Rabeneck Linda, Davila Jessica A, Thompson Michael, El-Serag Hashem B
Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada.
Am J Gastroenterol. 2004 Apr;99(4):668-75. doi: 10.1111/j.1572-0241.2004.04135.x.
The objective of this study was to examine the relationship between hospital surgical volume and long-term survival in patients with a new diagnosis of colorectal cancer who underwent surgical resection during fiscal years 1991-2000 in the Veterans Affairs (VA) health-care system.
This research was a cohort study of patients admitted to all VA hospitals with a new diagnosis of colorectal cancer who underwent surgical resection between October 1990 and September 2000 and followed through September 2001. Overall 5-yr cumulative survival was calculated from Kaplan-Meier estimates, while adjusted risk of death was estimated using a Cox proportional hazards model. Adjustment was made for differences in patient characteristics including comorbidity, receipt of therapy, and year of surgery.
We identified 34,888 individuals with a new diagnosis of colorectal cancer in VA hospitals during fiscal years 1991-2000, of whom 22,633 (65%) underwent surgical resection. The majority (98.5%) were men, the mean age was 68 yr, and the two largest race/ethnic groups were whites (75%) and blacks (17%). The 5-yr cumulative survival was greater among those who received surgery in high surgical volume hospitals as defined by 25 or more procedures per year (52.1%) than among those who received surgery in low volume hospitals (48.3%). After adjusting for differences in patient characteristics, comorbidity, receipt of adjuvant therapy, and year of surgery, we found 7% and 11% increases in 5-yr survival for patients with colon and rectal cancers, respectively, who underwent surgical resection in high volume hospitals compared with those who had surgery in low volume hospitals.
Greater hospital surgical volume is an independent predictor of prolonged long-term survival following surgery for both colon and rectal cancer in the VA health-care system. The volume-long-term mortality relationship is greater for rectal than for colon cancer patients, perhaps reflecting the fact that surgery for rectal cancer is more technically demanding. Future studies are needed to discover what aspects of clinical management explain these differences.
本研究旨在探讨1991 - 2000财年在退伍军人事务部（VA）医疗系统中首次诊断为结直肠癌并接受手术切除的患者，其医院手术量与长期生存之间的关系。
本研究为队列研究，研究对象为1990年10月至2000年9月期间入住所有VA医院且首次诊断为结直肠癌并接受手术切除，并随访至2001年9月的患者。采用Kaplan - Meier估计法计算总体5年累积生存率，同时使用Cox比例风险模型估计调整后的死亡风险。对患者特征差异进行了调整，包括合并症、治疗接受情况和手术年份。
我们确定了1991 - 2000财年在VA医院首次诊断为结直肠癌的34888例患者，其中22633例（65%）接受了手术切除。大多数（98.5%）为男性，平均年龄为68岁，两个最大的种族/族裔群体是白人（75%）和黑人（17%）。在每年进行25例或更多手术定义的高手术量医院接受手术的患者，其5年累积生存率（52.1%）高于在低手术量医院接受手术的患者（48.3%）。在调整患者特征、合并症、辅助治疗接受情况和手术年份的差异后，我们发现，与在低手术量医院接受手术的患者相比，在高手术量医院接受手术切除的结肠癌和直肠癌患者的5年生存率分别提高了7%和11%。
在VA医疗系统中，较高的医院手术量是结肠癌和直肠癌手术后长期生存延长的独立预测因素。直肠癌患者的手术量与长期死亡率的关系比结肠癌患者更大，这可能反映了直肠癌手术在技术上要求更高这一事实。未来需要开展研究，以发现临床管理的哪些方面可以解释这些差异。
