Adhia Akash, Feinglass Joseph, Schlick Cary Jo, Odell David
Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
J Thorac Dis. 2020 Oct;12(10):5446-5459. doi: 10.21037/jtd-20-1347.
We assessed adherence to four novel quality measures in patients with stage III esophageal cancer, a leading cause of death among GI malignancies.
We performed a retrospective cohort study of 22,871 stage III esophageal cancer patients identified from the National Cancer Database (NCDB) between 2004 and 2016. Four quality measures were defined from published guidelines: administration of induction therapy, >15 lymph nodes sampled, surgery within 60 days of neoadjuvant treatment, and R0 resection. The association of patient demographic and treatment variables with measure adherence was assessed using multiple logistic regression. Risk of all-cause mortality was assessed comparing adherent and non-adherent cases using Cox modeling. Kaplan-Meier survival estimates of groups that adhered to zero to four out of four quality measures were performed.
Adherence was high for neoadjuvant treatment (93.7%), timing of surgery (85.7%) and completeness of resection (92.0%), but low for nodal evaluation (45.9%). Medicaid insurance status was associated with decreased odds of adherence for neoadjuvant treatment [odds ratio (OR) 0.73, 95% confidence interval (CI): 0.54-0.99], nodal evaluation (OR 0.81, 95% CI: 0.68-0.96), and completeness of resection (OR 0.71, 95% CI: 0.54-0.92). From 2010 to 2016, when compared to cases from 2004 to 2005, there was a progressive increase in the odds of adequate induction therapy, nodal staging, and completeness of resection, but a progressive decrease in odds of well-timed surgery. Adherence was associated with decreased all-cause mortality for induction therapy, nodal staging, and R0 resection, but not for timing of surgery. Survival improved as the number of quality measures an individual patient adhered to increased.
Adherence to quality measures is associated with improved survival in patients with stage III esophageal cancer. Understanding variability in measure adherence may identify targets for quality improvement initiatives.
我们评估了III期食管癌患者对四项新质量指标的依从性，食管癌是胃肠道恶性肿瘤的主要死因。
我们对2004年至2016年间从国家癌症数据库（NCDB）中识别出的22871例III期食管癌患者进行了一项回顾性队列研究。根据已发表的指南定义了四项质量指标：诱导治疗的实施、采样淋巴结>15个、新辅助治疗后60天内进行手术以及R0切除。使用多因素逻辑回归评估患者人口统计学和治疗变量与指标依从性之间的关联。通过Cox模型比较依从和不依从病例来评估全因死亡率风险。对四项质量指标中依从零项至四项的组进行了Kaplan-Meier生存估计。
新辅助治疗（93.7%）、手术时机（85.7%）和切除完整性（92.0%）的依从性较高，但淋巴结评估的依从性较低（45.9%）。医疗补助保险状态与新辅助治疗依从性降低的几率相关[比值比（OR）0.73，95%置信区间（CI）：0.54 - 0.99]、淋巴结评估（OR 0.81，95% CI：0.68 - 0.96）以及切除完整性（OR 0.71，95% CI：0.54 - 0.92）。从2010年到2016年，与2004年至2005年的病例相比，充分诱导治疗、淋巴结分期和切除完整性的几率逐渐增加，但手术时机合适的几率逐渐降低。诱导治疗、淋巴结分期和R0切除的依从性与全因死亡率降低相关，但手术时机与全因死亡率无关。随着个体患者依从的质量指标数量增加，生存率提高。
III期食管癌患者对质量指标的依从性与生存率提高相关。了解指标依从性的变异性可能有助于确定质量改进措施的目标。
