Risk-Adjusted Mortality Rates as a Quality Proxy Outperform Volume in Surgical Oncology—A New Perspective on Hospital Centralization Using National Population-Based Data

PURPOSE Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery to safer hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume. METHODS We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for any of five major cancer types, splitting the data into training (2010-2015) and validation sets (2016-2018). For each surgical group, we calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modeled a market exit of low-performing hospitals, and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance or time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure. RESULTS Between 2016 and 2018, 158,079 patients were treated in 974 hospitals. At least 50% of high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In an RSMR centralization model, an average of 32 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, whereas 47 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery ranged from 10 minutes for colorectal cancer to 24 minutes for pancreatic cancer. Centralization on the basis of RSMR compared with volume would ensure lower median travel times for all cancer types, and these times would be lower than those observed. CONCLUSION RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.

Building a Personalized Medicine Infrastructure for Gynecological Oncology Patients in a High-Volume Hospital

Gynecological cancers require complex intervention since patients have specific needs to be addressed. Centralization to high-volume centers improves the oncological outcomes of patients with gynecological cancers. Research in gynecological oncology is increasing thanks to modern technologies, from the comprehensive molecular characterization of tumors and individual pathophenotypes. Ongoing studies are focusing on personalizing therapies by integrating information across genomics, proteomics, and metabolomics with the genetic makeup and immune system of the patient. Hence, several challenges must be faced to provide holistic benefit to the patient. Personalized approaches should also recognize the unmet needs of each patient to successfully deliver the promise of personalized care, in a multidisciplinary effort. This may provide the greatest opportunity to improve patients’ outcomes. Starting from a narrative review on gynecological oncology patients’ needs, this article focuses on the experience of building a research and care infrastructure for personalized patient management.

Treatment delay from aneurysmal subarachnoid hemorrhage to endovascular treatment: a high-volume hospital experience

Background Early treatment for patients with aneurysmal subarachnoid hemorrhage (aSAH) could significantly reduce the risk of re-bleeding and improve clinical outcomes. We assessed the different time intervals from the initial hemorrhage, admission, and endovascular treatment and identified the risk factors contributing to delay. Methods Between February 2017 and December 2019, 422 consecutive aSAH patients treated in a high-volume hospital were collected and reviewed. Risk factors contributing to admission delay and treatment delay were analyzed with univariate and multivariate analysis. Results One hundred twenty-two (28.9%) were admitted to the high-volume hospital at the day of symptom onset and 386 (91.5%) were treated with endovascular management at the same day of admission. The multivariate analysis found that younger age (P = 0.022, OR = 0.981, 95% CI 0.964–0.997) and good Fisher score (P = 0.002, OR = 0.420, 95% CI 0.245–0.721) were independent risk factors of admission delay. None was found to be related with treatment delay. Multivariate analysis (OR (95% CI)) showed that higher age 1.027 (1.004–1.050), poorer Fisher score 3.496 (1.993–6.135), larger aneurysmal size 1.112 (1.017–1.216), and shorter interval between onset to admission 1.845 (1.018–3.344) were independent risk factors of poorer clinical outcome. Conclusion Treatment delay was mainly caused by pre-hospital delay including delayed admission and delayed transfer. Our experience showed that cerebrovascular team could provide early treatment for aSAH patients. Younger age and good Fisher score were significantly related with admission delay. However, admission delay was further significantly correlated with better clinical outcome.

