D. Henneman

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.

Safety of Elective Colorectal Cancer Surgery: Non-Surgical Complications and Colectomies are Targets for Quality Improvement

Mortality following severe complications (failure‐to‐rescue, FTR) is targeted in surgical quality improvement projects. Rates may differ between colon‐ and rectal cancer resections.

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.

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

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).

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

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.

The influence of a composite hospital volume of upper gastrointestinal cancer resections on outcomes of gastric cancer surgery.

305 Background: There is a known volume-outcome association for complex surgial procedures such as oncologic gastric resections. The aim of this study was to describe the process of centralization for gastric cancer surgery in the Netherlands in relation to other types of upper gastrointestinal (GI) cancer resections and to investigate whether the quality of gastric cancer surgery is affected by the overall experience with those related complex surgical procedures. METHODS Data on all patients (n = 4251) who underwent surgical treatment for non metastatic invasive gastric cancer between 2005-2013 were obtained from the Netherlands Cancer Registry. Annual hospital volume categories were based on the overall volume of gastrectomies, esophagectomies and pancreatectomies together (composite hospital volume). Volume-outcome analyses were performed for lymph node yield, 30-day mortality, and overall survival. RESULTS The percentage of gastric cancer patients who underwent a resection in a hospital with a volume of at least 20 gastrectomies per year increased. At the same time, the percentage of gastric cancer patients who underwent surgery in hospitals with an annual composite hospital volume of at least 20 upper GI cancer resections, such as esophageal and pancreatic cancer resections, increased. A higher composite hospital volume was associated with a higher lymph node yield, a lower 30-day mortality, and an increased overall survival. CONCLUSIONS In the Netherlands, an increasing proportion of gastric cancer resections is performed in hospitals that are high volume centers for esophagectomies and pancreatectomies for cancer. Experience with these complex surgical procedures has a favorable effect on the outcomes of gastric cancer surgery.

In Reply: Centralization of Upper Gastrointestinal Cancer Care Should Be Dictated by Quality of Care

Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Department of Surgery, Medical Center Haaglanden, Medisch Centrum Haaglanden, The Hague, The Netherlands; Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands; Comprehensive Cancer Center South, Eindhoven, The Netherlands; Comprehensive Cancer Center The Netherlands, Leiden, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Radiotherapy, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Surgery, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

The Dutch Upper GI Cancer Audit: 2011-2014.

309 Background: In 2011, the Dutch Upper GI Cancer Audit (DUCA) group started with a nationwide registration of all patients who underwent surgery for esophageal or gastric cancer. The aim of this study was to describe the initiation and implementation of the DUCA and to provide an overview of the results. METHODS The DUCA is part of the Dutch Institute for Clinical Auditing. It provides (surgical) teams with reliable, weekly updated, benchmarked information on process and (casemix-adjusted) outcome measures. A web-based registration was designed, based on a set of predefined quality measures. RESULTS Between 2011 and 2014, a total of 4672 patients with esophageal or gastric cancer was registered in the DUCA. Case ascertainment has approached 100% for patients registered in 2014. The percentage of patients with esophageal cancer starting treatment within 5 weeks after diagnosis significantly increased over time (33 to 41%) and the percentage of patients with a minimum of 15 lymph nodes in the resected specimen significantly increased for both esophageal cancer (50 to 73%) and gastric cancer (48 to 74%). Postoperative mortality decreased for patients with gastric cancer (8.0% in 2011 to 4.0% in 2014; p = 0.020) and remained stable (around 4%) for patients with esophageal cancer. CONCLUSIONS Nationwide implementation of the DUCA has been successful. Results give a valuable insight in the quality of the surgical care for patients with esophageal or gastric cancer and show a positive trend for various process and outcome measures.

Safety of elective colorectal cancer surgery: Non-surgical complications and colectomies are targets for quality improvement: Targets for Quality Improvement

Mortality following severe complications (failure‐to‐rescue, FTR) is targeted in surgical quality improvement projects. Rates may differ between colon‐ and rectal cancer resections.

Safety of elective colorectal cancer surgery

Mortality following severe complications (failure‐to‐rescue, FTR) is targeted in surgical quality improvement projects. Rates may differ between colon‐ and rectal cancer resections.