Becerra Adan Z, Aquina Christopher T, Berho Mariana, Boscoe Francis P, Schymura Maria J, Noyes Katia, Monson John R, Fleming Fergal J
Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY; Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
Surgery. 2017 May;161(5):1299-1306. doi: 10.1016/j.surg.2016.11.029. Epub 2017 Jan 11.
The goals of this study were to characterize the variation in suboptimal lymph node examination for patients with colon cancer across individual surgeons, pathologists, and hospitals and to examine if this variation affects 5-year, disease-specific survival.
A retrospective cohort study was conducted by merging the New York State Cancer Registry with the Statewide Planning & Research Cooperative System, Medicaid, and Medicare claims to identify resections for stages I-III colon cancer from 2004-2011. Multilevel logistic regression models characterized variation in suboptimal lymph node examination (<12 lymph nodes). Multilevel competing-risks Cox models were used for survival analyses.
The overall rate of suboptimal lymph node examination was 32% in 12,332 patients treated by 1,503 surgeons and 814 pathologists at 187 hospitals. Patient-level predictors of suboptimal lymph node examination were older age, male sex, nonscheduled admission, lesser stage, and left colectomy procedure. Hospital-level predictors of suboptimal lymph node examination were a nonacademic status, a rural setting, and a low annual number of resections for colon cancer. The percent of the total clustering variance attributed to surgeons, pathologists, and hospitals was 8%, 23%, and 70%, respectively. Increasing the pathologist and hospital-specific rates of suboptimal lymph node examination were associated with worse 5-year, disease-specific survival.
There was a large variation in suboptimal lymph node examination between surgeons, pathologists, and hospitals. Collaborative efforts that promote optimal examination of lymph nodes may improve prognosis for colon cancer patients. Given that 93% of the variation was attributable to pathologists and hospitals, endeavors in quality improvement should focus on these 2 settings.
本研究的目的是描述结肠癌患者在个体外科医生、病理学家和医院之间次优淋巴结检查的差异，并探讨这种差异是否会影响5年疾病特异性生存率。
通过将纽约州癌症登记处与全州规划与研究合作系统、医疗补助和医疗保险理赔数据合并，进行一项回顾性队列研究，以确定2004年至2011年期间I-III期结肠癌的切除术。多水平逻辑回归模型描述了次优淋巴结检查（<12个淋巴结）的差异。多水平竞争风险Cox模型用于生存分析。
在187家医院接受1503名外科医生和814名病理学家治疗的12332例患者中，次优淋巴结检查的总体发生率为32%。次优淋巴结检查的患者水平预测因素包括年龄较大、男性、非计划入院、分期较低和左半结肠切除术。次优淋巴结检查的医院水平预测因素包括非学术地位、农村环境和结肠癌年度切除例数较少。外科医生、病理学家和医院在总聚类方差中所占的百分比分别为8%、23%和70%。次优淋巴结检查的病理学家和医院特定率增加与较差的5年疾病特异性生存率相关。
外科医生、病理学家和医院之间的次优淋巴结检查存在很大差异。促进淋巴结最佳检查的合作努力可能会改善结肠癌患者的预后。鉴于93%的差异可归因于病理学家和医院，质量改进工作应集中在这两个方面。
