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

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58 Volume Outcome KCE reports 113 Table 5.13: Oesophageal cancer surgery: Correlation-corrected logistic regression (GEE) estimates of determinants of 2-year mortality (surgeon volume) Model without adjustment for case mix Factor OR 95%CI Surgeon volume 1-5/year 1.38 0.92 2.08 ≥ 6 /year 1.00 1.00 1.00 Model with adjustment for patient characteristics (MCD data) Surgeon volume 1-5/year 1.24 0.83 1.86 ≥ 6 /year 1.00 1.00 1.00 sex (male vs female) 1.31 0.61 2.81 age (increase of 1 y.) 1.02 1.00 1.04 Principal Diagnosis Oesophagus vs cardia 0.85 0.52 1.40 tumour 1.00 1.00 1.00 Charlson score Increase of 1 1.28 1.01 1.63 Model with adjustment for patient and tumour characteristics (MCD and BCR data) Surgeon volume 1-5/year 1.30 0.88 1.91 ≥ 6 /year 1.00 1.00 1.00 sex (male vs female) 1.53 0.62 3.75 age (increase of 1 y.) 1.03 1.01 1.05 Principal Diagnosis Oesophagus vs cardia 0.70 0.36 1.36 tumour 1.00 1.00 1.00 Charlson score Increase of 1 1.50 1.16 1.92 Stage X 1.94 0.74 5.09 IV 3.66 0.96 13.91 III 4.80 2.37 9.75 II 1.05 0.42 2.62 0-I 1.00 1.00 1.00 Histology X 0.43 0.14 1.33 Adenocarcinoma 0.58 0.34 0.99 Other 1.98 0.61 6.37 Squamous Cell Carcinoma 1.00 1.00 1.00 Table 5.14 presents the same analysis on the short term mortality (at 3 months). Results are consistent: the data suggest that high volume surgeons have a high mortality than low volume surgeons (using the AHRQ cut off of 6 interventions per year): the odds ratio and 95% CI was 1.31 (0.78, 2.18). Table 5.14: Oesophageal cancer surgery: Correlation-corrected logistic regression (GEE) estimates of determinants of 3-months mortality (surgeon volume) Model without adjustment for case mix Factor OR 95%CI Surgeon volume 1-5/year vs ≥ 6/year 2.54 1.31 4.93 Model with adjustment for patient characteristics (MCD data) Surgeon volume 1-5/year vs ≥ 6/year 1.76 0.92 3.35 Model with adjustment for patient and tumour characteristics (MCD and BCR data) Surgeon volume 1-5/year vs ≥ 6/year 1.31 0.78 2.18
KCE Reports 113 Volume Outcome 59 5.2.7 Discussion 5.2.7.1 External validation of the definition of the procedure According to the Belgian Cancer Registry, there were 1 140 new cases of oesophagus and cardia cancer in Belgium in 2004 (see Table 5.1 (page 45). In the 2004 Minimal Clinical Data (MCD), we identified 1 401 patients with the principal diagnosis of malignant neoplasm of oesophagus or cardia. Only 377 of these 1 401 patients (26.9%) underwent major oesophageal cancer surgery. The MCD do not allow a distinction between surgery with palliative and curative intent. This percentage is similar to the one found in other countries. • In an English study, 30.9% of patients which were identified with a malignant neoplasm of the oesophagus or cardia, underwent surgical resection. 123 • Among all 4 904 Swedish residents who were diagnosed with oesophageal cancer in the period 1987-2000, only 24.4% underwent oesophageal cancer surgery with curative intent. This study only included resectable oesophageal cancers which implies that oesophagectomies with palliative intent were not counted. 127 5.2.7.2 Summarized results of literature review The systematic literature search identified 8 systematic reviews in which the volume 1, 5, 59, 60, 62, 64, 69, 70 outcome association (VOA) for oesophageal cancer surgery was studied. These systematic reviews were based on 22 primary studies. 93, 115, 116, 122, 123, 128-144 An additional search for more recent studies which were published in the period 2004- 2009 resulted in 15 additional primary studies. 14, 15, 50, 70, 124, 127, 145-153 This brings us to a total of 37 primary studies that analyzed the volume outcome association for oesophageal 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 oesophageal cancer surgery. 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. The highest-quality systematic review on oncologic procedures we identified in the literature study is the one by Killeen and al.. 69 The interesting thing about this study is that the authors estimated the number needed to treat, that is the number of patients who must be treated to prevent one adverse outcome, from pooling available absolute risk differences for each procedure. With respect to oesophageal cancer surgery, Killeen and colleagues calculated that the number of oesphagectomies that a highvolume provider needs to prevent one death is as low as seven to nine. Two minimal hospital volume thresholds were retained from the literature search: lower threshold of 6 oesophagectomies per annum and an upper threshold of 13 oesophagectomies per annum. These thresholds correspond more or less with the thresholds in the systematic reviews. More importantly, they correspond with the thresholds issued by the US Agency for Healthcare Research and Quality (i.e. 6 per 29, 126 annum) and the US Leapfrog Group (i.e. 13 per annum). Detailed results of the literature review, using the data extraction template, are described in the evidence tables in Appendix 8.
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73. Financiering van het zorgprogra
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