ Inspection of Healthcare” “ Quality of esopha...
High-volume vs. Low-volume Literature  Gruen et al. CA Cancer J Clin 2009; 59: 192-211 1 1 2 1 6 28 Studies Short- term Lo...
High-volume vs. Low-volume Literature  Gruen et al. CA Cancer J Clin 2009; 59: 192-211 1 1 2 1 6 28 Studies Short- term Lo...
High-volume vs. Low-volume Literature  Gruen et al. CA Cancer J Clin 2009; 59: 192-211
High-volume vs. Low-volume Literature Gruen et al. CA Cancer J Clin 2009; 59: 192-211
High-volume vs. Low-volume Literature Gruen et al. CA Cancer J Clin 2009; 59: 192-211
<ul><li>Studies support an association between case volume ( hospital (64%)  and surgeon (100%)) and outcome </li></ul><ul...
Volume or Outcome? Esophagectomies in NL Data-source: PRISMANT 1990-2004
Volume or Outcome? Esophagectomies in NL Data-source: PRISMANT 1990-2004 Volume?
Volume or Outcome? Esophagectomies in NL Data-source: PRISMANT 1990-2004 Outcome?
Volume or Outcome? Esophagectomies in NL Data-source: PRISMANT 1990-2004 Outcome?
<ul><li>Surgical audit for Esophagectomies </li></ul><ul><li>11 low-volume hospitals </li></ul><ul><li>10 years of retrosp...
Concentration of Esophagectomy Results: Treatment Outcome Wouters et al. Surg Oncol 2009; 16: 1789-98
Concentration of Esophagectomy Results: 2-years survival Log-rank   P =0.03 52%  (2000-2005) 43%  (1995-1999) 38%  (1990-1...
<ul><li>Conclusions: </li></ul><ul><li>Outcome of esophageal cancer surgery is determined by: </li></ul><ul><ul><li>Hospit...
<ul><li>Conclusions: </li></ul><ul><li>Outcome of esophageal cancer surgery is determined by: </li></ul><ul><ul><li>Hospit...
<ul><li>Conclusions: </li></ul><ul><li>Outcome of esophageal cancer surgery is determined by: </li></ul><ul><ul><li>Hospit...
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Endoscopy in Gastrointestinal Oncology - Slide 6 - P.D. Siersema - Centralization of esophageal cancer treatment

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  • One of the procedures showing a strong volume-outcome relationship are esophageal resections for cancer.
  • One of the procedures showing a strong volume-outcome relationship are esophageal resections for cancer.
  • One of the procedures showing a strong volume-outcome relationship are esophageal resections for cancer.
  • One of the procedures showing a strong volume-outcome relationship are esophageal resections for cancer.
  • One of the procedures showing a strong volume-outcome relationship are esophageal resections for cancer.
  • An example in regard to the last point: Esophageal resections for cancer, are high-risk surgical procedures for which strong variation in outcome is demonstrated between low and high volume hospitals....also in our country. In this funnel-plot based on data from the National In-Patient Registry (PRISMANT), we see all hospitals performing esophageal resections in a 15 years period, presented as small dots. On the lower right, there are 2 or 3 high-volume centers, performing more than 20 resections a year with a mortality rate of approximately 5%. To the left the other 90 hospitals are in a big low-volume cloud, with an enormous variation in mortality (in some hospitals more than 1 in 4 patients died post operatively).
  • An example in regard to the last point: Esophageal resections for cancer, are high-risk surgical procedures for which strong variation in outcome is demonstrated between low and high volume hospitals....also in our country. In this funnel-plot based on data from the National In-Patient Registry (PRISMANT), we see all hospitals performing esophageal resections in a 15 years period, presented as small dots. On the lower right, there are 2 or 3 high-volume centers, performing more than 20 resections a year with a mortality rate of approximately 5%. To the left the other 90 hospitals are in a big low-volume cloud, with an enormous variation in mortality (in some hospitals more than 1 in 4 patients died post operatively).
