Regionalization of Thoracic Surgery Improves Esophagectomy Outcomes for Patients with Esophageal Cancer
Sora Ely1, Amy Alabaster2, Simon K Ashiku3, Ashish Patel3, Jeffrey B Velotta3
1UCSF East Bay Surgery, Oakland, CA;2Kaiser Permanente - Division of Research, Oakland, CA;3Kaiser Permanente - Oakland Medical Center, Oakland, CA
Objective. Outcomes from esophagectomy for esophageal cancer have been shown to be better at higher-volume centers. We examined how regionalization of thoracic surgery, including esophagectomies, at Centers of Excellence within our integrated healthcare system changed overall care for our patients, and whether it resulted in improved outcomes. Methods. We conducted a retrospective chart review of 461 patients undergoing esophagectomy for esophageal cancer in our regional healthcare system of 20 hospitals between 2009-2016, spanning the 2014 shift to regionalization. We compared characteristics of the surgeon, hospital, and operation pre- and post-regionalization, and their effects on patient outcomes. Cohort demographic and clinical characteristics were compared using Chi-square tests. We used hierarchical linear and logistic mixed models, which adjusted for clustering within surgeon and facility levels and relevant covariates, to determine changes in post-operative length of stay, surgery time, and complication rates. Results. While there was no change in demographic characteristics (age, race, gender, tumor location), we found that regionalization shifted care to more experienced/specialized centers and surgeons with an increase in the minimally-invasive esophagectomy (MIE) approach, while also allowing sicker patients to undergo esophagectomy. Specifically, we found that patients undergoing esophagectomy post-regionalization were much more likely to have their surgery performed at a Center of Excellence (78.8% of cases compared to 34.2%, p<0.001), at a hospital at which ≥5 esophagectomies had been done the preceding year (92.1% from 75.7%, p<0.001), by a thoracic surgeon instead of general or other subspecialty surgeon (82.5% from 64.0%, p<0.001), by a surgeon who had done ≥5 esophagectomies the preceding year (78.8% from 58.8%, p<0.001), and by MIE versus open (60.8% from 22.1%, p<0.001). The patients undergoing esophagectomy were also more medically complex on average after regionalization, as evidenced by inclusion of patients with higher ASA ratings (p=0.03) and more advanced-stage tumors (p=0.01). Regionalization also resulted in improved outcomes for patients, most notably: length of stay (LOS) decreased by 2.4 days (95% CI: -3.5, -1.4); average MIE operative time decreased by 2 hours (-114 minutes, 95% CI: -146.7, -80.2); and 30-day complication rate decreased significantly, from 50.7% to 30.2% (adjusted OR 0.46, 95% CI: 0.26, 0.80). Mortality, both 30-day and 90-day, decreased modestly but was low pre-regionalization, and the difference did not reach significance. Conclusions. Regionalization of care in our hospital system resulted in esophagectomies being performed by more experienced surgeons at higher-volume centers, and we observed a concomitant improvement in outcomes. Regionalization of patients undergoing esophagectomy, particularly MIE, benefitted significantly in terms of overall morbidity especially with decreased LOS and perioperative complication rate. Our results suggest that, in a large integrated healthcare system, regionalization of care significantly improves overall outcomes for esophageal cancer patients undergoing esophagectomy.
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