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Meta-Analysis
. 2012 Mar 14;2012(3):CD005391.
doi: 10.1002/14651858.CD005391.pub3.

Workload and surgeon's specialty for outcome after colorectal cancer surgery

David Archampong  1 , David Borowski, Peer Wille-Jørgensen, Lene H Iversen
Affiliations
Meta-Analysis

Workload and surgeon's specialty for outcome after colorectal cancer surgery

David Archampong et al. Cochrane Database Syst Rev. .

Abstract

Background: A large body of research has focused on investigating the effects of healthcare provider volume and specialization on patient outcomes including outcomes of colorectal cancer surgery. However there is conflicting evidence about the role of such healthcare provider characteristics in the management of colorectal cancer.

Objectives: To examine the available literature for the effects of hospital volume, surgeon caseload and specialization on the outcomes of colorectal, colon and rectal cancer surgery.

Search methods: We searched Cochrane Central Register of Controlled Trials (CENTRAL), and LILACS using free text search words (as well as MESH-terms). We also searched Medline (January 1990-September 2011), Embase (January 1990-September 2011) and registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

Selection criteria: Non-randomised and observational studies that compared outcomes for colorectal cancer, colon cancer and rectal cancer surgery (overall 5-year survival, five year disease specific survival, operative mortality, 5-year local recurrence rate, anastomotic leak rate, permanent stoma rate and abdominoperineal excision of the rectum rate) between high volume/specialist hospitals and surgeons and low volume/specialist hospitals and surgeons.

Data collection and analysis: Two review authors independently abstracted data and assessed risk of bias in included studies. Results were pooled using the random effects model in unadjusted and case-mix adjusted meta-analyses.

Main results: Overall five year survival was significantly improved for patients with colorectal cancer treated in high-volume hospitals (HR=0.90, 95% CI 0.85 to 0.96), by high-volume surgeons (HR=0.88, 95% CI 0.83 to 0.93) and colorectal specialists (HR=0.81, 95% CI 0.71 to 0.94). Operative mortality was significantly better for high-volume surgeons (OR=0.77, 95% CI 0.66 to 0.91) and specialists (OR=0.74, 95% CI 0.60 to 0.91), but there was no significant association with higher hospital caseload (OR=0.93, 95% CI 0.84 to 1.04) when only case-mix adjusted studies were included. There were differences in the effects of caseload depending on the level of case-mix adjustment and also whether the studies originated in the US or in other countries. For rectal cancer, there was a significant association between high-volume hospitals and improved 5-year survival (HR=0.85, 95% CI 0.77 to 0.93), but not with operative mortality (OR=0.97, 95% CI 0.70 to 1.33); surgeon caseload had no significant association with either 5-year survival (HR=0.99, 95% CI 0.86 to 1.14) or operative mortality (OR=0.86, 95% CI 0.62 to 1.19) when case-mix adjusted studies were reviewed. Higher hospital volume was associated with significantly lower rates of permanent stomas (OR=0.64, 95% CI 0.45 to 0.90) and APER (OR=0.55, 95% CI 0.42 to 0.72). High-volume surgeons and specialists also achieved lower rates of permanent stoma formation (0.75, 95% CI 0.64 to 0.88) and (0.70, 95% CI 0.53 to 0.94, respectively).

Authors' conclusions: The results confirm clearly the presence of a volume-outcome relationship in colorectal cancer surgery, based on hospital and surgeon caseload, and specialisation. The volume-outcome relationship appears somewhat stronger for the individual surgeon than for the hospital; particularly for overall 5-year survival and operative mortality, there were differences between US and non-US data, suggesting provider variability at hospital level between different countries, making it imperative that every country or healthcare system must establish audit systems to guide changes in the service provision based on local data, and facilitate centralisation of services as required. Overall quality of the evidence was low as all included studies were observational by design. In addition there were discrepancies in the definitions of caseload and colorectal specialist. However ethical challenges associated with the conception of randomised controlled trials addressing the volume outcome relationship makes this the best available evidence.

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Conflict of interest statement

The contact author (DA) is a UK specialist trainee with interest in colorectal surgery. DWB is a consultant colorectal surgeon working in a specialist colorectal unit within a university teaching hospital in the UK. The supervising authors (PWJ) and (LH) are colorectal consultants working in specialised colorectal centres in Denmark.