  • An example in regard to the last point: Esophageal resections for cancer, are high-risk surgical procedures for which strong variation in outcome is demonstrated between low and high volume hospitals....also in our country. In this funnel-plot based on data from the National In-Patient Registry (PRISMANT), we see all hospitals performing esophageal resections in a 15 years period, presented as small dots. On the lower right, there are 2 or 3 high-volume centers, performing more than 20 resections a year with a mortality rate of approximately 5%. To the left the other 90 hospitals are in a big low-volume cloud, with an enormous variation in mortality (in some hospitals more than 1 in 4 patients died post operatively).
  • An example in regard to the last point: Esophageal resections for cancer, are high-risk surgical procedures for which strong variation in outcome is demonstrated between low and high volume hospitals....also in our country. In this funnel-plot based on data from the National In-Patient Registry (PRISMANT), we see all hospitals performing esophageal resections in a 15 years period, presented as small dots. On the lower right, there are 2 or 3 high-volume centers, performing more than 20 resections a year with a mortality rate of approximately 5%. To the left the other 90 hospitals are in a big low-volume cloud, with an enormous variation in mortality (in some hospitals more than 1 in 4 patients died post operatively).
  • Probably most of you have heard about the centralization project in the region of the Comprehensive Cancer Center Leiden... In 2000 none of the 11 hospitals performed more than 7 esophagectomies a year. Because of the growing evidence for a volume-outcome relation for esophageal cancer surgery in the literature,... the surgical oncologists decided to audit the quality of care in the region. 10 years retrospective data were retrieved from all hospitals .........and remarkable differences in outcome were revealed. This led to the concentration of procedures in 3 hospitals, based on their observed outcome. The audit was continued to monitor the effects of this outcome-based centralization from the year 2000 untill now. Not only for esophageal resections..., but also pancreatic, liver and soft tissue resections.
  • In this table we see the updated outcome data....There was a dramtic fall in hospital mortality from 12% in the 1995-1999 period to 4% in the 2000-2004 period. This was accompanied with a significant reduction in hospital stay and tumor-free margins.
  • Also, a significant improvement in survival was observed in the last 5-years episode ( marked with p3 ...for period three...in this figure).
  • Endoscopy in Gastrointestinal Oncology - Slide 6 - P.D. Siersema - Centralization of esophageal cancer treatment

    1. 1. Centralization of Esophageal Cancer Treatment Peter D. Siersema Dept. of Gastroenterology and Hepatology
    2. 2. Factors affecting outcome of esophageal cancer treatment <ul><li>5-year survival rate of esophageal cancer is still poor, varying between 15-30% depending on case selection </li></ul>
    3. 3. Factors affecting outcome of esophageal cancer treatment <ul><li>5-year survival rate of esophageal cancer is still poor, varying between 15-30% depending on case selection </li></ul><ul><li>Prognosis can be improved by: </li></ul><ul><ul><li>Early recognition and follow-up of increased risk subjects </li></ul></ul><ul><ul><li>Reducing the risk of metastatic spread in esophageal cancer </li></ul></ul><ul><ul><li>Improving results of esophageal cancer surgery </li></ul></ul>
    4. 4. Factors affecting outcome of esophageal cancer treatment <ul><li>5-year survival rate of esophageal cancer is still poor, varying between 15-30% depending on case selection </li></ul><ul><li>Prognosis can be improved by: </li></ul><ul><ul><li>Early recognition and follow-up of increased risk subjects </li></ul></ul><ul><ul><li>Reducing the risk of metastatic spread in esophageal cancer </li></ul></ul><ul><ul><li>Improving results of esophageal cancer surgery </li></ul></ul><ul><li>Results of esophageal cancer resection depend on: </li></ul><ul><ul><li>Case selection (age, co-morbidity, stage) </li></ul></ul><ul><ul><li>Number and quality of procedures performed (hospital volume, surgeon volume) </li></ul></ul>
    5. 5. Outcome of esophagectomy Practice makes perfect …..
