Cheng-Hung Lee

The combined effects of hospital and surgeon volume on short-term survival after hepatic resection in a population-based study.

Background The influence of different hospital and surgeon volumes on short-term survival after hepatic resection is not clearly clarified. By taking the known prognostic factors into account, the purpose of this study is to assess the combined effects of hospital and surgeon volume on short-term survival after hepatic resection. Methods 13,159 patients who underwent hepatic resection between 2002 and 2006 were identified in the Taiwan National Health Insurance Research Database. Data were extracted from it and short-term survivals were confirmed through 2006. The Cox proportional hazards model was used to assess the relationship between survival and different hospital, surgeon volume and caseload combinations. Results High-volume surgeons in high-volume hospitals had the highest short-term survivals, following by high-volume surgeons in low-volume hospitals, low-volume surgeons in high-volume hospitals and low-volume surgeons in low-volume hospitals. Based on Cox proportional hazard models, although high-volume hospitals and surgeons both showed significant lower risks of short-term mortality at hospital and surgeon level analysis, after combining hospital and surgeon volume into account, high-volume surgeons in high-volume hospitals had significantly better outcomes; the hazard ratio of other three caseload combinations ranging from 1.66 to 2.08 (p<0.001) in 3-month mortality, and 1.28 to 1.58 (p<0.01) in 1-year mortality. Conclusions The combined effects of hospital and surgeon volume influenced the short-term survival after hepatic resection largely. After adjusting for the prognostic factors in the case mix, high-volume surgeons in high-volume hospitals had better short-term survivals. Centralization of hepatic resection to few surgeons and hospitals might improve patients’ prognosis.

The safety and adequacy of resection on hepatocellular carcinoma larger than 10 cm: A retrospective study over 10 years

Background/purpose Current treatment options for HCC≥10 cm (huge HCC) are limited. Otherwise, the margin status is known as a prognostic factor. Our aim was to determine the safety, effectiveness, and risk factors for overall survival and disease-free survival for these patients. Methods A total of 211 consecutive patients from 2000/08 to 2010/12 were enrolled. Characteristics of patients, tumors, and treatment were compared between the huge group (HCCs; ≥10 cm, n = 23; 11%) and those with smaller group (HCC; <10 cm n = 188; 89%). Disease-free survival (DFS), overall survival (OS), and risk factors were analyzed. Results Median follow up was 37 months. Patients with huge HCC were more likely to be symptomatic, positive for preoperative portal vein thrombosis, longer surgical time, more blood loss and transfusions, and significantly shorter median OS and DFS. Both groups had similar postoperative mortality and morbidity rates. In the huge HCC, multivariate analysis identified two significant determinants of DFS (preoperative portal vein thrombosis on imaging and tumor-free margin less than 1 mm) and two significant determinants of OS (age over 80 and preoperative portal vein thrombosis). Even with positive margins, it still had no impact on OS. For DFS, 1 mm free margins appeared to be adequate. Conclusion Tumor-free margin is an independent risk factor for recurrence but has no impact on OS. Surgical margin >1 mm is adequate in patients with tumors ≥10 cm. Postoperative close follow up, especially of distant metastasis, and appropriate treatment of recurrence by a multidisciplinary approach may improve prognosis.

The association of socioeconomic status and access to low-volume service providers in breast cancer.

