Het volume van chirurgische ingrepen en de impact ervan op ... - KCE

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94 Volume Outcome KCE reports 113 Table 5.45 shows the effects of logistic regression when volume of centres and surgeons are taken into account simultaneously. This analysis confirmed the effects observed when volume of centre and surgeon were analyzed separately. The effect of volume of surgeon was consistent (inverse relationship) in low volume centres and high volume centres (no interaction between the two effects, data not shown). Table 5.45: Colon cancer surgery: Correlation-corrected logistic regression (GEE) estimates of determinants of 2-year mortality, surgeon volume and hospital volume Parameter Estimate Standard Error 95% Confidence Limits Log volume of surgeon -0.1491 0.0735 -0.2933 -0.0050 Log volume of hospital 0.1425 0.1064 -0.0661 0.3510 After adjustment for gender, age, Charlson score, principal diagnosis and stage Figure 5.21 shows that high volume surgeons (in pink) tend to operate in high volume centres, while low volume surgeons (in red) tend to operate in all centres. Figure 5.21: Colon cancer surgery: Hospital size versus surgeon size 5.4.7 Discussion 5.4.7.1 External validation of the definition of the procedure The Belgian Cancer Registry registered 5 482 new cases of colon and rectosigmoid junction cancer in Belgium in 2004. See Table 5.1 (page 45). This number corresponds well to the 5 756 patients with the principal diagnosis of these cancers which were identified in the 2004 Minimal Clinical Data (see Table 5.35, page 84). 5.4.7.2 Summarized results of literature review The systematic literature search identified 9 systematic reviews in which the volume 1, 5, 59, 60, 62, 64, 69, 73-75 outcome association (VOA) for colon cancer surgery was studied. 99, 115, 129, 133-135, 141, 142, 178, 179, These systematic reviews were based on 43 primary studies. 181-212, 213 An additional search for more recent studies which were published in the period 2004-2009 resulted in 5 additional primary studies. 153, 214-217 This brings us to a total of 48 primary studies that analyzed the volume outcome association for colon cancer surgery. For more insight in how these studies were retrieved see the Supplement. On the basis of the systematic reviews it was concluded in Chapter 2 (see Table 2.2 on page 19) that there is evidence for an inverse relation between hospital volume and mortality for colon cancer surgery.
KCE Reports 113 Volume Outcome 95 This means that mortality decreases when the number of procedures performed by a hospital increases. A similar relationship was found between surgeon volume and mortality. However, the effect of volume on outcome for this procedure, which is more common and often a less complex surgical procedure, is small when compared to other, more complex procedures such as pancreatic or oesophageal resection. Killeen et al. calculated that the magnitude of the volume effect on mortality was variable and small (approximately 1–2 per cent). They translated this into a number needed to treat of 50–100 patients. 69 With respect to a cut off point to define low and high volume, studies differed widely. Therefore, it was impossible to define one minimal hospital volume threshold. For example, Killeen et al., found that the definition of low volume ranged from one to fewer than 12 procedures for low-volume surgeons and from one to fewer than 84 operations per year for low-volume hospitals. 69 Detailed results of the literature review are described in the evidence tables in Appendix 8. 5.4.7.3 Comparative analysis of literature and Belgian data DEFINITION OF VOLUME As mentioned before, it was impossible to define a cut off point for hospital or surgeon volume on the basis of the literature review. OUTCOME With respect to the comparison of Belgian outcome data with those published in the studies that were selected (see 5.4.7.2), it was difficult to find studies that made the same patient selection as we did. • Many authors included rectum cancers in their selection. 185, 201 However, according to Dimick et al. mortality rates vary depending on the location of the tumour and are lowest for tumour of the rectum (2.4%) and highest for tumours of the left colon (4.5%). 185 Therefore, it seems not right to compare the mortality rate of colorectal cancer studies to our colon cancer study. • Ko et al., on the other hand, only selected cases with the diagnosis of colon cancer and excluded rectal and rectosigmoid cancers. 198 As was shown in Table 5.40, patients with cancer of the rectosigmoid junction had worse survival (57.0%) than those with colon cancer (72.6%). Again a reason not to compare Ko’s mortality rate with ours. • Schrag et al. defined a similar population as we did i.e. colon and rectosigmoid cancer patients with resection. 209, 210 However, they restricted their cohort to patients with a histological diagnosis of adenocarcinoma. In addition, patients were all 65 years or older since it concerned Medicare-enrolled patients. Schrag et al. found a 30-day mortality rate of 4.6%, a 2-year survival rate of 66.9% and a 5-year survival rate of 47.3%. 209, 210 Marusch and colleagues also specifically investigated only patients with carcinoma of the colon. 200 They found an overall 30-day mortality rate of 4.9%.
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