Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.
Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.
J Clin Oncol. 2022 Apr 1;40(10):1041-1050. doi: 10.1200/JCO.21.01488. Epub 2022 Jan 11.
Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery to safer hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume.
We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for any of five major cancer types, splitting the data into training (2010-2015) and validation sets (2016-2018). For each surgical group, we calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modeled a market exit of low-performing hospitals, and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance or time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure.
Between 2016 and 2018, 158,079 patients were treated in 974 hospitals. At least 50% of high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In an RSMR centralization model, an average of 32 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, whereas 47 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery ranged from 10 minutes for colorectal cancer to 24 minutes for pancreatic cancer. Centralization on the basis of RSMR compared with volume would ensure lower median travel times for all cancer types, and these times would be lower than those observed.
RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.
尽管医院年手术量与手术结果之间的关联早已为人所知，但在将高风险手术转移至更安全的医院方面进展甚微。本研究旨在探究风险标准化死亡率（RSMR）是否比手术量更能作为手术质量的替代指标。
我们纳入了 2010 年至 2018 年间在德国接受五种主要癌症类型的复杂肿瘤手术的所有患者，将数据分为训练集（2010-2015 年）和验证集（2016-2018 年）。对于每个手术组，我们计算了训练集中的年度手术量和 RSMR 五分位数，并将这些阈值应用于验证集。我们研究了这两种系统之间的重叠情况，模拟了低绩效医院的市场退出，并比较了基于手术量和 RSMR 的排名的有效性和效率。我们比较了为特定手术将患者重新分配到死亡率较低的最近医院所需的旅行距离或时间。
2016 年至 2018 年间，974 家医院共治疗了 158079 名患者。根据 RSMR 分组，至少有 50%的高手术量医院的排名不在低死亡率组内。在 RSMR 集中化模型中，平均需要将 32 名接受复杂肿瘤手术的患者重新安置到低死亡率的医院，才能挽救一条生命，而需要将 47 名患者重新安置到高手术量的医院。手术医院最近的医院之间的平均旅行时间差范围为 10 分钟（结直肠癌）至 24 分钟（胰腺癌）。与基于手术量的集中化相比，基于 RSMR 的集中化将确保所有癌症类型的中位旅行时间更短，且这些时间都将低于观察到的时间。
RSMR 是衡量手术质量的一个有前途的替代指标。与手术量相比，它在有效性、效率和患者可获得性方面表现更优。
