Department of Surgery, Yale School of Medicine, New Haven CT.
Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale School of Medicine, New Haven, CT.
Ann Surg. 2019 Aug;270(2):281-287. doi: 10.1097/SLA.0000000000002762.
To estimate the potential mortality reduction if patients chose the safest hospitals for complex cancer surgery.
Mortality after complex oncologic surgery is highly variable across hospitals, and directing patients away from unsafe hospitals could potentially improve survivorship. Hospital quality measures are becoming increasingly accessible at a time when patients are more engaged in choosing providers. It is currently unclear what information to share with patients to maximally capitalize on patient-centered realignment.
The National Cancer Database was queried for adults undergoing 5 complex cancer surgeries (pulmonary lobectomy, pneumonectomy, esophagectomy, gastrectomy, and colectomy) for a primary cancer between 2008 and 2012. Risk-standardized mortality rate (RSMR) methodology, currently used by Medicare-based hospital rating systems, was used to classify hospitals as "safest" and "least safe" by procedure. Patients were modeled moving from "least safe" to "safest" hospitals and the potential number of lives saved through patient realignment determined. As surgical volume has historically been used to distinguish safe hospitals, comparisons were made to models moving patients from low-volume to high-volume hospitals.
A total of 292,040 patients were analyzed. In an optimally modeled scenario, realignment using RSMR would result in a greater number of lives saved (3592 vs 2161, P < 0.01) and require only 15 patients to change hospitals to save a life, compared to 78 patients using volume models (P < 0.01).
Public reporting of hospital safety, specifically based on RSMR instead of volume, has the potential to lead to meaningful reductions in surgical mortality after complex cancer surgery, even in the setting of a modest patient realignment.
估算如果患者选择复杂癌症手术最安全的医院，潜在的死亡率降低情况。
复杂肿瘤手术后的死亡率在医院之间差异很大，将患者转移到不安全的医院可能会提高生存率。医院质量指标在患者越来越多地参与选择提供者的时期变得越来越容易获得。目前尚不清楚与患者共享哪些信息才能最大限度地利用以患者为中心的重新调整。
2008 年至 2012 年间，国家癌症数据库对接受 5 种复杂癌症手术（肺叶切除术、肺切除术、食管切除术、胃切除术和结肠切除术）治疗原发性癌症的成年人进行了查询。风险标准化死亡率（RSMR）方法目前用于基于医疗保险的医院评级系统，用于按程序对医院进行“最安全”和“最不安全”分类。患者被建模从“最不安全”转移到“最安全”的医院，并确定通过患者重新调整潜在的挽救生命数量。由于历史上一直使用手术量来区分安全的医院，因此将其与将患者从低容量转移到高容量医院的模型进行了比较。
共分析了 292040 名患者。在最优模型情景中，使用 RSMR 进行重新调整将导致更多的生命得到挽救（3592 人比 2161 人，P <0.01），并且与使用容量模型（78 人，P <0.01）相比，只需 15 名患者改变医院就可以挽救一条生命。
基于 RSMR 而不是基于容量的医院安全性的公开报告有可能导致复杂癌症手术后的手术死亡率显著降低，即使在适度的患者重新调整的情况下也是如此。