    6. 6. Hospital volume and esophagectomy <ul><li>Period 1993-1998 in The Netherlands </li></ul><ul><li>Prismant (DNMR): </li></ul><ul><ul><li>Hospital mortality after esophageal resection </li></ul></ul><ul><li>Palga (DNNDP): </li></ul><ul><ul><li>Demographic data (age and gender), </li></ul></ul><ul><ul><li>Indication for surgery (malignant, nonmalignant) </li></ul></ul><ul><ul><li>Pathology results (pTNM stage and histologic type of tumor) </li></ul></ul><ul><li>Three categories of hospital volume: </li></ul><ul><ul><li>High: >20 esophagectomies/year </li></ul></ul><ul><ul><li>Medium: 10- 20 esoph./year </li></ul></ul><ul><ul><li>Low: ≤10 esoph./year </li></ul></ul>van Lanschot et al. Cancer 2001; 91: 1574-8
    7. 7. <ul><li>Distribution of resections: </li></ul>Hospital volume and esophagectomy van Lanschot et al. Cancer 2001; 91: 1574-8
    8. 8. <ul><li>Hospital mortality (%) in hospital categories: </li></ul>Hospital volume and esophagectomy van Lanschot et al. Cancer 2001; 91: 1574-8
    9. 9. <ul><li>Period 1998-1999 in the USA </li></ul><ul><li>Medicare claims: </li></ul><ul><ul><li>Operative mortality after 4 cardiovascular procedures and 4 cancer resections </li></ul></ul><ul><li>Disorders: </li></ul><ul><ul><li>Malignancies: Lung cancer, cystectomy, pancreatic resection, esophagectomy </li></ul></ul><ul><li>Three categories of surgeon volume: </li></ul><ul><ul><li>High: > 6 esophagectomies/year </li></ul></ul><ul><ul><li>Medium: 2-6 esophagectomies/year </li></ul></ul><ul><ul><li>Low: ≤2 esophagectomies/year </li></ul></ul>Surgeon volume and esophagectomy Birkmeyer et al. NEJM 2003; 349: 2117-27
    10. 10. <ul><li>Adjusted operative mortality according to surgeon volume </li></ul>Surgeon volume and esophagectomy Birkmeyer et al. NEJM 2003; 349: 2117-27
    11. 11. <ul><li>Adjusted operative mortality according to surgeon volume and hospital volume </li></ul>Surgeon volume and esophagectomy Birkmeyer et al. NEJM 2003; 349: 2117-27
    12. 12. Dutch guidelines on esophageal cancer (2005)
    13. 13. Dutch guidelines on esophageal cancer (2005) “ At least 10 times per year” “ Inspection of Healthcare” “ Quality of esophageal cancer resection requires experience”
    14. 14. High-volume vs. Low-volume Literature Gruen et al. CA Cancer J Clin 2009; 59: 192-211 1 1 2 1 6 28 Studies Short- term Long-term Short- term Long-term Short-/Long-term 1 0 Hospital volume Quality of life 0 1 Hospital specialization 1 1 Hospital volume Survival 0 6 0 16 2 1 Surgeon volume 0 2 Surgeon volume 9 4 Hospital volume In-hospital mortality Results S NS Level Outcome
    15. 15. High-volume vs. Low-volume Literature Gruen et al. CA Cancer J Clin 2009; 59: 192-211 1 1 2 1 6 28 Studies Short- term Long-term Short- term Long-term Short-/Long-term 1 0 Hospital volume Quality of life 0 1 Hospital specialization 1 1 Hospital volume Survival 0 6 0 16 2 1 Surgeon volume 0 2 Surgeon volume 9 4 Hospital volume In-hospital mortality Results S NS Level Outcome
    16. 16. High-volume vs. Low-volume Literature Gruen et al. CA Cancer J Clin 2009; 59: 192-211
    17. 17. High-volume vs. Low-volume Literature Gruen et al. CA Cancer J Clin 2009; 59: 192-211
    18. 18. High-volume vs. Low-volume Literature Gruen et al. CA Cancer J Clin 2009; 59: 192-211
    19. 19. <ul><li>Studies support an association between case volume ( hospital (64%) and surgeon (100%)) and outcome </li></ul><ul><li>The estimate of the number of patients that needed to move from a low- to a high-volume center to save 1 volume-associated life ranges from 10-50 patients </li></ul><ul><li>The threshold above which mortality was <10% was ≥8 cases/year for esophageal cancer surgery ( <5%: 384 cases ) </li></ul>High-volume vs. Low-volume Literature Gruen et al. CA Cancer J Clin 2009; 59: 192-211
    20. 20. Volume or Outcome? Esophagectomies in NL Data-source: PRISMANT 1990-2004
    21. 21. Volume or Outcome? Esophagectomies in NL Data-source: PRISMANT 1990-2004 Volume?