Figures

1
1
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Funnel plot based on hospital volume and the adjusted operative mortality 4 Hospital volume (adjusted analysis), outcome: 4.2 Inpatient and 30 day mortality.
1.1
1.1. Analysis
Comparison 1 Hospital volume (unadjusted analysis), Outcome 1 Overall five year survival.
1.2
1.2. Analysis
Comparison 1 Hospital volume (unadjusted analysis), Outcome 2 Inpatient and 30 day mortality.
1.3
1.3. Analysis
Comparison 1 Hospital volume (unadjusted analysis), Outcome 3 Five year local recurrence rate.
1.4
1.4. Analysis
Comparison 1 Hospital volume (unadjusted analysis), Outcome 4 Anastomotic leak rate.
1.5
1.5. Analysis
Comparison 1 Hospital volume (unadjusted analysis), Outcome 5 Permanent stoma rate.
1.6
1.6. Analysis
Comparison 1 Hospital volume (unadjusted analysis), Outcome 6 Abdominoperineal excision of rectum rate.
2.1
2.1. Analysis
Comparison 2 Surgeon volume (unadjusted analysis), Outcome 1 Overall five year survival.
2.2
2.2. Analysis
Comparison 2 Surgeon volume (unadjusted analysis), Outcome 2 Five year disease specific survival.
2.3
2.3. Analysis
Comparison 2 Surgeon volume (unadjusted analysis), Outcome 3 Inpatient and 30 day mortality.
2.4
2.4. Analysis
Comparison 2 Surgeon volume (unadjusted analysis), Outcome 4 Anastomotic leak rate.
2.5
2.5. Analysis
Comparison 2 Surgeon volume (unadjusted analysis), Outcome 5 Permanent stoma rate.
2.6
2.6. Analysis
Comparison 2 Surgeon volume (unadjusted analysis), Outcome 6 Abdominoperineal excision of the rectum.
3.1
3.1. Analysis
Comparison 3 Surgeon specialization (unadjusted analysis), Outcome 1 Overall five year survival.
3.2
3.2. Analysis
Comparison 3 Surgeon specialization (unadjusted analysis), Outcome 2 Five year disease specific survival.
3.3
3.3. Analysis
Comparison 3 Surgeon specialization (unadjusted analysis), Outcome 3 Inpatient and 30 day mortality.
3.4
3.4. Analysis
Comparison 3 Surgeon specialization (unadjusted analysis), Outcome 4 Five year local recurrence.
3.5
3.5. Analysis
Comparison 3 Surgeon specialization (unadjusted analysis), Outcome 5 Anastomotic leak rate.
3.6
3.6. Analysis
Comparison 3 Surgeon specialization (unadjusted analysis), Outcome 6 Permanent stoma rate.
3.7
3.7. Analysis
Comparison 3 Surgeon specialization (unadjusted analysis), Outcome 7 Abdominoperineal excision of the rectum rate.
4.1
4.1. Analysis
Comparison 4 Hospital volume (adjusted analysis), Outcome 1 Overall five year survival.
4.2
4.2. Analysis
Comparison 4 Hospital volume (adjusted analysis), Outcome 2 Inpatient and 30 day mortality.
4.3
4.3. Analysis
Comparison 4 Hospital volume (adjusted analysis), Outcome 3 Five year local recurrence rate.
4.4
4.4. Analysis
Comparison 4 Hospital volume (adjusted analysis), Outcome 4 Anastomotic leak rate.
4.5
4.5. Analysis
Comparison 4 Hospital volume (adjusted analysis), Outcome 5 Permanent stoma rate.
4.6
4.6. Analysis
Comparison 4 Hospital volume (adjusted analysis), Outcome 6 Abdominoperineal excision of the rectum rate.
5.1
5.1. Analysis
Comparison 5 Surgeon volume (adjusted analysis), Outcome 1 Overall five year survival.
5.2
5.2. Analysis
Comparison 5 Surgeon volume (adjusted analysis), Outcome 2 Five year disease specific survival.
5.3
5.3. Analysis
Comparison 5 Surgeon volume (adjusted analysis), Outcome 3 Inpatient and 30 day mortality.
5.4
5.4. Analysis
Comparison 5 Surgeon volume (adjusted analysis), Outcome 4 Anastomotic leak rate.
