Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania.
Ann Surg. 2022 Jun 1;275(6):e743-e751. doi: 10.1097/SLA.0000000000004361. Epub 2020 Oct 14.
The study objective is to determine the association between travel distance and surgical volume on outcomes after esophageal, pancreatic, and rectal cancer resections.
"Take the Volume Pledge" aims to centralize esophagectomies, pancreatectomies, and proctectomies to hospitals meeting minimum volume standards. The impact of travel, and possible care fragmentation, on potential benefits of centralized surgery is not well understood.
Using the National Cancer Database (2004-2016), patients who underwent esophageal, pancreatic, or rectal resections at far HVH meeting volume standards versus local intermediate (IVH) and low-volume (LVH) hospitals were identified. Perioperative outcomes and 5-year OS were compared.
Of 49,454 patients, 17,544 (34.5%) underwent surgery at far HVH, 11,739 (23.7%) at local IVH, and 20,171 (40.8%) at local LVH. The median (interquartilerange) travel distances were 77.1 (51.1-125.4), 13.2 (5.8-27.3), and 7.8 (3.1-15.5) miles to HVH, IVH, and LVH, respectively. By multivariable analysis, LVH was associated with increased 30-day mortality for all resections compared to HVH, but IVH was associated with mortality only for proctectomies [odds ratio 1.90, 95% confidence interval (CI) 1.31-2.75]. Compared to HVH, both IVH (hazard ratio 1.25, 95% CI 1.19-1.31) and LVH (hazard ratio 1.35, 95% CI 1.29-1.42) were associated with decreased 5-year OS.
Compared to far HVH, 30-day mortality was higher for all resections at LVH, but only for proctectomies at IVH. Five-year OS was consistently worse at local LVH and IVH. Improving long-term outcomes at IVH may provide opportunities for greater access to quality cancer care.
本研究旨在确定旅行距离与食管、胰腺和直肠癌切除术术后结果之间的关系。
“承担手术量承诺”旨在将食管癌、胰腺癌和直肠癌手术集中到符合最低手术量标准的医院进行。旅行的影响以及可能存在的治疗碎片化对集中手术潜在益处的影响尚未得到充分理解。
利用国家癌症数据库（2004-2016 年），确定在距离高容量医院（HVH）较远的地方接受手术的食管、胰腺或直肠切除术患者，这些患者符合 HVH 容量标准，与在当地中等容量医院（IVH）和低容量医院（LVH）接受手术的患者进行比较。比较围手术期结果和 5 年总生存率。
在 49454 例患者中，17544 例（34.5%）在距离 HVH 较远的地方接受手术，11739 例（23.7%）在当地 IVH 接受手术，20171 例（40.8%）在当地 LVH 接受手术。HVH、IVH 和 LVH 的中位（四分位距）旅行距离分别为 77.1（51.1-125.4）、13.2（5.8-27.3）和 7.8（3.1-15.5）英里。多变量分析显示，与 HVH 相比，LVH 与所有切除术的 30 天死亡率增加相关，但 IVH 仅与直肠切除术的死亡率相关[比值比 1.90，95%置信区间（CI）1.31-2.75]。与 HVH 相比，IVH（危险比 1.25，95%CI 1.19-1.31）和 LVH（危险比 1.35，95%CI 1.29-1.42）均与 5 年总生存率降低相关。
与 HVH 相比，LVH 所有切除术的 30 天死亡率更高，但 IVH 仅与直肠切除术相关。5 年总生存率在当地 LVH 和 IVH 始终较差。改善 IVH 的长期结果可能为更多人获得高质量癌症治疗提供机会。
