title: The relationship between hospital volume and post-operative mortality rates for upper gastrointestinal cancer resections: Scotland 1982-2003.
abstract: 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.
authors.affiliation: Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK. rskipworth@hotmail.com
authors.forename: R J E
authors.initials: RJ
authors.lastname: Skipworth
authors.forename: R W
authors.initials: RW
authors.lastname: Parks
authors.forename: N A
authors.initials: NA
authors.lastname: Stephens
authors.forename: C
authors.initials: C
authors.lastname: Graham
authors.forename: D H
authors.initials: DH
authors.lastname: Brewster
authors.forename: O J
authors.initials: OJ
authors.lastname: Garden
authors.forename: S
authors.initials: S
authors.lastname: Paterson-Brown
mesh_terms: 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