Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Ann Thorac Surg. 2022 Oct;114(4):1176-1182. doi: 10.1016/j.athoracsur.2021.07.092. Epub 2021 Sep 3.
Esophageal cancer is a deadly disease requiring multidisciplinary coordination of care and surgical proficiency for adequate treatment. We hypothesize that quality of care is varied nationally.
From published guidelines, we developed quality measures for management of stage III esophageal cancer: utilization of neoadjuvant therapy, surgical sampling of at least 15 lymph nodes, resection within 60 days of chemotherapy or radiation, and completeness of resection. Measure adherence was examined across 1345 hospitals participating in the National Cancer Database from 2004 to 2016. We examined the association of volume, program accreditation, safety net status, geographic region, and patient travel distance on adequate adherence (≥85% of patients are adherent) using logistic regression modeling.
The rate of adequate adherence was worst in nodal staging (12.6%) and highest for utilization of neoadjuvant therapy (84.8%). Academic programs had the highest rate of adequate adherence for induction therapy (77.2%; P < .001), timing of surgery (56.6%; P < .001), and completeness of resection (78.5%; P < .001) but the lowest for nodal staging (4.4%; P = .018). For every additional esophagectomy performed per year, the odds of adequate adherence increased for induction therapy (odds ratio [OR]. 1.16; 95% confidence interval [CI], 1.06-1.27) and completeness of resection (OR, 1.15; 95% CI, 1.06-1.25) but decreased for nodal staging (OR, 0.76; 95% CI, 0.65-0.89).
Care provided at higher volume and academic facilities was more likely to be guideline concordant in some areas but not in others. Understanding the processes that support the delivery of guideline concordant care may provide valuable opportunities for improvement.
食管癌是一种致命疾病，需要多学科协调护理和熟练的外科手术来进行充分治疗。我们假设全国的护理质量存在差异。
根据已发表的指南，我们制定了 III 期食管癌管理的质量指标：新辅助治疗的使用、至少 15 个淋巴结的外科取样、化疗或放疗后 60 天内进行手术，以及切除的完整性。我们检查了 2004 年至 2016 年期间参与国家癌症数据库的 1345 家医院的措施遵守情况。我们使用逻辑回归模型检查了容量、项目认证、安全网状态、地理位置和患者旅行距离对充分遵守（≥85%的患者遵守）的关联。
在淋巴结分期方面，充分遵守的比例最差（12.6%），而新辅助治疗的利用率最高（84.8%）。学术项目在诱导治疗（77.2%；P <.001）、手术时机（56.6%；P <.001）和切除的完整性（78.5%；P <.001）方面具有最高的充分遵守率，但在淋巴结分期方面最低（4.4%；P =.018）。每年每增加一次食管癌切除术，充分遵守诱导治疗的可能性就会增加（优势比 [OR] 1.16；95%置信区间 [CI] 1.06-1.27）和切除的完整性（OR，1.15；95% CI，1.06-1.25），但淋巴结分期的可能性降低（OR，0.76；95% CI，0.65-0.89）。
在更高容量和学术设施中提供的护理在某些方面更有可能符合指南，但在其他方面则不然。了解支持提供符合指南的护理的流程可能会提供有价值的改进机会。
