Hospital teaching status and volume related to mortality after pancreatic cancer surgery in a national cohort.

BACKGROUND: The association between hospital teaching status and mortality after pancreatic resection is not well explored. Although hospital volume is related to short-term mortality, the effect on long-term survival needs investigation, taking into account hospital teaching status and selective referral patterns. METHODS: This was a nationwide retrospective register-based cohort study of patients undergoing pancreatic resection between 1990 and 2010. Follow-up for survival was carried out until 31 December 2011. The associations between hospital teaching status and annual hospital volume and short-, intermediate- and long-term mortality were determined by use of multivariable Cox regression models, which provided hazard ratios (HRs) with 95 per cent c.i. The analyses were mutually adjusted for hospital teaching status and volume, as well as for patients' sex, age, education, co-morbidity, type of resection, tumour site and histology, time interval, referral and hospital clustering. RESULTS: A total of 3298 patients were identified during the study interval. Hospital teaching status was associated with a decrease in overall mortality during the latest interval (years 2005-2010) (university versus non-university hospitals: HR 0·72, 95 per cent c.i. 0·56 to 0·91; P = 0·007). During all time periods, hospital teaching status was associated with decreased mortality more than 2 years after surgery (university versus non-university hospitals: HR 0·86, 0·75 to 0·98; P = 0·026). Lower annual hospital volume increased the risk of short-term mortality (HR for 3 or fewer compared with 4-6 pancreatic cancer resections annually: 1·60, 1·04 to 2·48; P = 0·034), but not long-term mortality. Sensitivity analyses with adjustment for tumour stage did not change the results. CONCLUSION: Hospital teaching status was strongly related to decreased mortality in both the short and long term. This may relate to processes of care rather than volume per se. Very low-volume hospitals had the highest short-term mortality risk.

Influence of co-morbidity on long-term quality of life after oesophagectomy for cancer.

BACKGROUND: The extent to which co-morbidities affect recovery of health-related quality of life (HRQoL) in long-term survivors of oesophageal cancer surgery is poorly understood. METHODS: This was a prospective, population-based, nationwide Swedish cohort study of patients who underwent surgery for oesophageal cancer between 2001 and 2005, and were alive 5 years after operation. The European Organization for Research and Treatment of Cancer QLQ-C30 and the QLQ-OES18 questionnaires were used to assess HRQoL up to 5 years after surgery. Eight aspects from the questionnaires were selected. Matched reference values from the Swedish general population were used as a proxy for HRQoL before presentation of the cancer. Adjusted multivariable linear mixed-effect models were used to assess mean score differences (MDs) of each HRQoL aspect in patients with or without co-morbidities. RESULTS: Of 616 patients who underwent surgery, 153 (24·8 per cent) survived 5 years, of whom 141 (92·2 per cent) completed the questionnaires at 5 years. Among these, 79 (56·0 per cent) had co-morbidities. Patients with co-morbidity had clinically relevant (MD at least 10) and statistically significantly poorer global quality of life (MD -10, 95 per cent confidence interval -12 to -7), and more problems with dyspnoea (MD 10, 6 to 13) throughout the whole follow-up period than those without co-morbidity. Patients with co-morbidity had a clinically relevant worse level of fatigue at 6 months (MD 10, 1 to 19) and 5 years (14, 4 to 24). With regard to specific co-morbidities, only patients with diabetes reported more clinically relevant, but not statistically significant, problems with fatigue at 6 months (MD 16, 2 to 31) and 5 years (MD 13, -5 to 31) compared with patients without co-morbidity. CONCLUSION: Among survivors of oesophageal cancer surgery, the presence of co-morbidity was associated with poor HRQoL over time and increasing symptoms of fatigue.