What is the impact of hospital and surgeon volumes on outcomes in rectal cancer surgery?
What is the impact of hospital and surgeon volumes on outcomes in rectal cancer surgery?
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DOI：
10.1111/codi.16745
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发表时间：
2023-09-13
影响因子：
3.4
通讯作者：
Fearnhead，Nicola S.
中科院分区：
文献类型：
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作者：
Boyle，Jemma M.;van Der Meulen，Jan;Fearnhead，Nicola S.
目的直肠癌手术是否存在正的容量-结果关系尚不清楚。本研究旨在评估英国国家医疗服务体系(NHS)医院和外科医生层面的直肠癌手术数量-结果关系。方法纳入2015-2019年在英国NHS接受直肠癌切除术的所有患者。采用多水平多变量Logistic回归对患者特征进行调整，建立预后与年平均医院和外科医生数量之间的关系模型(使用线性和二次项表示数量)。结果：共有13名 患者在16家医院接受治疗。6家医院(3.6%)每年进行的直肠癌手术少于10次，381名外科医生(45.0%)每年进行的此类手术少于5次。接受大容量外科医生治疗的患者住院时间缩短(p= 0.016)。在医院或外科医生水平上，90天死亡率、30天计划外再住院、计划外再入院、计划外返回手术室、前切除术后18 的吻合口、环切切缘阳性和2年全因死亡率之间没有统计学意义的相关性(pValue &> 0.05)。结论英国几乎一半的结直肠外科医生没有达到国家关于直肠癌外科医生每年至少进行五次大手术的标准。然而，我们的结果表明，以增加手术量为主要焦点的直肠癌手术集中化对NHS手术结果的影响可能有限。因此，质量改进计划应该涉及跨多学科护理途径的更广泛的循证过程措施，以改善直肠癌患者的预后。
AimEvidence for a positive volume–outcome relationship for rectal cancer surgery is unclear. This study aims to evaluate the volume–outcome relationship for rectal cancer surgery at hospital and surgeon level in the English National Health Service (NHS).MethodAll patients undergoing a rectal cancer resection in the English NHS between 2015 and 2019 were included. Multilevel multivariable logistic regression was used to model relationships between outcomes and mean annual hospital and surgeon volumes (using a linear plus a quadratic term for volume) with adjustment for patient characteristics.ResultsA total of 13 858 patients treated in 166 hospitals were included. Six hospitals (3.6%) performed fewer than 10 rectal cancer resections per year, and 381 surgeons (45.0%) performed fewer than five such resections per year. Patients treated by high‐volume surgeons had a reduced length of stay (p= 0.016). No statistically significant volume–outcome relationships were demonstrated for 90‐day mortality, 30‐day unplanned readmission, unplanned return to theatre, stoma at 18 months following anterior resection, positive circumferential resection margin and 2‐year all‐cause mortality at either hospital or surgeon level (pvalues > 0.05).ConclusionAlmost half of colorectal surgeons in England do not meet national guidelines for rectal cancer surgeons to perform a minimum of five major resections annually. However, our results suggest that centralizing rectal cancer surgery with the main focus of increasing operative volume may have limited impact on NHS surgical outcomes. Therefore, quality improvement initiatives should address a wider range of evidence‐based process measures, across the multidisciplinary care pathway, to enhance outcomes for patients with rectal cancer.