Schoppy David W, Rhoads Kim F, Ma Yifei, Chen Michelle M, Nussenbaum Brian, Orosco Ryan K, Rosenthal Eben L, Divi Vasu
Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University School of Medicine, Stanford, Palo Alto, California.
Motility Doc, San Jose, California.
JAMA Otolaryngol Head Neck Surg. 2017 Nov 1;143(11):1111-1116. doi: 10.1001/jamaoto.2017.1694.
Negative margins and lymph node yields (LNY) of 18 or more from neck dissections in patients with head and neck squamous cell carcinomas (HNSCC) have been associated with improved patient survival. It is unclear whether these metrics can be used to identify hospitals with improved outcomes.
To determine whether 2 patient-level metrics would predict outcomes at the hospital level.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of records from the National Cancer Database (NCDB) was used to identify patients who underwent primary surgery and concurrent neck dissection for HNSCC between 2004 and 2013. The percentage of patients at each hospital with negative margins on primary resection and an LNY 18 or more from a neck dissection was quantified. Cox proportional hazard models were used to define the association between hospital performance on these metrics and overall survival.
Margin status and lymph node yield at hospital level. Overall survival (OS).
We identified 1008 hospitals in the NCDB where 64 738 patients met inclusion criteria. Of the 64 738 participants, 45 170 (69.8%) were men and 19 568 (30.2%) were women. The mean SD age of included patients was 60.5 (12.0) years. Patients treated at hospitals attaining the combined metric of a 90% or higher negative margin rate and 80% or more of cases with LNYs of 18 or more experienced a significant reduction in mortality (hazard ratio [HR] 0.93; 95% CI, 0.89-0.98). This benefit in survival was independent of the patient-level improvement associated with negative margins (HR, 0.73; 95% CI, 0.71-0.76) and LNY of 18 or more (HR, 0.85; 95% CI, 0.83-0.88). Including these metrics in the model neutralized the association of traditional measures of hospital quality (volume and teaching status).
Treatment at hospitals that attain a high rate of negative margins and LNY of 18 or more is associated with improved survival in patients undergoing surgery for HNSCC. These surgical outcome measures predicted outcomes independent of traditional, but generally nonmodifiable characteristics. Tracking of these metrics may help identify high-quality centers and provide guidance for institution-level quality improvement.
头颈部鳞状细胞癌（HNSCC）患者颈部清扫术切缘阴性以及淋巴结收获量（LNY）达到18个或更多与患者生存率提高相关。目前尚不清楚这些指标是否可用于识别预后改善的医院。
确定两个患者层面的指标是否能预测医院层面的预后。
设计、设置和参与者：对国家癌症数据库（NCDB）的记录进行回顾性分析，以识别2004年至2013年间接受HNSCC原发手术及同期颈部清扫术的患者。对每家医院原发切除切缘阴性且颈部清扫术LNY达到18个或更多的患者百分比进行量化。采用Cox比例风险模型来确定这些指标的医院表现与总生存率之间的关联。
医院层面的切缘状态和淋巴结收获量。总生存率（OS）。
我们在NCDB中识别出1008家医院，其中64738名患者符合纳入标准。在这64738名参与者中，45170名（69.8%）为男性，19568名（30.2%）为女性。纳入患者的平均标准差年龄为60.5（12.0）岁。在切缘阴性率达到90%或更高且LNY达到18个或更多的病例占80%或更多的综合指标达标的医院接受治疗的患者死亡率显著降低（风险比[HR]0.93；95%CI，0.89 - 0.98）。这种生存获益独立于与切缘阴性（HR，0.73；95%CI，0.71 - 0.76）及LNY达到18个或更多（HR，0.85；95%CI，0.83 - 0.88）相关的患者层面的改善情况。将这些指标纳入模型可消除医院质量传统衡量指标（手术量和教学地位）的关联。
在切缘阴性率高且LNY达到18个或更多的医院接受治疗与HNSCC手术患者生存率提高相关。这些手术结局指标预测预后独立于传统但通常不可改变的特征。追踪这些指标可能有助于识别高质量中心并为机构层面的质量改进提供指导。
