Identifying best performing hospitals in colorectal cancer care; is it possible?

BACKGROUND: Comparing outcomes across hospitals to learn from best performing hospitals can be valuable. However, reliably identifying best performance is challenging. This study assesses the possibility to distinguish best performing hospitals on single outcomes and consistency of performance on different outcomes. METHODS: Data were derived from the Dutch ColoRectal Audit 2013-2015. Outcomes considered were textbook outcome (colon), (circumferential) resection margins, (serious) complications, mortality, and 'failure to rescue'. To include uncertainty in rankings, random effect logistic regression models were used to calculate expected ranks (ERs), for each hospital and outcome. Rankability was calculated for each outcome, as a measure of reliability of ranking. Furthermore, correlation between ERs on different outcomes was assessed. Correlation was considered weak <0.40, moderate between 0.40 - 0.59 and strong >0.60. RESULTS: The study included 32 143 patients; of whom 11 373 were treated in 2015 across 84 hospitals, 8181 colon and 3192 rectal cancer patients. In this one-year period 'Postoperative complications' had the highest rankability for colon (57%) and rectal (41%) surgery. No (group of) hospital(s) had the highest ER(s) on all outcomes. Correlation between ERs of outcomes was moderate in 2 (of 25) and strong in 4 (of 25) combinations. Rankability of colorectal mortality increased from 14% in 2015 to 35% when data over 2013-2015 were used. CONCLUSION: The highest reliability of identifying best performance based on an outcome was 57%. However, the balance between reliability and relevance of outcomes is vulnerable. No (group of) hospital(s) could be identified as best performer on all outcomes. Performance was not consistent on outcomes.

Surgeon perceived most important factors to achieve the best hospital performance on colorectal cancer surgery: a Dutch modified Delphi method.

OBJECTIVES: Hospital variation in risk-adjusted outcomes after colorectal cancer surgery has been shown. However, explanatory factors are not sufficiently clear. The objective of this study was to identify factors perceived by gastrointestinal surgeons as important to achieve excellent casemix-adjusted outcomes after colorectal cancer surgery. DESIGN: Based on literature and experts' opinion, 86 factors associated with serious complications, failure to rescue and mortality were listed. These were presented to gastrointestinal surgeons through two web-based surveys and an expert meeting. Participants were asked to choose their top 10 of most important factors. PARTICIPANTS: Dutch gastrointestinal surgeons (n=52) of different hospitals and different hospital types (general/teaching/academic). RESULTS: Of 31 invited experts for the first survey and meeting, 71% responded. Of 130 invited surgeons, 34 responded to the second survey. Factors deemed important were: procedural hospital volume (46% in top 10), specialised surgeons performing surgery, (elective 87%, emergency 60% and reoperations 62% in top 10), accessibility of, and daily ward rounds by specialised surgeons (41% and 38% in top 10), preoperative screening for malnutrition (57% in top 10), a protocol for recognition of anastomotic leakage and rapid reintervention (54% and 49% in top 10). CONCLUSION: Procedural hospital volume, specialisation of surgeons, screening for malnutrition, early recognition of complications followed by rapid action were perceived as most important factors to achieve good outcomes by gastrointestinal surgeons.

The influence of a composite hospital volume on outcomes for gastric cancer surgery: A Dutch population-based study.

BACKGROUND: Volume-outcome associations for complex surgical procedures have motivated centralization of care worldwide. The aim of this study was to investigate the association between overall hospital experience with complex upper gastrointestinal (GI) cancer resections and outcomes after gastric cancer surgery. METHODS: Data on all patients (n = 4837) who underwent a resection for non metastatic invasive gastric cancer between 2005 and 2014 were obtained from the Netherlands Cancer Registry (NCR). Annual hospital volume categories were based on the combined volume of gastrectomies, esophagectomies, and pancreatectomies (composite hospital volume). Volume-outcome analyses were performed for lymph node yield, 30-day mortality, and overall survival. RESULTS: The proportion of gastric cancer resections performed in hospitals with an annual composite hospital volume of ≥40 upper GI cancer resections increased from 6% in 2005 to 80% in 2014. A higher composite hospital volume was univariably associated with a higher lymph node yield, lower 30-day mortality, and increased overall survival. Statistical significance was lost after adjusting for case mix. But, sub group analysis including only elderly patients (≥75 years) showed a significant association between composite hospital volume and 30-day mortality. CONCLUSION: In the Netherlands, an increasing proportion of gastric cancer resections is performed in hospitals with a high composite hospital volume of gastric, esophageal, and pancreatic cancer resections. Special attention is warranted to referral of elderly patients, as these patients might specifically benefit from this centralization.

