title: Adhering to Quality Measures in Esophagectomy Is Associated With Improved Survival in All Stages of Esophageal Cancer.
abstract: BACKGROUND
  Quality measures for patients with early and locally advanced esophageal cancer undergoing esophagectomy have been made by national organizations. The rate of adherence to these measures as well as their association with overall survival are unknown.
  
  
  METHODS
  Esophagectomy patients were abstracted from the National Cancer Database. Because neoadjuvant status was available since 2006, the analysis of locally advanced patients began at this time point. Selected measures included: R0 resection, evaluation of 15 or more lymph nodes, and induction therapy for locally advanced tumors. Multivariate models identified variables associated with achieving quality measures. A Cox proportional hazards model evaluated factors associated with mortality.
  
  
  RESULTS
  From 1998 to 2012, 4,908 of 16,040 (30.6%) early-stage esophageal cancer patients (clinical T1A to T2N0 <2cm, well-differentiated) underwent esophagectomy. Of 4,672 patients 4,518 (96.7%) achieved R0 resection and 1,395 of 4,686 (29.8%) had 15 or more lymph nodes sampled. High-volume center type (>20 esophagectomies/year) was independently associated with meeting both measures (odds ratio [OR] 2.2, 95% confidence interval [CI]: 1.9 to 2.5). From 2006 to 2012, 7,747 of 20,437 (37.9%) locally advanced patients (clinical Stage IIB to IIIB) received esophagectomy. Of 6,966 patients 5,977 (85.8%) received induction therapy, 6,394 (91.8%) had R0 resection, and 2,852 (40.9%) had 15 or more lymph nodes sampled. High-volume center type was, again, associated with increased likelihood of meeting all quality measures (OR 2.17, 95% CI: 1.92 to 2.46). Meeting all quality measures was associated with the largest decrease in mortality for both early-stage (hazard ratio [HR] 0.27, 95% CI: 0.18 to 0.39) and locally advanced (HR 0.54, 95% CI: 0.40 to 0.73) esophageal cancer patients.
  
  
  CONCLUSIONS
  Adherence to recommended quality measures is independently associated with improved overall survival in both early and locally advanced stages of esophageal cancer. Currently, few patients are receiving care in accordance with these recommendations.
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
authors.forename: Pamela
authors.initials: P
authors.lastname: Samson
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
authors.forename: Varun
authors.initials: V
authors.lastname: Puri
authors.affiliation: Division of Cardiothoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Stephen
authors.initials: S
authors.lastname: Broderick
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
authors.forename: G Alexander
authors.initials: GA
authors.lastname: Patterson
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
authors.forename: Bryan
authors.initials: B
authors.lastname: Meyers
authors.affiliation: Division of Cardiothoracic Surgery, Southern Illinois University, Springfield, Illinois. Electronic address: tcrabtree53@siumed.edu.
authors.forename: Traves
authors.initials: T
authors.lastname: Crabtree
mesh_terms: D000368:Aged; D016208:Databases, Factual; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy / Q000401:mortality / Q000592:standards*; D005260:Female; D006801:Humans; D060828:Induction Chemotherapy; D008198:Lymph Nodes / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D016016:Proportional Hazards Models; D011787:Quality of Health Care; D015996:Survival Rate; D014481:United States / Q000453:epidemiology