Background No large-scale study has explored the combined effect of patients’ individual and neighborhood socioeconomic status (SES) on their access to a low-volume provider for breast cancer surgery. The purpose of this study was to explore under a nationwide universal health insurance system whether breast cancer patients from a lower individual and neighborhood SES are disproportionately receiving breast cancer surgery from low-volume providers. Methods 5,750 patients who underwent breast cancer surgery in 2006 were identified from the Taiwan National Health Insurance Research Database. The Cox proportional hazards model was used to compare the access to a low-volume provider between the different individual and neighborhood SES groups after adjusting for possible confounding and risk factors. Hosmer-Lemeshow goodness-of-fit statistic was used to determine how well the model fit the data. Results Univariate analysis data shows that patients in disadvantaged neighborhood were more likely to receive breast cancer surgery at low-volume hospitals; and lower-SES patients were more likely to receive surgery from low-volume surgeons. In multivariate analysis, after adjusting for patient characteristics, the odds ratios of moderate- and low-SES patients in disadvantaged neighborhood receiving surgery at low-volume hospitals was 1.47 (95% confidence interval=1.19-1.81) and 1.31 (95% confidence interval=1.05-1.64) respectively compared with high-SES patients in advantaged neighborhood. Moderate- and low-SES patients from either advantaged or disadvantaged neighborhood had an odds ratios ranging from 1.51 to 1.80 (p<0.001) to receiving surgery from low-volume surgeons. In Hosmer-Lemeshow goodness-of-fit test, p>0.05 that shows the model has a good fit. Conclusions In this population-based cross-sectional study, even under a nationwide universal health insurance system, disparities in access to healthcare existed. Breast cancer patients from a lower individual and neighborhood SES are more likely to receive breast cancer surgery from low-volume providers. The authorities and public health policies should keep focusing on these vulnerable groups.

Preoperative Risk Score Predicting 90-Day Mortality After Liver Resection in a Population-Based Study

AbstractThe impact of important preexisting comorbidities, such as liver and renal disease, on the outcome of liver resection remains unclear. Identification of patients at risk of mortality will aid in improving preoperative preparations. The purpose of this study is to develop and validate a population-based score based on available preoperative and predictable parameters predicting 90-day mortality after liver resection using data from a hepatitis endemic country.We identified 13,159 patients who underwent liver resection between 2002 and 2006 in the Taiwan National Health Insurance Research Database. In a randomly selected half of the total patients, multivariate logistic regression analysis was used to develop a prediction score for estimating the risk of 90-day mortality by patient demographics, preoperative liver disease and comorbidities, indication for surgery, and procedure type. The score was validated with the remaining half of the patients.Overall 90-day mortality was 3.9%. Predictive characteristics included in the model were age, preexisting cirrhosis-related complications, ischemic heart disease, heart failure, cerebrovascular disease, renal disease, malignancy, and procedure type. Four risk groups were stratified by mortality scores of 1.1%, 2.2%, 7.7%, and 15%. Preexisting renal disease and cirrhosis-related complications were the strongest predictors. The score discriminated well in both the derivation and validation sets with c-statistics of 0.75 and 0.75, respectively.This population-based score could identify patients at risk of 90-day mortality before liver resection. Preexisting renal disease and cirrhosis-related complications had the strongest influence on mortality. This score enables preoperative risk stratification, decision-making, quality assessment, and counseling for individual patients.

Incidence of and Risk Factors for Pediatric Metachronous Contralateral Inguinal Hernia: Analysis of a 17-Year Nationwide Database in Taiwan

Background Previous prospective, retrospective, and meta-analysis studies revealed that the overall incidence of metachronous contralateral inguinal hernia (MCIH) ranges from 5.76% to 7.3%, but long-term follow-up postoperative data are scant. We identified the incidence and risk factors of MCIH in pediatric patients during the follow-up using the Taiwan National Health Insurance Research Database (NHIRD). Methods Between 1996/01/01 and 2008/12/31, all pediatric patients with primary unilateral inguinal hernia repair who were born after 1996/01/01 were collected via ICD-9 diagnostic and procedure codes recorded in NHIRD. Patients with another operation during the same admission, complicated hernia, or laparoscopic procedure were excluded. Several reported risk factors, including age, sex, preterm birth, low body weight, and previous ventriculoperitoneal shunt placement, were used for analysis. The primary endpoint was the repairmen of MCIH following the initial surgery. All patients were followed until 2013/12/31 or withdrawal from national health insurance. Results A total of 31,100 pediatric patients underwent unilateral inguinal hernia repair, and 111.76 months of median follow-up data were collected. The overall rate of MCIH was 12.3%. Among the 31,100 patients who had the hernia repair, 63.6% had MCIH within 2 years and 91.5% had MCIH within 5 years. After initial surgery, the incidence of MCIH gradually and significantly decreased with age up to approximately 6 years. Multivariable analysis showed that age <4 y and girls were risk factors for subsequent MCIH. Conclusions After 17 years of follow-up, the overall MCIH rate was 12.3%, and 91.7% of patients needed repair for MCIH within the first 5 years after initial surgery. Age <4 years and girls were risk factors for MCIH. The contralateral exploration for inguinal hernia should be considered among these patients.