The Influence of Hospital Volume on Circumferential Resection Margin Involvement: Results of the Dutch Surgical Colorectal Audit.

UNLABELLED: This population-based study evaluates the association between hospital volume and CRM (circumferential resection margin) involvement, adjusted for other confounders, in rectal cancer surgery. A low hospital volume (<20 cases/year) was independently associated with a higher risk of CRM involvement (odds ratio=1.54; 95% CI: 1.12-2.11). OBJECTIVE: To evaluate the association between hospital volume and CRM (circumferential resection margin) involvement in rectal cancer surgery. BACKGROUND: To guarantee the quality of surgical treatment of rectal cancer, the Association of Surgeons of the Netherlands has stated a minimal annual volume standard of 20 procedures per hospital. The influence of hospital volume has been examined for different outcome variables in rectal cancer surgery. Its influence on the pathological outcome (CRM) however remains unclear. As long-term outcomes are best predicted by the CRM status, this parameter is of essential importance in the debate on the justification of minimal volume standards in rectal cancer surgery. METHODS: Data from the Dutch Surgical Colorectal Audit (2011-2012) were used. Hospital volume was divided into 3 groups, and baseline characteristics were described. The influence of hospital volume on CRM involvement was analyzed, in a multivariate model, between low- and high-volume hospitals, according to the minimal volume standards. RESULTS: This study included 5161 patients. CRM was recorded in 86% of patients. CRM involvement was 11% in low-volume group versus 7.7% and 7.9% in the medium- and high-volume group (P≤0.001). After adjustment for relevant confounders, the influence of hospital volume on CRM involvement was still significant odds ratio (OR) = 1.54; 95% CI: 1.12-2.11). CONCLUSIONS: The outcomes of this pooled analysis support minimal volume standards in rectal cancer surgery. Low hospital volume was independently associated with a higher risk of CRM involvement (OR = 1.54; 95% CI: 1.12-2.11).

Gastric perforation due to foreign body ingestion mimicking acute cholecystitis.

An 82-year-old man presented with signs and symptoms that were suggestive of acute cholecystitis. He underwent a laparoscopic cholecystectomy. During the intervention, a wooden foreign body was removed from the infiltrated omentum, probably after it had perforated the gastric antrum. The gastric perforation had led to a secondary infection of the gallbladder. The presumed gastric perforation was treated conservatively, and the patient recovered well and was discharged after 7 days. Secondary inflamed gallbladders are rare; the current case is, to the best of our knowledge, the first case reporting a secondary infection of the gallbladder due to a gastric perforation. Clinicians should be aware of possible ingestion of foreign bodies in elderly patients wearing dental prosthetic devices.

Centralization of esophagectomy: how far should we go?

BACKGROUND: This study was designed to define a statistically sound and clinically meaningful cutoff point for annual hospital volume for esophagectomy. Higher hospital volumes are associated with improved outcomes after esophagectomy. However, reported optimal volumes in literature vary, and minimal volume standards in different countries show considerable variation. So far, there has been no research on the noncategorical, nonlinear, volume-outcome relationship in esophagectomy. METHODS: Data were derived from the Netherlands Cancer Registry. Restricted cubic splines were used to investigate the nonlinear effects of annual hospital volume on 6 month and 2 year mortality rates. Outcomes were adjusted for year of diagnosis, case-mix, and (neo)adjuvant treatment. RESULTS: Between 1989 and 2009, 10,025 patients underwent esophagectomy for cancer in the Netherlands. Annual hospital volumes varied between 1 and 83 year, increasing over time. Increasing annual hospital volume showed a continuous, nonlinear decrease in hazard ratio (HR) for mortality along the curve. Increasing hospital volume from 20 year (baseline, HR = 1.00) to 40 and 60 year was associated with decreasing 6 month mortality, with a HR of 0.73 (95 % confidence interval (0.65-0.83) and 0.67 (0.58-0.77) respectively. Beyond 60 year, no further decrease was detected. Higher hospital volume also was associated with decreasing 2 year mortality until 50 esophagectomies year with a HR of 0.86 (0.79-0.93). CONCLUSIONS: Centralization of esophagectomy to a minimum of 20 resections/year has been effectively introduced in the Netherlands. Increasing annual hospital volume was associated with a nonlinear decrease in mortality up to 40-60 esophagectomies/year, after which a plateau was reached. This finding may guide quality improvement efforts worldwide.

