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

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60 Volume Outcome KCE reports 113 5.2.7.3 Comparative analysis of literature and Belgian data DEFINITION OF VOLUME In Table 5.10, Belgian hospital volumes for oesophageal cancer surgery were compared with international volume thresholds. It appears that 10 hospitals (14%) attain the threshold issued by the US Agency for Healthcare Research and Quality, which is set at 6 oesophagectomies per annum. 29 The cut off of 13 procedures (in use by the US Leapfrog Group) is only attained by 4 Belgian hospitals (5.7%). 126 When the same hospital thresholds are applied on Belgian surgeon volumes (because of lack of proper surgeon volume thresholds), we find that 8 surgeons (8.3%) attain the 6/yr threshold and 6 surgeons attain the 13/yr cut off (see Table 5.12). OUTCOME In this KCE study, in-hospital and approximate 30-day mortality is 9.1% after oesophagectomy for cancer. One-year and two-year mortality rates are, respectively, 30% and 45%. Median survival time was 29 months. Table 5.15 compares these Belgian outcome data with those published in the studies that were selected. • In the US study by Birkmeyer et al. for the years 1994 through 1999, the observed mortality rate (in-hospital or within 30 days after surgery) varies from 23.1% in very low volume hospital (19/yr). Unfortunately, Birkmeyer does not mention the mortality over all hospitals. 115 • A retrospective review of 1 125 English patients who had surgery for cardio-oesophageal cancer between 1992 and 1996 showed an overall 30day mortality rate of 10.0% with a median survival of 14 months and a 5year survival rate of 17.2%. Survival rate after one, two and three years can be deduced from Figure 1 of the article and is respectively 54.8, 31.7 and 23.9%. 123 • Canadian administrative data from between 1994 and 1999 showed a 30day mortality of 13.4% after oesophagectomy. 142 • The Swedish study by Rouvelas et al. which included all Swedish residents with resectable oesophageal cancer in the period 1987-2000 found a 30day mortality of 7.0% after oesophagectomy with curative intent. The observed 1-year, 3-year and 5-year survival rate were respectively 56.1%, 32.0% and 25.2%. 127 Another study by Rouvelas and colleagues studied oesophageal cancer surgery in a more recent period (2001-2005). This study illustrates the improved survival in recent years: 30-day mortality was only 3.0% while 90-day mortality was 7.9%. 148 A very similar patient population was studied in the study carried out by Rutegard et al. where postoperative mortality within 30 days of surgery amounted to only 2.8%. 124 • Clinical data from 903 oesophageal resections performed in 12 Dutch hospitals between 1990 and 1999 showed an in-hospital mortality of 8.0%. Median survival time was 21 months in low-volume hospitals and 22 months in high-volume hospitals. 152 This limited comparison leads us to conclude that the 9.1% approximate 30-day mortality found in this study is very comparable to the one found in other studies. Except for the Swedish mortality that is much lower. In relation to one- and two-year survival, this study’s results seem higher than those seen elsewhere. A possible explanation for this difference could be that patient selection (i.e. eligibility for surgery) is more selective in Sweden.
KCE Reports 113 Volume Outcome 61 Country Study period In-hospital or 30day mortality Median survival time Table 5.15: Oesophageal cancer surgery: Mortality: comparison of Volume- Outcome KCE study with other studies KCE 2004 Birkmeyer 2002 115 Belgium 2004 USA 1994-1999 9.1% 8.1% to 23.1% 29 months Gillison 2002 123 England 1992-1996 Urbach 2004 142 Canada 1994- 1999 Rouvelas 2007 127 Sweden 1987- 2000 1-year survival 70.2% 54.8% 56.1% 2-year survival 55.3% 31.7% PATIENT CASE MIX Rouvelas 2007 148 Sweden 2001- 2005 Rutegard 2009 124 Sweden 2001- 2005 Wouters 2008 152 NL 1990- 1999 10.0% 13.4% 7.0% 3.0% 2.8% 8.0% 14 months 21 to 22 months As shown in Table 5.16, the age and sex distributions are similar to those in foreign studies. Table 5.16: Oesophageal cancer surgery: Patient characteristics: comparison of Volume-Outcome KCE study with other studies KCE Dimick 2004 2001 122 Gillison 2002 123 Rouvelas 2007 148 Wouters 2008 152 Country Belgium USA England Sweden 2001- Netherlands Study period 2004 1984-1999 1992-1996 2005 1990-1999 Age 64 years 61 years 66 years 66 years 65 years (mean) (mean) (median) (mean) (mean) Male 80.1% 74% 70.9% 80.6% 76.1% A comparison of tumour characteristics in Table 5.17 shows a higher rate of oesophagus cancers among the patients in the KCE study; almost 70% versus approximately 55% in other European studies. Tumour histology, on the other hand, seems very similar to those in other studies. The tumour stage distribution, finally, is very similar to the one in the Swedish registry. 148 English patients had a more advanced 123, 152 stage of the cancer while the Dutch study had more patients with stage 2 disease.
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