Palliative Chemotherapy Affects Aggressiveness of End-of-Life Care

INTRODUCTION Although palliative chemotherapy during end-of-life care is used for relief of symptoms in patients with metastatic cancer, chemotherapy may lead to more aggressive end-of-life care and less use of hospice service. This is a population-based study of the association between palliative chemotherapy and aggressiveness of end-of-life care. PATIENTS AND METHODS Using the National Health Insurance Research Database of Taiwan, we identified 49,920 patients with metastatic cancer who underwent palliative chemotherapy from January 1, 2009, to December 31, 2011. Patients who received chemotherapy 2-6 months before death were included. Aggressiveness of end-of-life care was examined by previously reported indicators. Cardiopulmonary resuscitation and endotracheal tube intubation were included as indicators of aggressive end-of-life care. The association between palliative chemotherapy and hospice care was studied. RESULTS Palliative chemotherapy was associated with more aggressive treatment. After adjustment for patient age, sex, Charlson Comorbidity Index score, cancer group, primary physicians specialty, postdiagnosis survival, hospital characteristics, hospital caseload, urbanization, and geographic regions, more than one emergency room visit (p < .001), more than one intensive care unit admission (p < .001), and endotracheal intubation (p = .02) during end-of-life care were significantly more common in patients receiving palliative chemotherapy. Patients who did not receive palliative chemotherapy received more hospice care in the last 6 months of life (p < .001). CONCLUSION Although the decision to initiate palliative chemotherapy was made several months before death, this study showed that palliative chemotherapy was associated with more aggressive end-of-life care, including more emergency room visits and intensive care unit admissions, and endotracheal intubation. The patients who received palliative chemotherapy received less hospice service toward the end of life. IMPLICATIONS FOR PRACTICE Palliative chemotherapy is used for patients with incurable cancer toward the end of life (EOL). Aggressiveness of EOL care and hospice care are related to the quality of life of these patients. This study of data from the Taiwanese National Health Insurance Research Database found that palliative chemotherapy led to more aggressive EOL care and less hospice care. There is a need to provide patients with terminal cancer access to care information that best meets their needs, especially those patients who receive palliative chemotherapy.

The effect of individual and neighborhood socioeconomic status on esophageal cancer survival in working-age patients in Taiwan.

AbstractEsophageal cancer is the sixth leading cause of cancer mortality. More than 90% of patients with esophageal cancer in Taiwan have squamous cell carcinoma. Survival of such patients is related to socioeconomic status (SES). We studied the association between SES (individual and neighborhood) and the survival of working-age patients with esophageal cancer in Taiwan. A population-based study was conducted of 4097 patients diagnosed with esophageal cancer between 2002 and 2006. Each was traced for 5 years or until death. Individual SES was defined by enrollee job category. Neighborhood SES was based on household income and dichotomized into advantaged or disadvantaged. Multilevel logistic regression was used to compare the survival rates by SES group after adjustment for possible confounding and risk factors. Hospital and neighborhood SES were used as random effects in multilevel logistic regression. In patients younger than 65 years, 5-year overall survival rates were worst for those with low individual SES living in disadvantaged neighborhoods. After adjustment for patient characteristics, esophageal cancer patients with high individual SES had a 39% lower risk of mortality than those with low individual SES (odds ratio 0.61, 95% confidence interval 0.48–0.77). Patients living in disadvantaged areas with high individual SES were more likely to receive surgery than those with low SES (odds ratio 1.45, 95% confidence interval 1.11–1.89). Esophageal cancer patients with low individual SES have the worst 5-year survival, even with a universal healthcare system. Public health, education, and social welfare programs should address the inequality of esophageal cancer survival.

