title: Is It Time to Centralize High-risk Cancer Care in the United States? Comparison of Outcomes of Esophagectomy Between England and the United States.
abstract: OBJECTIVE
  To determine the difference in in-hospital mortality and length of hospital stay (LOS) after esophagectomy between the United States and England.
  
  
  BACKGROUND
  Since 2001, complex procedures such as esophagectomy have been centralized in England, but in the United States no formal plan for centralization exists.
  
  
  METHODS
  Patients who underwent esophagectomy for cancer between 2005 and 2010 were identified from the Nationwide Inpatient Sample (United States) and the Hospital Episodes Statistics (England). In-hospital mortality and LOS were compared.
  
  
  RESULTS
  There were 7433 esophagectomies performed in 66 English hospitals and 5858 resections in 775 US hospitals; median number of resections per center per year was 17.5 in England and 2 in the United States. In-hospital mortality was greater in US hospitals (5.50% vs 4.20%, P = 0.001). In multiple regression analysis, predictors of mortality included patient age, comorbidities, hospital volume, and surgery performed in the United States [odds ratio (OR) = 1.20 (1.02-1.41), P = 0.03]. Median LOS was greater in the English hospitals (15 vs 12 days, P < 0.001). However, when subset analysis was done on high-volume centers in both health systems, mortality was significantly better in US hospitals (2.10% vs 3.50%, P = 0.02). LOS was also seen to decrease in the US high-volume centers but not in England.
  
  
  CONCLUSIONS
  The findings from this international comparison suggest that centralization of high-risk cancer surgery to centers of excellence with a high procedural volume translates into an improved clinical outcome. These findings should be factored into discussions regarding future service configuration of major cancer surgery in the United States.
authors: *Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, Praed Street, London, UK †Virginia Mason Medical Center, Seattle, WA; and ‡St Mark's Hospital and Academic Institute, Watford Road, Harrow, UK.
authors: Aruna
authors: A
authors: Munasinghe
authors: Sheraz R
authors: SR
authors: Markar
authors: Ravikrishna
authors: R
authors: Mamidanna
authors: Ara W
authors: AW
authors: Darzi
authors: Omar D
authors: OD
authors: Faiz
authors: George B
authors: GB
authors: Hanna
authors: Donald E
authors: DE
authors: Low
mesh_terms: D000368:Aged; D002173:Cancer Care Facilities / Q000706:statistics & numerical data; D015897:Comorbidity; D004739:England / Q000453:epidemiology; D004938:Esophageal Neoplasms / Q000453:epidemiology / Q000601:surgery*; D016629:Esophagectomy / Q000401:mortality / Q000706:statistics & numerical data*; D005260:Female; D017052:Hospital Mortality; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology