The Effect of Regionalization on Outcome in Pulmonary Lobectomy: a Canadian National Study

Overview

Journal J Thorac Cardiovasc Surg

Specialties Cardiology & Vascular Diseases
General Surgery
Pulmonary Medicine

Date 2010 Sep 21

PMID 20850656

Citations 16

Authors

Christian J Finley

Anna Bendzsak

George Tomlinson

Shaf Keshavjee

David R Urbach

Gail E Darling

Affiliations

Soon will be listed here.

Abstract

Objective: To examine the effect of regionalization of thoracic surgery services in Canada by evaluating change over time in hospital volumes of pulmonary lobectomy and its impact on length of stay and in-hospital mortality.

Methods: Data on pulmonary lobectomy between 1999 and 2007 were abstracted from the Canadian Institute for Health Information Discharge Abstract Database. In-hospital mortality was analyzed by logistic regression, and log-transformed length of stay was analyzed by linear regression. Cross-sectional analysis of hospital volume, in-hospital mortality, and length of stay was performed, controlling for clustering. Within-hospital changes in annual volume on outcome was analyzed using multivariable logistic regression, controlling for Charlson comorbidity index and other confounders.

Results: Of 19,732 patients, 10, 281 (52%) were male, with an average age of 63.3 years. There was a 45% (95% confidence interval, 21-61; P = .001) relative risk reduction in in-hospital mortality with a 19% reduction in length of stay (95% confidence interval, 12-25; P < .0001). On comparison of volume between hospitals, an increase of 20 cases was associated with a 15% relative risk reduction (95% confidence interval, 9-19; P < .0001) in in-hospital mortality and a 5% relative decrease (95% confidence interval, 3-7; P < .001) in length of stay. Within hospitals there was a nonsignificant relationship between volume and in-hospital mortality.

Conclusions: In-hospital mortality and length of stay for lobectomies have decreased in Canada. In multivariate analysis, volume was associated with improved in-hospital mortality, but there was no reduction in mortality when volume was increased within a given hospital. However, the proportion of patients treated in high-volume centers has increased over time, inferring the importance of high-volume centers in improved outcomes. This supports regionalization policies for pulmonary lobectomy.

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References

Bach P, Cramer L, Schrag D, Downey R, Gelfand S, Begg C . The influence of hospital volume on survival after resection for lung cancer. N Engl J Med. 2001; 345(3):181-8. DOI: 10.1056/NEJM200107193450306. View

Birkmeyer N, Goodney P, Stukel T, Hillner B, Birkmeyer J . Do cancer centers designated by the National Cancer Institute have better surgical outcomes?. Cancer. 2004; 103(3):435-41. DOI: 10.1002/cncr.20785. View

Berry M, Hanna J, Tong B, Burfeind Jr W, Harpole D, DAmico T . Risk factors for morbidity after lobectomy for lung cancer in elderly patients. Ann Thorac Surg. 2009; 88(4):1093-9. DOI: 10.1016/j.athoracsur.2009.06.012. View

Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi J . Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005; 43(11):1130-9. DOI: 10.1097/01.mlr.0000182534.19832.83. View

Ghaferi A, Birkmeyer J, Dimick J . Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009; 361(14):1368-75. DOI: 10.1056/NEJMsa0903048. View

Begg C, Cramer L, Hoskins W, Brennan M . Impact of hospital volume on operative mortality for major cancer surgery. JAMA. 1998; 280(20):1747-51. DOI: 10.1001/jama.280.20.1747. View

Li B, Evans D, Faris P, Dean S, Quan H . Risk adjustment performance of Charlson and Elixhauser comorbidities in ICD-9 and ICD-10 administrative databases. BMC Health Serv Res. 2008; 8:12. PMC: 2267188. DOI: 10.1186/1472-6963-8-12. View

Hannan E, Radzyner M, Rubin D, Dougherty J, Brennan M . The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer. Surgery. 2002; 131(1):6-15. DOI: 10.1067/msy.2002.120238. View

Simunovic M, Rempel E, Theriault M, Coates A, Whelan T, Holowaty E . Influence of hospital characteristics on operative death and survival of patients after major cancer surgery in Ontario. Can J Surg. 2006; 49(4):251-8. PMC: 3207572. View

10.

Birkmeyer J . Should we regionalize major surgery? Potential benefits and policy considerations. J Am Coll Surg. 2000; 190(3):341-9. DOI: 10.1016/s1072-7515(99)00270-7. View

11.

Meguid R, Brooke B, Chang D, Sherwood J, Brock M, Yang S . Are surgical outcomes for lung cancer resections improved at teaching hospitals?. Ann Thorac Surg. 2008; 85(3):1015-24. DOI: 10.1016/j.athoracsur.2007.09.046. View

12.

Finlayson E, Goodney P, Birkmeyer J . Hospital volume and operative mortality in cancer surgery: a national study. Arch Surg. 2003; 138(7):721-5; discussion 726. DOI: 10.1001/archsurg.138.7.721. View

13.

Meguid R, Weiss E, Chang D, Brock M, Yang S . The effect of volume on esophageal cancer resections: what constitutes acceptable resection volumes for centers of excellence?. J Thorac Cardiovasc Surg. 2009; 137(1):23-9. PMC: 2631576. DOI: 10.1016/j.jtcvs.2008.09.040. View

14.

Urschel J, Urschel D . The hospital volume-outcome relationship in general thoracic surgery. Is the surgeon the critical determinant?. J Cardiovasc Surg (Torino). 2000; 41(1):153-5. View

15.

Memtsoudis S, Besculides M, Zellos L, Patil N, Rogers S . Trends in lung surgery: United States 1988 to 2002. Chest. 2006; 130(5):1462-70. DOI: 10.1378/chest.130.5.1462. View

16.

Treasure T, Utley M, Bailey A . Assessment of whether in-hospital mortality for lobectomy is a useful standard for the quality of lung cancer surgery: retrospective study. BMJ. 2003; 327(7406):73. PMC: 164918. DOI: 10.1136/bmj.327.7406.73. View

17.

Boffa D, Allen M, Grab J, Gaissert H, Harpole D, Wright C . Data from The Society of Thoracic Surgeons General Thoracic Surgery database: the surgical management of primary lung tumors. J Thorac Cardiovasc Surg. 2008; 135(2):247-54. DOI: 10.1016/j.jtcvs.2007.07.060. View

18.

Khuri S, Daley J, Henderson W, Hur K, Hossain M, Soybel D . Relation of surgical volume to outcome in eight common operations: results from the VA National Surgical Quality Improvement Program. Ann Surg. 1999; 230(3):414-29; discussion 429-32. PMC: 1420886. DOI: 10.1097/00000658-199909000-00014. View

19.

Ho V, Heslin M, Yun H, Howard L . Trends in hospital and surgeon volume and operative mortality for cancer surgery. Ann Surg Oncol. 2006; 13(6):851-8. DOI: 10.1245/ASO.2006.07.021. View

20.

Gordon T, Burleyson G, Tielsch J, Cameron J . The effects of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg. 1995; 221(1):43-9. PMC: 1234493. DOI: 10.1097/00000658-199501000-00005. View