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

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82 Volume Outcome KCE reports 113 VOLUME OUTCOME ASSOCIATION The present study suggests that patients treated in hospital performing less than 11 interventions per year (the AHRQ cut off) have a higher 2-year mortality, taking into account patient and tumour characteristics, than patients operating in hospitals performing at least 11 interventions per year (56.1% vs 48.2%, OR and 95% CI 1.25 (0.83, 1.89). This association did not reach statistical significance. With respect to the relationship between surgeon volume and 2-year mortality, our study showed that patients operated by surgeons performing less than 6 interventions per year (the AHRQ cut off) have a higher risk of mortality, taking into account patient and tumour characteristics (OR 1.51 (95% CI 1.06, 2.16)). These results are a confirmation of what we found in the literature review. Key points on volume outcome association for peripancreatic cancer surgery • A total of 1 842 patients were hospitalized in 2004 (retrieved in MCD 2004) for a diagnosis of malignant neoplasm of pancreas (or peripancreas). 17% of these patients underwent a pancreatectomy. • The population studied consisted of those 301 patients with pancreatectomy 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 67% of stays. There was a good agreement between the diagnosis in MCD and the tumour location in BCR. • These interventions were performed in 74 centres by 112 surgeons. Five hospitals and four surgeons had a volume higher than 11 interventions per year (the US AHRQ and Leapfrog cut off). • Two-year mortality was 53%. Regression models were fitted to assess the association between hospital or surgeon volume and outcome. The following factors were taken into account in all analyses: sex, age, principal diagnosis (pancreas or peripancreas), Charlson score (co morbidity) and tumour stage. • Based on the study of systematic reviews, it was concluded that there is evidence for an inverse relation between hospital volume and mortality for pancreatic cancer surgery. One minimal hospital volume threshold was retained from the literature search i.e. 11 pancreatic resections per annum. • The present study suggests that patients treated in hospital performing less than 11 interventions per year (the AHRQ cut off) have a higher 2-year mortality than patients operating in hospitals performing at least 11 interventions per year (56.1% vs 48.2%, OR and 95% CI 1.25 (0.83, 1.89). • The literature review also concluded that there is inverse relationship between surgeon volume and mortality. • Our findings were in agreement with literature: there was a statistically significant inverse association between the volume of surgeons and the 2year mortality: 58% for surgeons performing less than 6 interventions per year and 43% for surgeons performing at least 6 interventions per year (OR and 95% CI 1.51 (1.06, 2.16). • Data from two years are required to have more precise estimates. • 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), type of surgical resection (total or partial resection).
KCE Reports 113 Volume Outcome 83 5.4 COLON CANCER SURGERY 5.4.1 General description of procedure Colectomy, which is a surgical procedure to remove the section of colon containing cancer and nearby lymph nodes, is the standard treatment for colon cancer and remains 120, 177 the only curative option. 5.4.2 Primary data selection in MCD 2004 First selection of data was based on ICD-9-CM diagnostic and procedure codes as 178, 179 proposed by Harmon et al. and Rabeneck et al., and on NIHDI procedure codes. Neoplasms of the rectosigmoid junction (i.e. the segment of the gut where the colon merges with the rectum) should also be included in the selection. Therefore, the Hartmann’s procedure was added. This procedure refers to the anterior resection of the sigmoid and the rectum with closure of the distal resection margin and end colostomy. According to Vlayen et al., Hartmann’s procedure is encoded with the non specific ICD-9-CM procedure code 45.75 (for left hemicolectomy) and the very specific NIHDI procedure code 244064. 180 This selection resulted in a total of 20 264 stays. This selection is too broad since it also includes patients with a secondary diagnosis of malignant neoplasm. This implies that patients with colon cancer as pre-existing condition are also included (see section 4.2.1, page 39). The definition of the population studied will be defined in the next section. Table 5.34: Colon cancer surgery: Primary data selection in MCD 2004 SELECTION 1 SELECTION 2 SELECTION 3 ICD-9-CM (principal or secondary) diagnosis code 153x Malignant neoplasm of colon 1540 Malignant neoplasm of rectosigmoid junction STAYS SELECTED = 14 383 stays ICD-9-CM procedure code 457x Open and other partial excision of large intestine 458x Total intra-abdominal colectomy NIHDI procedure code 243040 Total colectomy 243062 Right or left hemicolectomy or segmentary colectomy or sigmoidectomy or partial resection of the rectum with restoration of continuity 243084 Segmentary colectomy with double colostomy 243106 Ileo-colo-recto plasty 244064 Hartmann’s procedure STAYS SELECTED STAYS SELECTED = 9 105 stays = 7 282 stays TOTAL STAYS SELECTED = 20 264 stays (selection 1 OR selection 2 OR selection 3)
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73. Financiering van het zorgprogra
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