Ranking and rankability of hospital postoperative mortality rates in colorectal cancer surgery.

OBJECTIVES: To examine to what extent random variation and variation in case-mix influence hospital rankings on the basis of mortality rates and to determine the suitability of mortality for ranking hospitals in colorectal surgery. BACKGROUND: Comparing and ranking postoperative mortality rates between hospitals becomes increasingly popular. Differences in hospital case-mix, and chance variation related to caseload, may influence rankings. The suitability of mortality for rankings remains unclear. METHODS: Data were derived from the Dutch Surgical Colorectal Audit. Hospital rankings based on fixed- and random-effects logistic regression models, unadjusted and adjusted for case-mix were compared with the percentile based on expected ranks (the chance that a hospital performs better than a random hospital). Rankability, measuring which part of variation between hospitals is not due to chance, was calculated. RESULTS: Some 25,591 patients undergoing colorectal resections in 92 hospitals were evaluated. Postoperative mortality rates ranged between 0% and 8.8%. Adjustment for case-mix with a fixed-effects model caused large changes in rankings. A smaller additional effect on changes in rankings occurred after adjusting with a random-effects model, with lower volume hospitals moving toward the mean. Percentile based on expected ranks ranged between 10% and 85%. Rankability was 38%, meaning that 62% of hospital variation in mortality was due to chance. CONCLUSIONS: Hospital ranks changed after case-mix adjustment and random-effects models, compared with unadjusted analysis. A large proportion of hospital variation in mortality was due to chance. Caution should be warranted when interpreting hospital rankings on the basis of postoperative mortality. Percentiles of expected ranks may help identify hospitals with exceptional performance.

Synchronous colorectal carcinoma: a risk factor in colorectal cancer surgery.

BACKGROUND: Synchronous colorectal carcinoma occurs in 1% to 8% of cases. There are little data on the impact of synchronous colorectal cancer on surgical treatment and short-term postoperative outcomes. OBJECTIVE: The purpose of this work was to evaluate clinical characteristics and treatment patterns of synchronous colorectal carcinoma and their influence on short-term postoperative outcomes in comparison with solitary colorectal carcinoma. DESIGN: This was a population-based observational study. Patient and tumor characteristics, treatment patterns, and postoperative outcomes are described for patients with a solitary and synchronous colorectal carcinoma separately. Multivariable logistic regression analysis was used to analyze the association between synchronous colorectal carcinoma and postoperative complications in comparison with a solitary colorectal carcinoma. SETTINGS: The study included in-hospital registration for the Dutch Surgical Colorectal Audit. PATIENTS: Patients were those with primary colorectal carcinoma from 2009 to 2011. MAIN OUTCOME MEASURES: Severe postoperative complications, reinterventions, and 30-day mortality were measured. RESULTS: Of 25,413 patients with colorectal cancer, 884 (3.5%) had synchronous colorectal tumors. Patients with synchronous colorectal carcinoma were older and more often of male sex compared with patients with solitary colorectal carcinoma. In ≥ 35% of cases, an extended surgical procedure was conducted (n = 310). In multivariable logistic regression analysis, synchronous colorectal carcinoma was associated with a higher risk of severe postoperative complications (OR, 1.40; 95% CI, 1.20-1.63) and reinterventions (OR, 1.37; 95% CI, 1.14-1.65) compared with solitary colorectal carcinoma but not with higher 30-day mortality (OR, 1.34; 95% CI, 0.96-1.88). LIMITATIONS: This study was limited by the data being self-reported. Case-mix adjustment was limited to information available in the data set, and no long-term outcome data were available. CONCLUSIONS: Synchronous colorectal carcinomas are prevalent in 3.5% of patients and require a different treatment strategy in comparison with solitary colorectal carcinoma. Postoperative outcomes are unfavorable, most likely because of extensive surgery.

Safety of elective colorectal cancer surgery: non-surgical complications and colectomies are targets for quality improvement.