Comparison of a single-use, digital flexible ureteroscope with a reusable, fiberoptic ureteroscope for management of patients with urolithiasis

Objectives: Ureteroscopy is one of the commonest procedures performed to manage urolithiasis. Flexible ureteroscopy has been traditionally based on reusable, fiber-optic ureteroscopes. Technology advancements permitted the development of single-use scopes with digital image. The aim of this study is to compare efficacy and safety between a reusable, fiberoptic ureteroscope with a single-use, digital scope. Patients and methods: We collected data based on chart review from a prospectively collected database on a tertiary, high-volume hospital in Greece. Baseline, perioperative and postoperative data were gathered and analyzed. Chi-square and Fisher's exact test was used to compare qualitative data and unpaired t-test for continuous data, with a statistical significance set at a = 0.05. Results: 40 patients underwent flexible ureteroscopy with a single- use digital scope, while 37 with the reusable scope. The two groups were matched regarding baseline characteristics and stone-related parameters. After data analysis, a shorter operative time in favor of single-use flexible ureteroscope was detected (45 vs 65 min, p = 0.001), while safety was also in favor of this type of scope with a significantly higher immediate stonefree rate (70% vs 43%, p = 0.005). Overall complications did not differ between the two groups, although a lower sepsis rate was detected in patients treated with single-use scope. Conclusions: Our findings indicate that single-use, digital ureteroscopes are a viable alternative for flexible ureteroscopy and management of urolithiasis, especially in centers with deficient facilities for sterilization and ensured funds for more expensive reusable scopes.

1638 Decade-Long Trends in Surgery for Acute Type A Aortic Dissection

Background Little is known about unwarranted variations in care and outcomes of patients who undergo surgical repair for type A acute aortic dissection(TAAD). We aim to investigate decade-long trends in TAAD surgical repair in England. Method Retrospective review of the National Institute for Cardiovascular Outcomes Research (NICOR) National Adult Cardiac Surgery Audit (NACSA) registry from January 2009 to December 2018 , which prospectively collects demographic and peri-operative clinical information for all adult cardiac surgery procedures in the UK. Results Over the 10-year period,3,686 TAAD patients underwent surgical repair in England. A steady doubling in the overall number of operations conducted in England was observed from 237 cases recorded in 2009 to 510 in 2018. Number of procedures per hospital per year also doubled, from 10 in 2009 to 21 in 2018. The risk profile of the operated patients remained unchanged. Overall, in-hospital mortality was 17.4% with a trend toward lower mortality in the most recent years (from 22.8% in 2009 to 14.7% in 2018). There was a significant variation in operative mortality across regions with a trend towards lower mortality in regions with a high-volume hospital. Conclusions Surgery is the only treatment for acute TAAD but is associated with high mortality. Prompt diagnosis and referral to a specialist center is paramount. The number of operations conducted in England has doubled in 10 years and the associated survival following surgery has improved. Regional variations exist in service provision with a trend towards better survival in high volume centers.

Association between Moving to a High-Volume Hospital in the Capital Area and the Mortality among Patients with Cancer: A Large Population-Based Cohort Study

This study aimed to identify the association between moving to a high-volume hospital and the mortality of patients with cancer living in the district. The study population comprised participants diagnosed with cancer within the past nine years (2004–2012). The final sample included 8197 patients with cancer, 3939 were males (48.1%), and 4258 were females (51.9%). A Cox proportional hazard model was used to estimate the hazard ratio (HR) for death. Confounding variables including sex, age, type of social security, income level, disability, and utilization volume were incorporated into the model. Among patients with cancer living in the district, 2874 (35.1%) used healthcare services in Seoul. About 10% (n = 834) of patients died during the follow-up period. The HR for death in females (HR: 0.68, 95% CI: 0.58–0.81) was lower than that in males. Additionally, the HR for the death of patients using healthcare services in Seoul (HR: 1.30, 95% CI: 1.11–1.53) was higher than those patients who did not use healthcare services in Seoul. Among patients utilizing services in the province, wealthier patients’ survival probability was significantly higher than that of others. The cause of income differences should be identified, and accessibility to medical use of low-income families should be enhanced to prevent mortality of patients from cancer disparities.

