The relationship between hospital volume and post-operative mortality rates for upper gastrointestinal cancer resections: Scotland 1982-2003.
BACKGROUND
Centralisation of surgical treatment of cancer has resulted in improved outcomes. We aimed to determine evidence of benefit for specialised management of upper gastrointestinal cancer in high-volume centres in Scotland.


METHODS
Discharge records of patients undergoing oesophagectomy, gastrectomy, hepatectomy or pancreatectomy between 1982 and 2003 were identified. Hospital data were analysed on a year-by-year basis to derive 'hospital-years'. Hospital-years were divided into quartiles by volume, and were analysed with regard to in-hospital mortality during the operative admission [Chi-square test (chi(2)) and Chi-square test for trend (chi(2)(trend))].


RESULTS
10,625 patients and 982 in-hospital deaths were included. In-hospital mortality rates declined during the study period: oesophagectomy 11.7-7.9%; gastrectomy 11.2-7.2%; hepatectomy 11.1-3.0%; and pancreatectomy 8.3-4.9%. For all resections except gastrectomy, mortality decreased as quartile of hospital-year volume increased (oesophagectomy: chi(2)p=0.006, chi(2)(trend)p=0.001; hepatectomy: chi(2)p=0.004, chi(2)(trend)p=0.003; pancreatectomy: chi(2)p=0.002, chi(2)(trend)p=0.001). ORs of death were lower for oesophagectomy (OR=0.58; 95%CI=0.39, 0.88; p=0.009) and pancreatectomy (OR=0.35; 95%CI=0.19, 0.64; p<0.001) in hospital-years within highest-volume quartiles compared with lowest. Scattergraphs of all resection types demonstrated inverse power relationships between number of resections per hospital-year and mortality.


CONCLUSIONS
Concentration of cancer care has had major effects on health service delivery in Scotland. Centralisation should be supported in surgical management of upper gastrointestinal cancer.
Skipworth
R J E
RJ
Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK. rskipworth@hotmail.com
Parks
R W
RW
Stephens
N A
NA
Graham
C
C
Brewster
D H
DH
Garden
O J
OJ
Paterson-Brown
S
S
D016629:Esophagectomy / Q000401:mortality / Q000706:statistics & numerical data; D005743:Gastrectomy / Q000401:mortality / Q000706:statistics & numerical data; D005770:Gastrointestinal Neoplasms / Q000401:mortality / Q000601:surgery*; D006498:Hepatectomy / Q000401:mortality / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D010180:Pancreatectomy / Q000401:mortality / Q000706:statistics & numerical data; D012606:Scotland / Q000453:epidemiology