BACKGROUND: Mortality following severe complications (failure-to-rescue, FTR) is targeted in surgical quality improvement projects. Rates may differ between colon- and rectal cancer resections. METHODS: Analysis of patients undergoing elective colon and rectal cancer resections registered in the Dutch Surgical Colorectal Audit in 2011-2012. Severe complication- and FTR rates were compared between the groups in univariate and multivariate analysis. RESULTS: Colon cancer (CC) patients (n = 10,184) were older and had more comorbidity. Rectal cancer (RC) patients (n = 4,906) less often received an anastomosis and had more diverting stomas. Complication rates were higher in RC patients (24.8% vs. 18.3%, P < 0.001). However, FTR rates were higher in CC patients (18.6% vs. 9.4%, P < 0.001). Particularly, FTR associated with anastomotic leakage, postoperative bleeding, and infections was higher in CC patients. Adjusted for casemix, CC patients had a twofold risk of FTR compared to RC patients (OR 1.89, 95% CI 1.06-3.37). CONCLUSIONS: Severe complication rates were lower in CC patients than in RC patients; however, the risk of dying following a severe complication was twice as high in CC patients, regardless of differences in characteristics between the groups. Efforts should be made to improve recognition and management of postoperative (non-)surgical complications, especially in colon cancer surgery.

Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review.

BACKGROUND: In the setting of difficult dissection of Calot's triangle during laparoscopic cholecystectomy, conversion is commonly advocated. An alternative approach aimed at preventing bile duct injury is laparoscopic partial cholecystectomy (LPC). The safety and efficacy of this procedure are unclear. METHODS: A systematic review of the literature was performed independently by three researchers. The outcomes were conversion rate, hospital length of stay (LOS), bile duct injury, bile leak, symptomatic gallstones in the remnant gallbladder, need for reoperation, postoperative endoscopic retrograde cholangiopancreaticography (ERCP), percutaneous intervention, and mortality. RESULTS: The review included 15 publications, which reported on 625 patients. Four different operative techniques could be distinguished. Conversion to open (partial) cholecystectomy was performed in 10.4 % of the cases. The median LOS was 4.5 days (range, 0-48 days). The most common complication was postoperative bile leak, which occurred in 66 patients (10.6 %). One case of bile duct injury occurred. During the follow-up period, 2.2 % of the patients experienced recurrent symptoms of gallstones. Eight patients (2.7 %) underwent reoperation. Postoperative ERCP was performed for 26 (7.5 %) of 349 patients. A percutaneous intervention was performed for 5 (1.4 %) of 353 patients. Three deaths were described in the reviewed series (1 of pulmonary sepsis and 2 of myocardial infarctions). A rough comparison showed that fewer bile leaks, less need for ERCP, and less recurrent symptoms of gallstones seemed to occur when the cystic duct and gallbladder remnant were closed. CONCLUSIONS: Literature concerning LPC is scarce. Four different LPC techniques can be distinguished. When a difficult gallbladder is encountered during LC, LPC seems to be a safe and feasible alternative to conversion. Closing of the cystic duct, gallbladder remnant, or both seems to be preferable.

Effect of laparoscopy on the indications for adrenalectomy.

BACKGROUND: Laparoscopic adrenalectomy is now the criterion standard for removal of most benign adrenal lesions and may be used for malignant lesions as well. At the same time, improved imaging has led to an increase in the number of incidentally detected adrenal masses. The aim of this study was to determine whether the introduction of laparoscopy has changed the indications for adrenalectomy. DESIGN: Retrospective cohort study of patients operated on for primary adrenal disease between September 1, 1987, and August 17, 2007. SETTING: Academic hospital. PATIENTS: Sixty-six patients treated before (group 1) and 203 treated after (group 2) introduction of laparoscopic adrenalectomy. MAIN OUTCOME MEASURES: Patient characteristics, comorbidity, tumor size, indication, and time between diagnosis and surgery. RESULTS: Group 2 had more patients in American Society of Anesthesiologists class III with gastrointestinal and metabolic-endocrine comorbidities. Tumor size did not change, and, despite an increase in the number of adrenalectomies, indications for surgery remained consistent over time. CONCLUSION: Despite an increased volume of procedures, the introduction of laparoscopic adrenalectomy in our hospital did not change the indications for surgical intervention.