title: Impact of hepatobiliary service centralization on treatment and outcomes in patients with colorectal cancer and liver metastases.
abstract: BACKGROUND
  Centralization of specialist surgical services can improve patient outcomes. The aim of this cohort study was to compare liver resection rates and survival in patients with primary colorectal cancer and synchronous metastases limited to the liver diagnosed at hepatobiliary surgical units (hubs) with those diagnosed at hospital Trusts without hepatobiliary services (spokes).
  
  
  METHODS
  The study included patients from the National Bowel Cancer Audit diagnosed with primary colorectal cancer between 1 April 2010 and 31 March 2014 who underwent colorectal cancer resection in the English National Health Service. Patients were linked to Hospital Episode Statistics data to identify those with liver metastases and those who underwent liver resection. Multivariable random-effects logistic regression was used to estimate the odds ratio of liver resection by presence of specialist hepatobiliary services on site. Survival curves were estimated using the Kaplan-Meier method.
  
  
  RESULTS
  Of 4547 patients, 1956 (43·0 per cent) underwent liver resection. The 1081 patients diagnosed at hubs were more likely to undergo liver resection (adjusted odds ratio 1·52, 95 per cent c.i. 1·20 to 1·91). Patients diagnosed at hubs had better median survival (30·6 months compared with 25·3 months for spokes; adjusted hazard ratio 0·83, 0·75 to 0·91). There was no difference in survival between hubs and spokes when the analysis was restricted to patients who had liver resection (P = 0·620) or those who did not undergo liver resection (P = 0·749).
  
  
  CONCLUSIONS
  Patients with colorectal cancer and synchronous metastases limited to the liver who are diagnosed at hospital Trusts with a hepatobiliary team on site are more likely to undergo liver resection and have better survival.
authors.affiliation: Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
authors.forename: A E
authors.initials: AE
authors.lastname: Vallance
authors.affiliation: Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.|Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: J
authors.initials: J
authors.lastname: vanderMeulen
authors.affiliation: Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Kuryba
authors.affiliation: The John Goligher Colorectal Surgery Unit, Leeds Teaching Hospitals NHS Trust, London, UK.
authors.forename: I D
authors.initials: ID
authors.lastname: Botterill
authors.affiliation: Department of General Surgery, Manchester Royal Infirmary, Manchester, UK.
authors.forename: J
authors.initials: J
authors.lastname: Hill
authors.affiliation: The John Goligher Colorectal Surgery Unit, Leeds Teaching Hospitals NHS Trust, London, UK.|Faculty of Medicine and Health, University of Leeds, Leeds, UK.
authors.forename: D G
authors.initials: DG
authors.lastname: Jayne
authors.affiliation: Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.|Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: K
authors.initials: K
authors.lastname: Walker
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002497:Centralized Hospital Services; D002648:Child; D002675:Child, Preschool; D015179:Colorectal Neoplasms / Q000473:pathology*; D005260:Female; D006498:Hepatectomy; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016522:Oncology Service, Hospital; D016016:Proportional Hazards Models; D016896:Treatment Outcome; D055815:Young Adult