Key message
If surgeries for esophageal, pancreatic, liver, lung and ovarian cancers were performed only in high-volume hospitals, a total of 4,775 hospital days and 391 lives could be saved annually.
Background
Surgery is often a part of treatment for patients with esophageal, pancreatic, liver, lung or ovarian cancer. While many patients fare well after surgery, some experience adverse outcomes given that these cancer surgeries are complex and require a high level of specialized knowledge and experience. There is evidence that regionalization of complex surgical procedures can lead to improved patient outcomes. Regionalization is defined as “the deliberate reorientation of cancer surgical procedures, based on explicit and planned processes and structures, with the intent of improving the quality of care.”1 This Special Feature highlights the number of cancer resections as well as the association between hospital volume and outcomes of interest—in-hospital mortality, number of hospital days saved and number of lives saved—for esophageal, pancreatic, liver, ovarian and lung cancers across Canada.
| The Special Feature provides a snapshot of some key findings from the report Approaches to High-Risk, Resource Intensive Cancer Surgical Care in Canada by Finley et al. The pan-Canadian report provides analysis and discussion of the approaches to high-risk, resource-intensive surgical procedures for esophageal, pancreatic, liver, ovarian and lung cancers and provides actionable recommendations to optimize patient care. |
Methods
Hospital data on inpatient admissions in nine provinces (all except Quebec) were extracted from the Canadian Institute for Health Information Discharge Abstract Database. Cases with primary cancers and associated surgical procedures from 2004 to 2012 were included; only 2010–12 data are reported here. To calculate age-standardized resection rates, the 1991 Canadian population structure was used as the reference population. Multivariate regression analyses were performed to examine the association between hospital volume and the outcomes of interest—in-hospital mortality, number of hospital days saved and number of lives saved—controlling for patient, institutional and surgeon factors. A detailed description of methodology can be found in the full report.
Results
High-risk, resource-intensive cancer resections in Canada
There were substantial variations in the age-standardized per capita number of resections for esophageal, lung, liver and pancreatic cancer in Canada. For these cancers, patients residing in the province with the highest number of resections per capita were twice as likely to receive potentially curative surgery as patients residing in the province with the lowest number of resections (Figure 4.7).
Of the five cancers, the numbers of resections for esophageal, pancreatic and liver cancer were relatively low in all reporting provinces compared with the number of ovarian or lung cancer resections (Figure 4.7). Cancer incidence and clinical indication may be the primary drivers of the observed differences in the number of resections performed.
Some notable provincial trends emerged with respect to the number of cancer resections performed (Table 4.1). Of the eight reporting provinces, New Brunswick and Newfoundland and Labrador generally had among the lowest numbers of resections (per 100,000) across cancer sites. In contrast, British Columbia generally fell mid-range or had among the highest numbers of resections (per 100,000) across cancer sites.
Extent of regionalization for high-risk, resource-intensive cancer surgeries in Canada
The volume of resections performed in hospitals varied by cancer site (Table 4.2). Of the five cancers, lung cancer had the greatest regionalization of surgical procedures. In contrast to lung cancer, there were nearly half as many resections for ovarian cancer, but the resections were performed in three times as many hospitals, with many reporting small annual case volumes.
Impact of hospital volume on patient outcomes
An increase in hospital volume for pancreatic, esophageal, lung and ovarian cancer resections was significantly associated with a reduced risk of in-hospital mortality (Table 4.3). An increase in hospital volume was predicted to have the greatest effect on in-hospital mortality for pancreatic and esophageal cancers, where every 10-case increase in volume predicted a 22% and 23% decreased risk of in-hospital mortality, respectively.
If surgeries for pancreatic, esophageal, liver, ovarian and lung cancers were performed only in high-volume hospitals† (assuming the quality of care and outcomes are the same across all high-volume hospitals), a total of 4,775 hospital days could be saved annually. Lung cancer was predicted to have the greatest potential number of hospital days saved annually, at 3,335 (Table 4.3). In addition, 391 lives could be saved through consolidation of cancer resections in high-volume hospitals. The greatest effect was observed for consolidating lung cancer resections, with a predicted 209 lives potentially saved (Table 4.3).
Conclusions
The regionalization of complex surgical procedures has the potential to improve patient outcomes and quality of life. Given the association between hospital volume and outcomes, the current state of ovarian cancer surgical care may be in need of a regionalization effort. The findings presented here and in the full report are intended to inform administrators, health care planners and policy makers about the current state of surgical care and outcomes for high-risk, resource-intensive surgeries; to highlight areas for potential improvement; and to provide recommendations to optimize quality of care.
For the full Approaches to High-Risk, Resource Intensive Cancer Surgical Care in Canada report by Finley et al., please visit: http://www.cancerview.ca/cv/portal/Home/QualityAndPlanning/QPProfessionals/SystemPlanning/QualityInitiatives/AccessAndQualityCancerSurgery.
Notes
† A high-volume hospital is defined as a hospital in the highest-volume tertile.
References
- Finley C, Schneider L, Shakeel S, Akhtar-Danesh N, Elit L, Dixon E, et al. Approaches To High-Risk, Resource Intensive Cancer Surgical Care In Canada. Toronto (ON): 2015. 176 p.