Bilateral primary inguinal hernia repair in Taiwanese adults: A nationwide database analysis

Objective: The objective of this study was to identify the long-term rates of and treatment options for recurrence of bilateral primary inguinal hernias following various hernia repair methods, namely, open inguinal hernia repair (OIHR) without mesh, OIHR with mesh (OIHR-M), and laparoscopic inguinal hernia repair (LIHR). Materials and Methods: Data in this retrospective study were retrieved from the Taiwans National Health Insurance Research Database. All adult patients who underwent primary bilateral inguinal hernia repair were selected from this database using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes. Results: From 2000 to 2010, 13,636 adult patients underwent elective bilateral inguinal hernia repair, with a median follow-up of 63.95 months. The risk of recurrence was significantly lower in the LIHR group than in the OIHR group (hazard ratio [HR] =0.691,P = 0.003) and was similar to that in the OIHR-M group (HR = 1.187,P = 0.184). The median recurrence-free period was 28.93 months. After recurrence, 52.6% of patients underwent repair at the same hospital, and 35.5% of patients were operated on by the same surgeons. The LIHR group had a significantly shorter median recurrent period than did the other groups (OIHR, OIHR-M, and LIHR: 33.83, 23.33, 16.56 months, respectively;P < 0.001). Moreover, recurrence occurred in a significantly higher proportion of patients who were treated by the same surgeon (OIHR vs. OIHR-M vs. LIHR = 31.8% vs. 40.1% vs. 48.6%,P < 0.001). Conclusions: In this large cohort study, the recurrence risk was significantly lower in the LIHR group than in the OIHR group and was similar to that in the OIHR-M group, for primary bilateral hernia repair. In addition, the LIHR group experienced similar mortality as the other groups but lower readmission rates. Moreover, the proportion of LIHR patients treated by the same doctor was significantly higher than that of traditional hernia repair patients. In short, LIHR is a reliable procedure and may offer an improved surgical experience for bilateral primary inguinal hernia repair.

Surgical resection of metachronous hepatic metastases from gastric cancer improves long-term survival: A population-based study

Introduction Hepatic metastases are diagnosed synchronously in 3–14% of patients with gastric cancer, and metachronously in up to 37% of patients following ‘‘curative” gastrectomy. Most patients who have gastric cancer and hepatic metastasis are traditionally treated with palliative chemotherapy. The impact of liver resection is still controversial. We attempted to assess whether liver resection can improve survival in cases of metachronous hepatic metastases from gastric cancer through a nationwide database. Materials and methods We conducted a nationwide cohort study using a claims dataset from Taiwan’s National Health Insurance Research Database (NHIRD). We identified all patients with gastric cancer (diagnostic code ICD-9: 151.x) from the Registry for Catastrophic Illness Patient Database (RCIPD) of the NHIRD who received gastrectomy and as well as those with metachronous (≥180 days after gastrectomy) liver metastases (ICD-9 code: 197.7) between 1996/01/01 and 2012/12/31. Patients with other malignancies, with metastasis in the initial admission for gastrectomy and with other metastases were excluded. They were divided into two groups, liver resection group and non-resection group. All patients were followed till 2013/12/31 or withdrawn from the database because of death. Results 653 patients who fullfilled the inclusion criteria were included in the research. They were divided into liver resection group (34 patients) and non-resection group (619 patients). There were no differences between the two groups in gender, Charlson Comorbidity index and major coexisting disease. Kaplan-Meier analysis demostrated the liver resection group had significantly better overall survival than the non-resection group. (1YOS: 73.5% vs. 19.7%, 3YOS: 36.9% vs. 6.6%, 5YOS: 24.5.3% vs. 4.4%, p <0.001). After COX analysis, the liver resection group showed statistical significance for improved patient survival (HR = 0.377, 95%CI: 0.255–0.556. p<0.001). Conclusion Liver resection in patients presenting with metachronous hepatic metastases as the sole metastases after curative resection of gastric cancer is associated with a significant survival improvement and should be considered a treatment option for such patients.

Better Long-Term Prognosis: Comparison Between Surgery and TACE as Initial Treatment for Operable Huge HCCs (≥10 cm) After More Than 5 Years of Follow Up

The objective of this study was to research the long-term survival difference between surgery and transarterial chemoembolization (TACE) for operatable hepatocellular carcinoma (HCC) ≥10 cm. Little...