Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
Surgery. 2024 Sep;176(3):873-879. doi: 10.1016/j.surg.2024.04.043. Epub 2024 Jun 17.
Process-based quality metrics are important for improving long-term outcomes after surgical resection. We sought to develop a practical surgical quality score for patients diagnosed with pancreatic ductal adenocarcinoma undergoing curative-intent resection.
Patients who underwent surgical resection for pancreatic ductal adenocarcinoma between 2010 and 2017 were identified using the National Cancer Database. Five surgical quality metrics were defined: minimally invasive approach, adequate lymphadenectomy, negative surgical margins, receipt of adjuvant therapy, and no prolonged hospitalization. Log-rank test and multivariable Cox regression analysis were used to determine the association of quality metrics with overall survival.
A total of 38,228 patients underwent curative-intent resection for pancreatic ductal adenocarcinoma. Median age at diagnosis was 68 years (interquartile range = 61-75), and roughly half the cohort was male (n = 19,562; 51.2%). Quality metrics were achieved on a varied basis: minimally invasive approach (n = 5,701; 14.9%), adequate lymphadenectomy (n = 27,122; 80.0%), negative surgical margin (n = 29,248; 76.5%), receipt of adjuvant therapy (n = 26,006; 68.0%), and absence of prolonged hospitalization (n = 26,470; 69.2%). An integer-based surgical quality score from 0 (no quality metrics) to 16 (all quality metrics) was calculated. Patients with higher scores had progressively better overall survival. Median overall survival differed substantially among the score categories (score = 0-4 points, 8.7 [8.0-9.6] months; 5-8 points, 17.5 [16.9-18.2] months; 9-12 points, 22.1 [21.6-22.8] months; and 13-16 points, 30.8 [30.2-31.3] months; P < .001). On multivariable analysis, risk-adjusted mortality hazards decreased in a stepwise manner with higher scores (0-4 points: reference; 5-8 points: multivariable adjusted hazard ratio = 0.60; 95% CI, 0.57-0.63; 9-12 points: adjusted hazard ratio = 0.49; 95% CI, 0.47-0.52; 13-16 points: and adjusted hazard ratio = 0.37; 95% CI, 0.34-0.40; all P < .001).
Adherence to quality metrics may be associated with improved overall survival. Efforts aimed at increasing compliance with quality metric measures may help optimize long-term outcomes among patients undergoing surgical resection for pancreatic ductal adenocarcinoma.
基于过程的质量指标对于改善外科切除术后的长期结局非常重要。我们旨在为接受根治性切除的胰腺导管腺癌患者制定一种实用的外科质量评分。
使用国家癌症数据库确定了 2010 年至 2017 年间接受胰腺导管腺癌手术切除的患者。定义了 5 个手术质量指标：微创方法、充分的淋巴结清扫、阴性手术切缘、接受辅助治疗和无长时间住院。对数秩检验和多变量 Cox 回归分析用于确定质量指标与总生存率的关联。
共 38228 例患者接受了胰腺导管腺癌的根治性切除术。中位诊断年龄为 68 岁（四分位间距=61-75），约一半的患者为男性（n=19562；51.2%）。质量指标的实现程度各不相同：微创方法（n=5701；14.9%）、充分的淋巴结清扫（n=27122；80.0%）、阴性手术切缘（n=29248；76.5%）、接受辅助治疗（n=26006；68.0%）和无长时间住院（n=26470；69.2%）。计算了一个从 0（无质量指标）到 16（所有质量指标）的基于整数的外科质量评分。得分较高的患者总体生存率逐渐提高。在评分类别中，中位总生存率差异显著（评分=0-4 分，8.7[8.0-9.6]个月；5-8 分，17.5[16.9-18.2]个月；9-12 分，22.1[21.6-22.8]个月；13-16 分，30.8[30.2-31.3]个月；P<0.001）。多变量分析显示，随着评分的升高，风险调整后的死亡率呈逐步下降趋势（0-4 分：参考；5-8 分：多变量调整后的危险比=0.60；95%CI，0.57-0.63；9-12 分：调整后的危险比=0.49；95%CI，0.47-0.52；13-16 分：调整后的危险比=0.37；95%CI，0.34-0.40；所有 P<0.001）。
遵守质量指标可能与改善总体生存率相关。旨在提高对质量指标措施的遵守率的努力可能有助于优化接受胰腺导管腺癌手术切除的患者的长期结局。
