German Research Center for Environmental Health, Institute for Health Economics and Health Care Management (IGM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany; Ludwig-Maximilians-University Hospital (LMU) Munich, Medical Clinic V - Pneumology, Ziemssenstr. 1, 80336 München, Germany; Ludwig-Maximilians-University Hospital (LMU) Munich, Department of Thoracic Surgery, Marchioninistraße 15, 81377 München, Germany; German Center for Lung Research (DZL), Aulweg 130, 35392 Gießen, Germany.
Ludwig-Maximilians-University Hospital (LMU) Munich, Medical Clinic V - Pneumology, Ziemssenstr. 1, 80336 München, Germany; German Center for Lung Research (DZL), Aulweg 130, 35392 Gießen, Germany.
Health Policy. 2020 Nov;124(11):1217-1225. doi: 10.1016/j.healthpol.2020.07.012. Epub 2020 Aug 15.
In light of political discussions about minimum case volumes and certified lung cancer centers, this observational study investigates differences in therapy and survival between high vs. low patient volume hospitals (HPVH vs. LPVH).
We identified 12,374 lung cancer patients treated in HPVH (>67 patients) and LPVH in 2013 from German health insurance claims. Stratified by metastasis status (no metastases, nodal metastases, systemic metastases), we compared HPVHs and LPVHs regarding likelihood of resection and systemic therapy, type of systemic therapy, and surgical outcomes, using multivariate logistic models. Three-year survival was modeled using Cox regression. We adjusted all regression models for age, gender, comorbidity, and residence area, and included a cluster variable for the hospital.
Around 24 % of patients were treated in HPVHs. Irrespective of stratum and subgroup, three-year survival was significantly better in HPVHs. In patients with systemic metastases (OR = 1.84, CI=[1.22,2.76]) and without metastases (OR = 3.28, CI=[2.13, 5.04]), resection was more likely in HPVHs. Among patients with systemic therapy, the odds of receiving pemetrexed was higher in HPVHs, in patients with nodal metastases (OR = 1.57, CI=[1.01,2.45]). In resected patients without metastases the odds ratio of receiving a thoracoscopic lobectomy was 2.28 (CI=[1.04,4.99]) in HPVHs.
Our data suggests that case volume is clinically relevant in resected and non-resected lung cancer patients, but optimal minimum case volumes may differ for subgroups.
鉴于有关最低病例量和认证肺癌中心的政治讨论，本观察性研究调查了高容量医院（HPVH）与低容量医院（LPVH）之间治疗和生存的差异。
我们从德国健康保险索赔中确定了 2013 年在 HPVH（>67 例）和 LPVH 治疗的 12374 例肺癌患者。根据转移状态（无转移、淋巴结转移、全身转移）分层，我们使用多变量逻辑模型比较了 HPVH 和 LPVH 切除和全身治疗的可能性、全身治疗的类型以及手术结果。使用 Cox 回归模型对 3 年生存率进行建模。我们调整了所有回归模型的年龄、性别、合并症和居住地区，并包含了医院的聚类变量。
约 24%的患者在 HPVH 治疗。无论分层和亚组如何，HPVH 患者的 3 年生存率均显著提高。在全身转移患者（OR=1.84，CI=[1.22,2.76]）和无转移患者（OR=3.28，CI=[2.13,5.04]）中，HPVH 更有可能进行切除术。在接受全身治疗的患者中，HPVH 中接受培美曲塞的可能性更高，在淋巴结转移患者中（OR=1.57，CI=[1.01,2.45]）。在无转移的接受切除术的患者中，HPVH 行胸腔镜肺叶切除术的比值比为 2.28（CI=[1.04,4.99]）。
我们的数据表明，病例量在接受切除术和未接受切除术的肺癌患者中具有临床相关性，但最佳的最小病例量可能因亚组而异。