Abstract P875: Disparities in Delivery of Endovascular Therapy: Data From the Florida State Registry

Background: Access to endovascular therapy (EVT) should be equitable to all eligible ischemic stroke patients presenting within the treatment time window. In the Florida Stroke Registry (FSR) we sought to determine sex, race/ethnic, hospital and regional disparities in the delivery of EVT. Methods: From January 2010 to January 2020, a total of 99,088 ischemic stroke cases within 24 hours of symptom onset were enrolled. Multivariable logistic regression with generalized estimating equations evaluated independent predictors of EVT utilization. Results: A total of 7,812 patients received EVT (51.2% female, mean age 71.3 ± SD 14.6 years, 61.4% white, 17.4% black, 21.2% Hispanic). Compared to those not treated, EVT treated patients were more likely Hispanic (21.2% vs. 14.6%), arrived earlier to the hospital (median 120 min (IQR 292) vs. 170 min (IQR 446)), via EMS (94% vs. 66%), with more severe strokes (median NIHSS 15 (IQR11) vs. 5 (IQR 9)), to large hospitals (≥ 680 beds) (73.4% vs. 47.7%), in South Florida (50.8% vs. 38.2%). In multivariable analysis, female sex (OR 1.05, 95% CI 1-1.11), atrial fibrillation (OR 1.57, 95% CI 1.45-1.7), higher NIHSS (> 6) (OR 6.19, 95% CI 5.11-7.51) and presenting to a high-volume hospital (OR 3.47, 95% CI 2.25-5.36) positively predicted EVT utilization, whereas older age (>80 years) (OR 0.88, 95% CI 0.80-0.96), and black race (vs. white OR 0.87, 95% CI 0.76-1), were independently associated with lower use of EVT. Conclusions: In this large state-wide registry study, we found significant race-ethic and geographical disparities in delivery of EVT. Systems of care should address disparities in stroke treatment to improve access to EVT for all eligible stroke patients.

Effects of 1-Year Hospital Volume on Surgical Margin and Biochemical-Failure-Free Survival in Patients Undergoing Robotic versus Nonrobotic Radical Prostatectomy: A Nationwide Cohort Study from the National Taiwan Cancer Database

Purpose: To examine the effect of hospital volume on positive surgical margin (PSM) and biochemical-failure-free survival (BFS) rates in patients with prostate cancer (PC) undergoing robotic-assisted or nonrobotic-assisted radical prostatectomy (RP). Patients and Methods: The patients were men collected in the National Taiwan Cancer Registry diagnosed as having PC without distant metastasis who received RP from 44 multi-institutes in Taiwan. The logistic regression method was used to analyze the risk from RP to PSM in included patients with hospital volume (i.e., number of patients with PC receiving robotic RP per year), and the Cox proportional hazards method was used to analyze the time from the index date to biochemical recurrence. Results: After propensity score adjustment, compared with hospitals with >100 patients/year, the adjusted odds ratios (aORs; 95% confidence intervals) of PSM in the robotic RP group in hospitals with 1–25, 26–50, and 51–100 patients/year were 2.25 (2.10–3.11), 1.42 (1.25–2.23), and 1.33 (1.13–2.04), respectively (type III p < 0.0001). Sensitivity analysis indicated that the aORs of PSM were 1.29 (1.07–1.81), 1.07 (0.70–1.19), and 0.61 (0.56–0.83), respectively, for patients receiving robotic RP compared with nonrobotic RP within hospitals with 1–25, 26–50, and 51–100 patients/year, respectively. Compared with hospitals with >100 patients/year, the adjusted hazard ratios (aHRs) of biochemical failure in the robotic RP group were 1.40 (1.04–1.67), 1.34 (1.06–1.96), and 1.31 (1.05–2.15) in hospitals with 1–25, 26–50, and 51–100 patients/year, respectively. Conclusions: Hospital volume significantly affected PSM and BFS in robotic RP, but not in nonrobotic RP. When patients with PC want to receive robotic RP, it should be performed in a relatively high-volume hospital (>100 patients/year).