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

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64 Volume Outcome KCE reports 113 Key points on volume outcome association for oesophageal cancer surgery • A total of 1 401 patients were hospitalized in 2004 (retrieved in MCD 2004) with a diagnosis of malignant neoplasm of oesophagus or cardia. 27% of those patients underwent a resection of the oesophagus. • The population studied consisted of those 329 patients with oesophagectomy and whose data could be linked to IMA databases. • In 80% of the cases, information on tumour could be retrieved in the BCR database. Data on stage was available for 68% of stays. Low-volume as well as high-volume hospitals missed data on stage; there seemed to be no association between percentage of linkage with BCR and hospital volume. • These interventions were performed in 72 centres by 99 surgeons. 10 hospitals and 8 surgeons had a volume higher or equal to 6 interventions per year (the current AHRQ criteria in US). • Two-year mortality was 45%. Regression models were fitted to assess the association between hospital or surgeon volume with this outcome. The following factors were taken into account in all analyses: sex, age, principal diagnosis (oesophagus or cardia), Charlson score (co morbidity), tumour stage and tumour histology (adenocarcinoma or squamous cell carcinoma). • Based on the study of systematic reviews, it was concluded that there is evidence for an inverse relation between hospital volume and mortality for oesophageal cancer surgery. Two minimal hospital volume thresholds were retained from the literature search: a lower threshold of 6 oesophagectomies per annum and an upper threshold of 13 oesophagectomies per annum. • In contrast to scientific literature, however, Belgian data did not show an inverse relationship between volume of centres and 2-year mortality: respectively 43.8% in centre with less than 6 interventions per year and 45.4% in centres with at least 6 interventions per year. • The literature review also concluded that there is inverse relationship between surgeon volume and mortality. • As well, Belgian data suggest an inverse association (not statistically significant) between the volume of surgeons and 3 months mortality: 13.5% for surgeons with less than 6 interventions per year and 6.4% for surgeons with at least 6 interventions per year. Results at two years were consistent. • Several years of observations are required to increase precision of effects. • Because data were not retrieved or not available in the databases, the following characteristics could not be used for risk adjustment: use of (neo) adjuvant therapy (chemo- or radiation therapy), acuity of admission (elective versus urgent), intention of surgery (palliative versus curative).
KCE Reports 113 Volume Outcome 65 5.3 PANCREATIC CANCER SURGERY 5.3.1 General description of procedure Surgical removal of the pancreas (i.e. pancreatectomy) is still the only chance of longterm survival for patients with pancreas cancer. Belgian guidelines, which were recently published in KCE report 105, recommend that “patients with resectable pancreatic cancer who are fit for surgery should undergo radical pancreatic resection (pancreaticoduodenectomy for pancreatic head tumours and distal pancreatectomy for pancreatic body and tail tumours)”. 154 5.3.2 Primary data selection in MCD 2004 First selection of data was based on ICD-9-CM diagnostic and procedure codes as proposed by Glasgow et al., and on NIHDI procedure codes. 155 In addition to the ICD-9-CM diagnosis code for pancreatic cancer (157), codes for malignant neoplasm of duodenum (1520), of extrahepatic bile ducts (1561) and of ampulla of Vater (1562) were added to the selection criteria. The rationale of this elaborate selection is that patients can be labelled with the latter diagnoses at the end of their hospital stay - and be coded as such in the MCD - on the basis of suspicious lesions that were visualised with medical imaging. It is often only a few days after the hospitalisation that the final diagnosis can be attributed on the basis of the results of the histopathologic examination of the tumour. Therefore, it was decided to make a broad selection at the level of MCD. Figure 5.8: Pancreas and surrounding organs Source: Wikimedia Commons (Public Domain) This selection resulted in a total of 4 949 stays (Table 5.18). This selection is too broad since it also includes patients with a secondary diagnosis of malignant neoplasm. This implies that patients with pancreatic cancer as pre-existing condition are also included (see section 4.2.1, page 39). The definition of the population studied (i.e. patients with a principal diagnosis of malignant neoplasm of pancreas who underwent surgical resection of the pancreas) will be defined in the next section.
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