Simunovic Marko, Rempel Eddy, Thériault Marc-Erick, Coates Angela, Whelan Timothy, Holowaty Eric, Langer Bernard, Levine Mark
Department of Surgery, Faculty of Health Sciences, McMaster University, the Juravinski Cancer Centre, Hamilton, ON.
Can J Surg. 2006 Aug;49(4):251-8.
There is a lack of information from Canadian hospitals on the role of hospital characteristics such as procedure volume and teaching status on the survival of patients who undergo major cancer resection. Therefore, we chose to study these relationships using data from patients treated in Ontario hospitals.
We used the Ontario Cancer Registry from calendar years 1990-2000 to obtain data on patients who underwent surgery for breast, colon, lung or esophageal cancer or who underwent major liver surgery related to a cancer diagnosis between 1990 and 1995 in order to assess the influence of volume of procedures and teaching status of hospitals on in-hospital death rate and long-term survival. For each disease site and before observing patient outcomes data, volume cut-off points were selected to create volume groups with similar numbers of patients. Teaching hospitals were those directly affiliated with a medical school. Logistic regression and proportional hazards models were used to consider the clustering of data at the hospital level and to assess operative death and long-term survival. We also used 4 measures to gauge the degree of procedure regionalization across the province including (1) the number of hospitals performing a procedure; (2) the percentage of patients treated in teaching hospitals; (3) the percentage of rural patients treated in higher volume procedure hospitals; and (4) median distances travelled by patients to receive care.
The number of patients in our cohorts who underwent resection of the breast, colon, lung, esophagus or liver was 14 346, 8398, 2698, 629 and 362, respectively. Surgery in a high-volume versus a low-volume hospital did not have a statistically significant influence on the odds of operative death for patients who underwent colon, liver, lung or esophageal cancer resection. The risk of long-term death was increased in low-volume versus high-volume hospitals for patients who underwent resection of the breast (hazard ratio [HR] 1.2, 95% confidence interval [95% CI] 1.0-1.4, p < 0.05), lung (HR 1.3, 95% CI 1.1-1.6, p < 0.01) and liver (HR 1.7, 95% CI 1.0-2.7, p = 0.04). There were no significant differences in the odds of operative (in-hospital) death or risk of long-term death among patients treated in teaching compared with nonteaching hospitals. There was more regionalization of liver, lung and esophageal operations versus breast and colon operations.
Increased hospital procedure volume correlated with improved longterm survival for patients in Ontario who underwent some, but not all, cancer resections, whereas hospital teaching status had no significant impact on patient outcomes. Across the province, further regionalization of care may help improve the quality of some cancer procedures.
加拿大医院缺乏关于诸如手术量和教学地位等医院特征对接受重大癌症切除术患者生存率影响的信息。因此，我们选择使用安大略省医院治疗患者的数据来研究这些关系。
我们使用1990 - 2000历年的安大略癌症登记处数据，获取1990年至1995年间接受乳腺癌、结肠癌、肺癌或食管癌手术或与癌症诊断相关的重大肝脏手术患者的数据，以评估手术量和医院教学地位对住院死亡率和长期生存的影响。对于每个疾病部位，在观察患者结局数据之前，选择手术量分界点以创建患者数量相似的手术量组。教学医院是指直接隶属于医学院的医院。使用逻辑回归和比例风险模型来考虑医院层面数据的聚类情况，并评估手术死亡和长期生存情况。我们还使用4种方法来衡量全省手术区域化程度，包括：（1）进行某项手术的医院数量；（2）在教学医院接受治疗的患者百分比；（3）在手术量较大的医院接受治疗的农村患者百分比；（4）患者接受治疗所行进的中位距离。
我们队列中接受乳腺、结肠、肺、食管或肝脏切除术的患者数量分别为14346例、8398例、2698例、629例和362例。对于接受结肠癌、肝癌（疑有误，结合前文推测此处为“肝脏”）、肺癌或食管癌切除术的患者，在手术量大的医院与手术量小的医院进行手术，对手术死亡几率没有统计学上的显著影响。对于接受乳腺（风险比[HR] 1.2，95%置信区间[95% CI] 1.0 - 1.4，p < 0.05）、肺（HR 1.3，95% CI 1.1 - 1.6，p < 0.01）和肝脏（HR 1.7，95% CI 1.0 - 2.7，p = 0.04）切除术的患者，手术量小的医院与手术量大的医院相比，长期死亡风险增加。在教学医院与非教学医院接受治疗的患者中，手术（住院）死亡几率或长期死亡风险没有显著差异。与乳腺和结肠手术相比，肝脏、肺和食管手术的区域化程度更高。
在安大略省，医院手术量增加与接受部分但并非全部癌症切除术患者的长期生存改善相关，而医院教学地位对患者结局没有显著影响。在全省范围内，进一步的医疗区域化可能有助于提高某些癌症手术质量。
