Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
J Gastrointest Surg. 2011 Mar;15(3):471-9. doi: 10.1007/s11605-010-1410-9. Epub 2010 Dec 21.
Evaluation of ≥ 12 lymph nodes after colon cancer resection has been adopted as a hospital quality measure, but compliance varies considerably. We sought to quantify relative proportions of the variation in lymph node assessment after colon cancer resection occurring at the patient, surgeon, pathologist, and hospital levels.
The 1998-2005 Surveillance, Epidemiology, and End Results-Medicare database was used to identify 27,101 patients aged 65 years and older with Medicare parts A and B coverage undergoing colon cancer resection. Multilevel logistic regression was used to model lymph node evaluation as a binary variable (≥ 12 versus <12) while explicitly accounting for clustering of outcomes.
Patients were treated by 4,180 distinct surgeons and 2,656 distinct pathologists at 1,113 distinct hospitals. The overall rate of 12-lymph node (12-LN) evaluation was 48%, with a median of 11 nodes examined per patient, and 33% demonstrated lymph node metastasis on pathological examination. Demographic and tumor-related characteristics such as age, gender, tumor grade, and location each demonstrated significant effects on rate of 12-LN assessment (all P < 0.05). The majority of the variation in 12-LN assessment was related to non-modifiable patient-specific factors (79%). After accounting for all explanatory variables in the full model, 8.2% of the residual provider-level variation was attributable to the surgeon, 19% to the pathologist, and 73% to the hospital.
Compliance with the 12-LN standard is poor. Variation between hospitals is larger than that between pathologists or surgeons. However, patient-to-patient variation is the largest determinant of 12-LN evaluation.
结肠癌切除术后评估≥12 个淋巴结已被采纳为医院质量指标，但符合率差异很大。我们旨在量化结肠癌切除术后淋巴结评估的变化在患者、外科医生、病理学家和医院水平上的相对比例。
使用 1998-2005 年监测、流行病学和最终结果-医疗保险数据库，确定了 27,101 名年龄在 65 岁及以上、有医疗保险 A 部分和 B 部分覆盖的患者，他们接受了结肠癌切除术。多水平逻辑回归用于对淋巴结评估作为二元变量（≥12 与<12）进行建模，同时明确考虑了结果的聚类。
患者由 4,180 名不同的外科医生和 2,656 名不同的病理学家在 1,113 家不同的医院进行治疗。12 个淋巴结（12-LN）评估的总体率为 48%，中位数为每位患者检查 11 个淋巴结，33%的患者在病理检查中显示淋巴结转移。年龄、性别、肿瘤分级和肿瘤位置等人口统计学和肿瘤相关特征均对 12-LN 评估率有显著影响（均 P<0.05）。12-LN 评估的大部分差异与不可改变的患者特定因素有关（79%）。在全模型中考虑所有解释变量后，外科医生的 8.2%、病理学家的 19%和医院的 73%的剩余提供者水平差异归因于该因素。
12-LN 标准的依从性很差。医院之间的差异大于病理学家或外科医生之间的差异。然而，患者之间的差异是 12-LN 评估的最大决定因素。
