High-Volume Surgeons Have Improved Outcomes after Robotic Transthoracic Esophagectomy in the Community Setting

ObjectiveTo evaluate the influence of distance on access to high-volume surgical treatment for patients with uterine cancer in Maryland.MethodsThe Maryland Health Services Cost Review Commission database was retrospectively searched to identify primary uterine cancer surgical cases from 1994 to 2010. Race, type of insurance, year of surgery, community setting, and both surgeon and hospital volume were collected. Geographical coordinates of hospital and patient’s zip code were used to calculate primary independent outcomes of distance traveled and distance from nearest high-volume hospital (HVH). Logistic regression was used to calculate odds ratios and confidence intervals.ResultsFrom 1994 to 2010, 8529 women underwent primary surgical management of uterine cancer in Maryland. Multivariable analysis demonstrated white race, rural residence, surgery by a high-volume surgeon and surgery from 2003 to 2010 to be associated with both travel 50 miles or more to the treating hospital and residence 50 miles or more from the nearest HVH (allP< 0.05). Patients who travel 50 miles or more to the treating hospital are more likely to have surgery at a HVH (odds ratio, 6.03; 95% confidence interval, 4.67–7.79) In contrast, patients, who reside ≥50 miles from a HVH, are less likely to have their surgery at an HVH. (odds ratio, 0.37; 95% confidence interval, 0.32–0.42).ConclusionIn Maryland, 50 miles or more from residence to the nearest HVH is a barrier to high-volume care. However, patients who travel 50 miles or more seem to do so to receive care by a high-volume surgeon at an HVH. In Maryland, Nonwhites are more likely to live closer to an HVH and more likely to use these services.

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P199 IS ROUTINE ICU ADMISSION NECESSARY AFTER TRANSTHORACIC ESOPHAGECTOMY FOR ESOPHAGEAL AND ESOPHAGOGASTRIC JUNCTION CANCER?

Diseases of the Esophagus ◽

10.1093/dote/doz092.199 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Andrea Pansa ◽

Roit Anna Da ◽

Silvia Basato ◽

Damiano Gentile ◽

Pietro Riva ◽

...

Keyword(s):

Hospital Stay ◽

Complication Rate ◽

Esophagogastric Junction ◽

Length Of Hospital Stay ◽

High Volume ◽

Type I ◽

Transthoracic Esophagectomy ◽

Short Term ◽

Icu Admission ◽

Esophagogastric Junction Cancer

Abstract Aim We evaluated short-term outcomes of esophagectomy for esophageal and esophagogastric carcinoma without routine postoperative admission to Intensive Care Unit (ICU). Background & Methods esophagectomy is subject to high rates of complications and mortality even when performed in high-volume centers and conventional postoperative management often involves routine ICU admission according to recent guidelines and recommendations1 . From January 2018 to June 2019 a total of 112 esophagectomies were performed in the Upper GI Surgery division of Humanitas Research Hospital. We included the 83 patients that underwent transthoracic esophagectomy with a hybrid technique (laparoscopy + right thoracotomy) and high intrathoracic anastomosis for esophageal and esophagogastric junction cancer. Preoperative assessment included a prehabilitation program (nutritional evaluation, respiratory physiotherapy and adjustment of cardiologic therapy). Postoperatively, patients were managed by surgical team members. We retrospectively recorded data on necessity of ICU, operative times, complication rate (according to ECCG)2,3, length of hospital stay, in-hospital, 30-day and 90-day mortality. Results 68 patients were males and 15 females. Mean age was 65 years old (range 29-82). 67 patients underwent neoadjuvant therapy (49 chemo-radiotherapy, 18 chemotherapy alone). Postoperative ICU admission was necessary in 6 patients (9,5%), reasons for admission were necessity of ventilatory weaning in 2 patients, high lactate levels in one patient, glottic oedema following oro-tracheal intubation in one patient, while in the other cases ICU admission was planned for severe comorbidities. Mean duration of prehabilitation was 20.3 days (1-107). Mean surgery duration was 452.4 minutes (337-549). Overall complication rate was 33.8%, with the most common complications being atrial fibrillation (50% of all complications) and urinary retention (20%). There were two type I anastomotic leaks. Median length of hospital stay was 11 days (range 8-29). All patients were alive at 30 and 90 days after surgery. Conclusion routine ICU admission is not necessary after transthoracic esophagectomy for cancer in over 90% of patients. Careful patients’ evaluation, stratification of the surgical risk and systematic use of a prehabilitation program, along with adequate peri-operative management, can narrow the need for postoperative ICU admission in the setting of a high-volume centre without any impact on short-term outcomes.

