Patient survival after surgical treatment of rectal cancer: Impact of surgeon and hospital characteristics

Abstract

BACKGROUND: Surgeon and hospital factors are associated with the survival of patients treated for rectal cancer. The relative contribution of each of these factors toward determining outcomes is poorly understood. METHODS: We used data from the Surveillance, Epidemiology, and End Results-Medicare database to analyze the outcomes of patients aged 65 years and older undergoing operative treatment for nonmetastatic rectal cancer, diagnosed in the United States between 1998 and 2007. These data were linked to a registry to identify whether the treating surgeon was a board-certified colorectal surgeon versus a noncolorectal surgeon. Hospital volume and hospital certification as a National Cancer Institute-designated Comprehensive Cancer Centers were also analyzed. The primary outcome of interest was long-term survival. RESULTS: Our data source yielded 6432 patients. Initial analysis demonstrated improved long-term survival in patients treated by higher-volume colorectal surgeons, higher-volume hospitals, teaching hospitals, and National Cancer Institute (NCI)-designated Comprehensive Cancer Centers. Based on an iterative approach to modeling the interactions between these various factors, we found a robust effect of surgeon subspecialty status, hospital volume, and NCI designation. Surgeon volume was not distinctly associated with long-term survival. CONCLUSIONS: Patients treated for rectal cancer by board-certified colorectal surgeons in centers that are higher volume and/or NCI-designated Comprehensive Cancer Centers experience better overall survival. These differences persist after adjustment for a broad range of patient and contextual risk factors, including surgeon volume. Patients and payers can use these results to identify surgeons and hospitals where outcomes are most favorable.

Hospital volume and acute myeloid leukemia mortality in Medicare beneficiaries aged 65 years and older

“…Previous studies have shown that hospital characteristics, such as National Cancer Institute designation, are predictive of improved surgical oncology outcomes. 18,19 We did not adjust for hospital characteristics in this study because this would identify the independent effect of volume on mortality, over and above hospital characteristics.…”

Minimum Volume Discussion in the Treatment of Colon and Rectal Cancer: A Review of the Current Status and Relevance of Surgeon and Hospital Volume regarding Result Quality and the Impact on Health Economics

“…Contrary to the logistic regression model, which is most commonly used in the literature, the authors defined models that control for time-invariant heterogeneity, such as the biometrical method of proven superiority. The critical influence of biometric methods on the results has also been recognized by other groups [9,16,19,23]. In our analysis, we did not use box plots generating average values to calculate a significance for 'pro' or 'contra', since such an important decision of making a recommendation to a patient where and by whom he has to receive CC or RC treatment should be made without doubts in the literature, namely without the numerous 'maybes' or 'contras' that we cited.…”

“…We also outlined the known threats of centralization, namely unjustified exclusion of high-quality surgeons, leaving excluded surgeons and hospitals [11,13,30], leaving emergency surgery to low-volume surgeons (LVS) or LVH (excluded from selective surgery), implicating worse experience with surgical oncological treatment of CRC offered to the patients with the highest risk [11], the realistic danger of overload concerning HV [11], and, last but not least, the observation that patients who traveled farther for their care had worse outcomes than expected. This statement, cited in the review by Etzioni et al [23] and called 'reverse distance bias' in their discussion, may be relevant for the US situation but not necessarily for Western European countries, e.g. Germany.…”

“…However, we definitely need more objective quality parameters, as these have significant impact on the patients' benefit. In addition to volume alone, besides our list cited above, the following aspects are regarded as important for treatment quality in CC and RC: training and expertise of the surgeons [1,8,22,23,32,33], establishment of multidisciplinary teams [11-13, 23, 34], and, for monitoring and benchmarking quality, the establishment of audits [12-14, 16, 34]. With these strong statements the discussion of 'volume alone' should be abandoned, as has been previously practiced by German authors/associations [7,8] and by the GCS.…”

“…The scientific basis of recommendations for minimum volumes has been severely criticized because of biometrical reasons. Several authors have stated that trials are very heterogeneous concerning patient and hospital characteristics (table 3) or are applying less adequate biometrical methods, altogether having a substantial impact on the outcome of a trial and, therewith, the conclusions [9,16,19,22,23].…”