Directing surgical quality improvement initiatives: comparison of perioperative mortality and long-term survival for cancer surgery.
OBJECTIVE
Quality-improvement initiatives are being developed to decrease volume-based variability in surgical outcomes. Resources for national and hospital quality-improvement initiatives are limited. It is unclear whether quality initiatives in surgical oncology should focus on factors affecting perioperative mortality or long-term survival. Our objective was to determine whether differences in hospital surgical volume have a larger effect on perioperative mortality or long-term survival using two methods.


METHODS
From the National Cancer Data Base, 243,103 patients who underwent surgery for nonmetastatic colon, esophageal, gastric, liver, lung, pancreatic, or rectal cancer were identified. Multivariable modeling was used to evaluate 60-day mortality and 5-year conditional survival (excluding perioperative deaths) across hospital volume strata. The number of potentially avoidable perioperative and long-term deaths were calculated if outcomes at low-volume hospitals were improved to those of the highest-volume hospitals.


RESULTS
Risk-adjusted perioperative mortality and long-term conditional survival worsened as hospital surgical volume decreased for all cancer sites, except for liver resections where there was no difference in survival. When comparing low- with high-volume hospitals, the hazard ratios for perioperative mortality were substantially larger than for long-term survival. However, the number of potentially avoidable deaths each year in the United States, if outcomes at low-volume hospitals were improved to the level of highest-volume centers, was significantly larger for long-term survival.


CONCLUSIONS
Although the magnitude of the hazard ratios implies that quality-improvement efforts should focus on perioperative mortality, a larger number of deaths could be avoided by focusing quality initiatives on factors associated with long-term survival.
Bilimoria
Karl Y
KY
Department of Surgery, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, USA. k-bilimoria@northwestern.edu
Bentrem
David J
DJ
Feinglass
Joseph M
JM
Stewart
Andrew K
AK
Winchester
David P
DP
Talamonti
Mark S
MS
Ko
Clifford Y
CY
D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000401:mortality / Q000601:surgery*; D017063:Outcome Assessment, Health Care; D016016:Proportional Hazards Models; D011785:Quality Assurance, Health Care; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology; D016526:Workload