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Variation in the use of intensity-modulated radiation therapy (IMRT) in the state of Michigan: 2005-2010.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.34_suppl.219 ◽

2012 ◽

Vol 30 (34_suppl) ◽

pp. 219-219 ◽

Cited By ~ 1

Author(s):

James Hayman ◽

Kent A. Griffith ◽

Reshma Jagsi ◽

Mary Uan-Sian Feng ◽

Jean M. Moran ◽

...

Keyword(s):

Radiation Oncology ◽

Repeated Measures ◽

Intensity Modulated Radiation Therapy ◽

High Volume ◽

Freedom Of Information ◽

External Beam ◽

Improved Outcomes ◽

Primary Driver ◽

Low Volume ◽

Reported Data

219 Background: Interest is growing in value in health care, defined as better outcomes at lower costs. A primary driver of cost in radiation oncology is the use of IMRT. We examined the patterns and correlates of use of IMRT across Michigan using publicly available data. Methods: As a certificate of need state, Michigan requires every radiation oncology facility to report yearly the number of external beam and IMRT treatments delivered. Data for 2005-2008 were obtained through a Freedom of Information Act request of the Michigan Department of Community Health, while 2009-2010 data were available at its website. Percentage of external beam treatments delivered using IMRT (IMRT%) was examined across centers over time and repeated-measures longitudinal linear regression was used to identify factors associated with use. Results: During 2005-2010, 48 to 65 centers reported data. Median IMRT% (range) rose steadily during the study period: 2005 16% (0-64); 2006 21% (0-57); 2007 27% (0-79); 2008 37% (7-85); 2009 41% (0-87) 2010 45% (7-100). There was also significant between-center variation (see table). Regression modeling demonstrated that IMRT% was associated with year (+6.7% per year, p<0.0001), facility type (+7.1% freestanding versus hospital, p<0.11), facility annual volume (+5.0% high volume: 7,000+ versus low: <7,000, p=0.01) and the interaction between year and volume (low volume +2.4% per year versus high volume p<0.02). The significant interaction between year and volume suggests that the greatest IMRT% growth was in low volume centers (6.7% per year versus 4.3% per year for high volume). Conclusions: IMRT utilization has grown steadily across Michigan between 2005 and 2010. There is significant variation in its use that appears to be related in part to facility characteristics. The newly established Michigan Radiation Oncology Quality Collaborative (MROQC) is beginning to explore the use of IMRT in patients with breast and lung cancer statewide to identify those groups of patients where improved outcomes may justify its higher cost. [Table: see text]

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Treatment at high-volume facilities and academic centers in relation to overall survival in patients with locally advanced pancreatic cancer: A National Cancer Database analysis

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.4_suppl.392 ◽

2018 ◽

Vol 36 (4_suppl) ◽

pp. 392-392

Author(s):

John David ◽

Sungjin Kim ◽

Erik Anderson ◽

Arman Torossian ◽

Simon Lo ◽

...

Keyword(s):

Pancreatic Cancer ◽

Overall Survival ◽

Surgical Resection ◽

Locally Advanced ◽

Advanced Pancreatic Cancer ◽

High Volume ◽

Locally Advanced Pancreatic Cancer ◽

Median Income ◽

National Cancer Database ◽

Improved Outcomes

392 Background: Numerous studies have shown that treatment at a high volume facility (HVF) for patients (pts) with pancreatic cancer is associated with improved outcomes, particularly with pancreatectomy. In fact, a recent study showed that pts undergoing a pancreatectomy at an academic center (AC) is independently associated with improved outcomes. However, the role of chemotherapy (CT) and radiation (RT) in the treatment of locally advanced pancreatic cancer (LAPC) at HVF and AC, to our knowledge, has not been studied. Herein, we investigate the benefit of treatment at HVF and AC compared to low volume facilities (LVF) and non-academic centers (NAC) with CT or chemoradiation (CRT) in pts with LAPC. Methods: The National Cancer Database (NCDB) was utilized to identify LAPC patients treated at all facility types. All patients were treated with CT or CRT. Univariate (UVA) and multivariate (MVA) Cox regression were performed to identify the impact of HVF and AC on overall survival (OS) when compared to LVF and NAC, respectively. HVF was defined as the top 5% of facilities by number of pts treated. Results: From 2004 – 2014, a total of 10139 pts were identified. The median age was 66 years (range 22-90) with median follow up of 48.8 months (46-52.1 months); 49.9% were male and 50.1% female. All pts had clinical stage 3/T4 disease irrespective of nodal metastases. Of these, 4779 pts were treated at an AC and 5260 were treated at a NAC and 588 were treated at HVF and 9551 were treated at LVF. On UVA, age, high median income, high education level, comorbidities, and recent year of diagnosis were associated with improved OS. ACs were associated with improved OS when compared to non-AC (HR 0.92 95% CI 0.88 – 0.96, p = 0.004), as were HVF when compared to LVH (HR 0.84 95% CI 0.76 – 0.92, p < 0.001). Odds ratio for undergoing surgical resection at HVF and AC was 1.68 and 1.37 (p < 0.001), respectively, when compared to LVF and NAC. Conclusions: The treatment of LAPC patients with CT or CRT at an AC led to significantly improved rate of surgical resection and OS. In the absence of prospective data, these results support the referral of pts with LAPC to HVF and/or AC for evaluation and treatment.

