title: The effect of a regional hepatopancreaticobiliary surgical program on clinical volume, quality of cancer care, and outcomes in the Veterans Affairs system.
abstract: OBJECTIVE
  Malignant neoplasms of the hepatopancreaticobiliary (HPB) system constitute a significant public health problem worldwide. Treatment coordination for these tumors is challenging and can result in substandard care. Referral centers for HPB disease have been used as a strategy to improve postoperative outcomes, but their effect on accomplishing regionalization of care and improving quality of cancer care is not well known.
  
  
  OBJECTIVE
  To evaluate the effect of implementing a multidisciplinary HPB surgical program (HPB-SP) on regionalization of care, the quality of cancer care, and surgical outcomes within an integrated health care system.
  
  
  METHODS
  We designed a retrospective cohort study in a tertiary referral Veterans Affairs (VA) medical center within an 8-state designated VA health care region from November 23, 2005, through December 31, 2013. We compared patients with HPB tumors undergoing evaluation by the surgical oncology service before and after implementation of the HPB-SP on November 1, 2008.
  
  
  METHODS
  Implementation of the HPB-SP to improve access to specialized, multidisciplinary cancer care for veterans across the region.
  
  
  METHODS
  Clinical and surgical volume, proportion of patients undergoing a comprehensive multidisciplinary evaluation, and postoperative adverse events included as a composite outcome defined by occurrence of postoperative mortality, severe complications, and/or reoperation.
  
  
  RESULTS
  We identified 516 patients referred to the surgical oncology service. Establishment of the HPB-SP resulted in significant increases in regional referrals (17.3% vs 44.4%; P < .001), median monthly clinic visits (5 vs 20; P < .001), and median number of HPB surgical procedures (3 vs 9; P = .003) per quarter. Multidisciplinary assessment increased from 52.6% to 70.0% (P < .001). When we compared patients with hepatocellular carcinoma before (n = 55) and after (n = 131) implementation, more patients received any treatment (35 [63.6%] vs 109 [83.2%]; P = .004) with increased use of liver resection (0 vs 20 [15.3%]; P = .002), percutaneous ablation (0 vs 15 [11.5%]; P = .009), and oncosurgical strategies (0 vs 16 [12.2%]; P = .007) after implementation. Among patients with colorectal liver metastases (29 before vs 76 after implementation), a significant shift occurred from use of ablations (5 [17.2%] vs 3 [3.9]%; P = .02) to resections (6 [20.7%] vs 40 [52.6%]; P = .003), and use of perioperative chemotherapy increased (5 of 11 [45.5%] vs 33 of 43 [76.7%]; P = .01). The HPB-SP was associated with lower odds of postoperative adverse events, even after adjusting for important covariates (odds ratio, 0.29 [95% CI, 0.12-0.68]; P = .005), and a high rate of margin-negative liver (94.6%) and pancreatic (90.0%) resections.
  
  
  CONCLUSIONS
  The development of an HPB-SP led to regionalization of care and improved quality of cancer care and surgical outcomes. Establishment of regional programs within the VA system can help improve the quality of care for patients presenting with complex cancers requiring subspecialized care.
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
authors.forename: Kelsey
authors.initials: K
authors.lastname: Lau
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
authors.forename: Aitua
authors.initials: A
authors.lastname: Salami
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas2Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
authors.forename: Gala
authors.initials: G
authors.lastname: Barden
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
authors.forename: Shumaila
authors.initials: S
authors.lastname: Khawja
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
authors.forename: Diana L
authors.initials: DL
authors.lastname: Castillo
authors.affiliation: Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
authors.forename: Victoria
authors.initials: V
authors.lastname: Poppelaars
authors.affiliation: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas3Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
authors.forename: Avo
authors.initials: A
authors.lastname: Artinyan
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas2Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas3Operative Care L.
authors.forename: Samir S
authors.initials: SS
authors.lastname: Awad
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas2Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas3Operative Care L.
authors.forename: David H
authors.initials: DH
authors.lastname: Berger
authors.affiliation: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
authors.forename: Daniel
authors.initials: D
authors.lastname: Albo
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas2Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas3Operative Care L.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Anaya
mesh_terms: D000553:Ambulatory Care / Q000706:statistics & numerical data*; D015331:Cohort Studies; D004067:Digestive System Neoplasms / Q000601:surgery*; D006498:Hepatectomy; D006787:Hospitals, Veterans / Q000458:organization & administration*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008495:Medical Oncology / Q000458:organization & administration; D017063:Outcome Assessment, Health Care / Q000592:standards*; D015397:Program Evaluation; D011787:Quality of Health Care / Q000458:organization & administration*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013781:Texas; D014481:United States; D014493:United States Department of Veterans Affairs / Q000458:organization & administration