Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.
Ann Surg Oncol. 2020 Dec;27(13):5039-5046. doi: 10.1245/s10434-020-08815-w. Epub 2020 Jul 29.
Understanding variation and heterogeneity in practice patterns allows programs to develop effective strategies to improve patient outcomes. Cytoreductive surgery is a potentially highly morbid operation that could benefit from systematic assessments directed towards quality improvement. We describe the hospital-level variation and benchmarks for programs performing cytoreductive surgery.
Cytoreductive and tumor debulking operations with or without hyperthermic intraperitoneal chemotherapy performed for cancer between January 1, 2013 and June 30, 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Risk-adjusted hospital-level variation in 30-day death, serious morbidity, reoperation, readmission, and a composite of death or serious morbidity (DSM) were evaluated using hierarchical models. National Cancer Institute (NCI)-designated cancer center (NCI-CC) status was also explored.
A total of 6203 operations across 589 hospitals were included, of which 56 were at NCI-CCs. Unadjusted rates of death, serious morbidity, reoperation, readmission, and DSM were 1.4%, 12.9%, 3.6%, 8.6%, and 13.4%, respectively. The coefficients of variation for hospital-level performance were 4.7%, 2.1%, 4.6%, 14.4%, and 1.0% for DSM, death, serious morbidity, unplanned reoperation, and unplanned readmissions, respectively. When compared with other hospitals, NCI-CCs had better risk-adjusted 30-day mortality (median odds ratio 0.984 versus 0.998, p < 0.001), but not for the other outcomes studied.
Hospital-level variation was modestly detected using the usual measures of perioperative outcomes. Given the increasing interest in cytoreductive surgery, we demonstrate a clear opportunity to not only improve the quality of our care but to also better improve the way quality is measured for these patients.
了解实践模式中的差异和异质性可以使项目制定有效的策略来改善患者的预后。细胞减灭术是一种潜在的高度病态手术，可以从针对质量改进的系统评估中受益。我们描述了进行细胞减灭术的医院水平的差异和基准。
在美国外科医师学院国家外科质量改进计划登记处，确定了 2013 年 1 月 1 日至 2018 年 6 月 30 日期间为癌症进行的细胞减灭和肿瘤去块手术，其中包括或不包括腹腔内热疗。使用层次模型评估 30 天死亡率、严重发病率、再次手术、再入院和死亡或严重发病率（DSM）复合的风险调整后医院水平差异。还探讨了美国国家癌症研究所（NCI）指定癌症中心（NCI-CC）的地位。
共纳入了 589 家医院的 6203 例手术，其中 56 例来自 NCI-CC。未调整的死亡率、严重发病率、再次手术、再入院和 DSM 发生率分别为 1.4%、12.9%、3.6%、8.6%和 13.4%。医院水平表现的变异系数分别为 DSM、死亡、严重发病率、计划外再次手术和计划外再入院的 4.7%、2.1%、4.6%、14.4%和 1.0%。与其他医院相比，NCI-CC 的 30 天死亡率风险调整后更好（中位数优势比 0.984 对 0.998，p<0.001），但其他研究结果并非如此。
使用围手术期结局的常用指标检测到适度的医院水平差异。考虑到细胞减灭术的兴趣日益增加，我们不仅展示了改善我们护理质量的明确机会，而且还展示了更好地衡量这些患者质量的方式。