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The Impact of Regionalization of Pancreaticoduodenectomy for Pancreatic Cancer in North Carolina since 2004

The American Surgeon ◽

10.1177/000313481408000619 ◽

2014 ◽

Vol 80 (6) ◽

pp. 561-566 ◽

Cited By ~ 12

Author(s):

Ryan Z. Swan ◽

David J. Niemeyer ◽

Ramanathan M. Seshadri ◽

Kyle J. Thompson ◽

Amanda Walters ◽

...

Keyword(s):

North Carolina ◽

Significant Risk ◽

High Volume ◽

Major Morbidity ◽

The North ◽

Time Period ◽

Improved Outcomes ◽

Before And After ◽

Low Volume ◽

The Impact

Pancreaticoduodenectomy (PD) carries a significant risk. High-volume centers (HVCs) provide improved outcomes and regionalization is advocated. Rapid regionalization could, however, have detrimental effects. North Carolina has multiple HVCs, including an additional HVC added in late 2006. We investigated regionalization of PD and its effects before, and after, the establishment of this fourth HVC. The North Carolina Hospital Discharge Database was queried for all PDs performed during 2004 to 2006 and 2007 to 2009. Hospitals were categorized by PD volume as: low (one to nine/year), medium (10 to 19/year), and high (20/year or more). Mortality and major morbidity was assessed by comparing volume groups across time periods. Number of PDs for cancer increased 91 per cent (129 to 246 cases) at HVCs, whereas decreasing at low-volume (62 to 58 cases) and medium-volume (80 to 46 cases) centers. Percentage of PD for cancer performed at HVCs increased significantly (47.6 to 70.3%) while decreasing for low- and medium-volume centers ( P < 0.001). Mortality was significantly less at HVCs (2.8%) compared with low-volume centers (10.3%) for 2007 to 2009. Odds ratio for mortality was significantly lower at HVCs during 2004 to 2006 (0.31) and 2007 to 2009 (0.34). Mortality for PD performed for cancer decreased from 6.6 to 4.6 per cent ( P = 0.31). Major morbidity was not significantly different between groups within either time period; however, there was a significant increase in major morbidity at low-volume centers ( P = 0.018). Regionalization of PD for cancer is occurring in North Carolina. Mortality was significantly lower at HVCs, and rapid regionalization has not detracted from the superior outcomes at HVCs.

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Is the Distance Worth It? Patients With Rectal Cancer Traveling to High-Volume Centers Experience Improved Outcomes

Diseases of the Colon & Rectum ◽

10.1097/dcr.0000000000000924 ◽

2017 ◽

Vol 60 (12) ◽

pp. 1250-1259 ◽

Cited By ~ 34

Author(s):

Zhaomin Xu ◽

Adan Z. Becerra ◽

Carla F. Justiniano ◽

Courtney I. Boodry ◽

Christopher T. Aquina ◽

...

Keyword(s):

Rectal Cancer ◽

High Volume ◽

Improved Outcomes

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PERSPECTIVES ON NEONATAL RESUSCITATION TRAINING IN A CANADIAN PEDIATRIC RESIDENCY PROGRAM: COMMUNITY VERSUS TERTIARY CARE EXPERIENCES

Paediatrics & Child Health ◽

10.1093/pch/pxy054.061 ◽

2018 ◽

Vol 23 (suppl_1) ◽

pp. e24-e25

Author(s):

Mary Woodward ◽

Andrea Hunter ◽

Meghan McConnell ◽

Connie Williams

Keyword(s):

