Higher surgeon and hospital volume improves long‐term survival after radical cystectomy

Abstract

BACKGROUND: Hospital and surgeon (provider) volume are associated with clinically significant outcomes for many types of surgery. Volume-outcome studies in patients undergoing radical cystectomy for bladder cancer have focused primarily on postoperative mortality. In the current study, the authors assessed the effect of cystectomy provider volume on long-term mortality. METHODS: Using administrative databases, 2535 patients who underwent cystectomy by 199 surgeons in 90 hospitals in Ontario, Canada, between 1992 and 2004 were identified. The impact of provider volume on overall survival (OS) was assessed using Cox proportional hazards models fully adjusted for patient and tumor characteristics. Separate models were fit to examine the effect of surgeon and hospital volume. To confirm that the impact of volume on OS was independent of the effect of volume on short-term mortality, analyses were repeated excluding those patients experiencing postoperative deaths. RESULTS: Of 2535 patients, 1796 (70.9%) died during the study period. Both higher hospital volume (hazards ratio [per unit increase in average annual number of procedures], 0.995; 95% confidence interval, 0.990-1.000 [P 5.044]) and higher surgeon volume (hazards ratio, 0.984; 95% confidence interval, 0.975-0.994 [P 5.002]) were found to be significantly associated with improved OS. Excluding post-operative deaths did not alter the results. Further analyses revealed that the benefit of high volume was attained by receiving care from either high-volume hospitals or highvolume surgeons. CONCLUSIONS: High-volume providers were associated with improved long-term mortality rates compared with low-volume providers. This finding was independent of the effect of volume on perioperative mortality, suggesting that provider volume effects continue to manifest long after surgery. Cancer 2013;119:3546-54. V C 2013 American Cancer Society.KEYWORDS: cystectomy; bladder cancer; quality of health care; outcomes; bladder neoplasm. INTRODUCTIONPatients who undergo radical cystectomy for bladder cancer are at significant risk of postoperative death and have a poor life expectancy. Postoperative mortality rates and 5-year overall survival rates typically range between 1% and 4% and 40% and 60%, 1-6 respectively. One way to improve on these outcomes is to optimize the quality of care for patients undergoing radical cystectomy. Several studies have demonstrated that hospitals and surgeons with higher cystectomy volumes generally have better postoperative outcomes compared with lower-volume providers.

Untitled

“…These observations are in line with those of other studies involving oncologic surgery, in which long-term results significantly improved with greater surgeon experience. [24][25][26][27] Moreover, these results are consistent with the primary hypothesis of this study that, whereas the immediate and perhaps midterm outcomes are equally influenced by individual experiences of surgeons during hepatectomy and graft implantation, the long-term outcomes are affected mostly by the experiences of surgeons performing graft implantation. Interestingly, the positive effects of greater experience of the surgeon performing graft implantation were observed only for conventional and not for piggyback liver transplant procedures.…”

Recommendations for the improvement of bladder cancer quality of care in Canada: A consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015

“…290,291 Findings from other researchers has shown superior outcomes for surgeries performed by urologic oncologists (compared to urologists); in academic centres (vs. non-academic centres); and by bladder-cancer-focused surgeons (vs. nonbladder-cancer-focused). 292,293 Thirty-and 90-day postoperative morality rates in academic centres in Canada have been reported to be 1.3% and 3.2%, respectively, with five-year overall survival of 57%.…”

“…294 This five-year survival rate is markedly higher than reported population-based outcomes across Canada, which have ranged from 30-43%. 290,291,295 With respect to cystectomies, 42.6% of procedures were performed in hospitals with a case volume of fewer than 10 cystectomies per year. 291 Only 23.1% of cystectomies were performed in hospitals with case volumes of more than 25 per year.…”

“…304 Analyses of Canadian data have also consistently demonstrated that higher volume of cases correlates with better outcomes, including lower mortality risk. 290,291,305 Improving bladder cancer care…”

Surgical Subspecialization: Escape Route for Surgeons or Added Benefit for Patients?

“…Evidence is mounting to show that higher surgeon volumes of specific cases lead to lower morbidity and mortality as well as shorter length of stay. [18][19][20][21][22][23] Even more compelling, recent research suggests that breast cancer patients and colon cancer patients are more likely to receive standard-of-care surgical treatment from trained subspecialists. [24][25][26] A shortage of 41 000 general surgeons is projected by 2025, 5 but in the face of data like these, perhaps we should worry more about improving the population's access to surgical subspecialists.…”