    22. 22. Volume or Outcome? Esophagectomies in NL Data-source: PRISMANT 1990-2004 Outcome?
    23. 23. Volume or Outcome? Esophagectomies in NL Data-source: PRISMANT 1990-2004 Outcome?
    24. 24. <ul><li>Surgical audit for Esophagectomies </li></ul><ul><li>11 low-volume hospitals </li></ul><ul><li>10 years of retrospective data (1990-1999) </li></ul><ul><li>INTERVENTION in 2000 </li></ul><ul><li>Concentration of procedures in 3 hospitals </li></ul><ul><li>-Prospective registration of </li></ul><ul><li>case-mixed adjusted outcomes (2000-2008) </li></ul>How to Use Outcome Analysis Quality improvement in a Dutch Region Wouters et al. Surg Oncol 2009; 16: 1789-98
    25. 25. Concentration of Esophagectomy Results: Treatment Outcome Wouters et al. Surg Oncol 2009; 16: 1789-98
    26. 26. Concentration of Esophagectomy Results: 2-years survival Log-rank P =0.03 52% (2000-2005) 43% (1995-1999) 38% (1990-1994) Log rank: p2 vs p3: p =0.01 p1 vs p3: p <0.001 p1 vs p2: p =0.34 p3 p2 p2 p1 Wouters et al. Surg Oncol 2009; 16: 1789-98
    27. 27. <ul><li>Conclusions: </li></ul><ul><li>Outcome of esophageal cancer surgery is determined by: </li></ul><ul><ul><li>Hospital volume </li></ul></ul><ul><ul><li>Surgeon volume </li></ul></ul><ul><ul><li>Case-mix population </li></ul></ul>Outcome of esophagectomy Centralization or regionalization?
    28. 28. <ul><li>Conclusions: </li></ul><ul><li>Outcome of esophageal cancer surgery is determined by: </li></ul><ul><ul><li>Hospital volume </li></ul></ul><ul><ul><li>Surgeon volume </li></ul></ul><ul><ul><li>Case-mix population </li></ul></ul><ul><li>Centralization based on volume ánd outcome improves the results of esophageal cancer surgery </li></ul>Outcome of esophagectomy Centralization or regionalization?
    29. 29. <ul><li>Conclusions: </li></ul><ul><li>Outcome of esophageal cancer surgery is determined by: </li></ul><ul><ul><li>Hospital volume </li></ul></ul><ul><ul><li>Surgeon volume </li></ul></ul><ul><ul><li>Case-mix population) </li></ul></ul><ul><li>Centralization based on volume ánd outcome improves the results of esophageal cancer surgery </li></ul><ul><li>Should a national audit program for esophageal cancer surgery be considered to further improve quality? </li></ul>Outcome of esophagectomy Centralization or regionalization?

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