Qualitative Methodology ◽

Cognitive Theory ◽

A Priori ◽

Tertiary Care ◽

Neonatal Resuscitation ◽

Community Setting ◽

High Volume ◽

Resuscitation Training ◽

Tertiary Center ◽

Clinical Cases

Abstract BACKGROUND The competencies involved in neonatal resuscitation include a thorough knowledge of transitional neonatal physiology as well as technical expertise, the ability to lead a multidisciplinary team, and appropriate management of resources. In Canadian paediatric training programs, residents acquire neonatal resuscitation competency in both community and tertiary care settings. There is limited literature regarding experiences of training in variable settings and no literature with respect to the integration of neonatal competency acquisition across training environments. OBJECTIVES To explore residents’ and recent paediatric graduates’ perspectives on acquisition of competencies and neonatal resuscitation training in community and tertiary care centers. DESIGN/METHODS This project employed an interpretive design qualitative methodology, using an a priori educational theory incorporating the principles of social cognitive theory, deliberate practice, distributive practice, and ‘choke phenomenon’. Semi structured focus groups of residents and paediatricians were used for data collection. Interpretive analysis in the style of Crabtree and Miller was employed. Data validity was optimized through member checking and triangulation of themes across investigators. Validity criteria as described by Lincoln and Guba were applied. Institutional ethics board approval was obtained. RESULTS Overall, the participants described a large ‘disconnect’ (lack of communication and congruence of curriculum) between community and tertiary training environments for neonatal resuscitation. Inherent challenges in the community included the variable skill and experience of the interdisciplinary team, availability of resources, and a lack of confidence in their own leadership. In addition, gaps in preceptor knowledge and communication were identified. Strengths of the community setting included: more autonomy for the learner, a high volume of clinical cases with particular emphasis on the ‘normal’; and opportunity for observed feedback with preceptors. In comparison, tertiary center experiences were perceived to be ‘overwhelming’ with a demanding workload and limited opportunity for direct observation and feedback from faculty. Strengths of the tertiary center experience included: variety and high volume of acute clinical cases, facilitating technical skill expertise and self-confidence; and a strong academic focus on physiology and knowledge translation. CONCLUSION Participants described both valuable opportunities and challenges for training and competency acquisition in neonatal resuscitation in tertiary and community settings. Integration of curricula or competencies across settings and across residency level of experience was lacking. This work suggests areas for collaboration within and across training centres to align opportunities in neonatal resuscitation competency training.

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682 ENDOFLIP TAILORED PER-ORAL ENDOSCOPIC MYOTOMY (POEM): EXPERIENCE IN TWO UK CENTRES.

Diseases of the Esophagus ◽

10.1093/dote/doab052.682 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

William Knight ◽

Kaveetha Kandiah ◽

Jennifer Couch ◽

Nila Tewari ◽

Krish Ragunath ◽

...

Keyword(s):

Length Of Stay ◽

Clinical Success ◽

High Volume ◽

Poor Responders ◽

Per Oral Endoscopic Myotomy ◽

Type Iv ◽

Eckardt Score ◽

Improved Outcomes ◽

Endoscopic Myotomy ◽

Per Oral

Abstract Per-oral endoscopic myotomy (POEM) is an effective treatment for achalasia. Efficacy is equivalent to Laparoscopic Heller’s myotomy with the advantage of minimal access and shorter length of stay. Post-operative reflux rates are higher in POEM. The Functional Luminal Imaging Probe (FLIP) allows the measurement of lower oesophageal distensibility during per-oral endoscopic myotomy. In theory, this enables the operator to tailor the myotomy to ensure adequate distensibility whilst minimising post-operative reflux risk. Methods Two prospectively collected POEM databases were analysed from 2 UK tertiary upper GI centres. The operators in each centre used intraoperative FLIP measurements to ensure adequate myotomy. Outcome measures included Eckardt score (where ≤3 indicated clinical success) and proton pump inhibitor use (PPI), collected at the first post-operative appointment. Length of stay was recorded, as were complications. Results 142 patients underwent POEM between 2015 and 2019 with 90% (128/142) clinical success. This improved to 93% (68/73) in the latter half of each series. 79% of the poor responders had previous interventions compared to 55% of responders (p = 0.09). Average post myotomy distensibility was 5.2 mm2/mmHg in responders and 3.11 in non-responders(p = 0.11). DI of >4.5 mm2/mmHg was associated with 100% clinical success. Myotomy length of <7 cm was associated with 93% clinical success and 40% post op PPI use compared to 60% with longer myotomies. There were 2 type IIIa, 2 type IIIb and one type IV Clavien-Dindo complications. Conclusion This study represents one of the largest UK series of FLIP tailored per-oral endoscopic myotomy. FLIP allows intraoperative monitoring of oesophageal distensibility allowing tailoring of myotomies. Tailored myotomies ≤6 cm were effective and were associated with less PPI use post operatively. Early referral of patients to high volume centres, where myotomies can be tailored using FLIP may lead to improved outcomes. More collaborative data from high volume centres is needed to decipher optimal myotomy profiles.

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