5.5
5.5. Analysis
Comparison 5 Surgeon volume (adjusted analysis), Outcome 5 Permanent stoma rate.
5.6
5.6. Analysis
Comparison 5 Surgeon volume (adjusted analysis), Outcome 6 Abdominoperineal excision of rectum rate.
6.1
6.1. Analysis
Comparison 6 Surgeon specialization (adjusted analysis), Outcome 1 Overall five year survival.
6.2
6.2. Analysis
Comparison 6 Surgeon specialization (adjusted analysis), Outcome 2 Five year disease specific survival.
6.3
6.3. Analysis
Comparison 6 Surgeon specialization (adjusted analysis), Outcome 3 Inpatient and 30 day mortality.
6.4
6.4. Analysis
Comparison 6 Surgeon specialization (adjusted analysis), Outcome 4 Five year local recurrence rate.
6.5
6.5. Analysis
Comparison 6 Surgeon specialization (adjusted analysis), Outcome 5 Anastomotic leak rate.
6.6
6.6. Analysis
Comparison 6 Surgeon specialization (adjusted analysis), Outcome 6 Permanent stoma rate.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Billingsley 2007 {published data only}
    1. Billingsley K, Morris A, Dominitz J, Matthews B, Dobie S, Barlow W, Wright G, Baldwin L. Surgeon and Hospital Characteristics as Predictors of Major Adverse Outcomes Following Colon Cancer Surgery. Understanding the Volume‐Outcome Relationship. Archives of Surgery 2007;142:23‐31. - PubMed
Birkmeyer 2002 {published data only}
    1. Birkmeyer J, Siewers A, Finlayson E, Stukel T, Lucas F, Batista I, Welch H, Wennberg D. Hospital volume and surgical mortality in the United States. The New England Journal of Medicine 2002;346:1128‐1137. - PubMed
Borowski 2007 {published and unpublished data}
    1. Borowski DW, Kelly SB, Bradburn DM, Wilson RG, Gunn A, Ratcliffe AA. Impact of surgeon volume and specialization on short‐term outcomes in colorectal cancer surgery. British Journal of Surgery 2007;94:880‐889. - PubMed
Borowski 2010 {published and unpublished data}
    1. Borowski DW, Bradburn DM, Mills SJ, Bharanthan B, Wilson RG, Gunn A, Ratcliffe AA, Kelly SB on behalf of the members of the Northern Region Colorectal Cancer Audit Group (NORCCAG). Volume‐outcome analysis of colorectal cancer‐related outcomes. British Journal of Surgery 2010;97(9):1416‐30. - PubMed
Carter et al 1995 {published data only}
    1. The Consultant surgeons and pathologists of the Lothian and Borders Health Boards. Lothian and Borders large bowel cancer project: immediate outcome after surgery. British Journal of Surgery 1995;82:888‐90. - PubMed
COLOR Study Group {published data only}
    1. COLOR Study Group. Impact of hospital case volume on short‐term outcome after laparoscopic operation for colonic cancer. Surgical Endoscopy 2005;19:687‐92. - PubMed
Debes 2008 {published data only}
    1. Debes AJ, Storkson RH, Jacobsen MB. Curative rectal cancer surgery in a low‐volume hospital: a quality assessment. European Journal of Surgical Oncology 2008;34:382‐9. - PubMed
Dimick 2003 {published data only}
    1. Dimick JB, Cowan JA, Upchurch JR, Colletti LM. Hospital volume and surgical outcomes for elderly patients with colorectal cancer in the United States. Journal of Surgical Research 2003;114(1):50‐6. - PubMed
Dorrance 2000 {published data only}
    1. Dorrance H, Docherty G, O'Dwyer P. effect of surgeon specialty interest on patient outcome after potentially curative colorectal cancer surgery. Diseases of the Colon and Rectum 2000;43:492‐98. - PubMed
Drolet 2011 {published data only}
    1. Drolet S, Maclean A, Myers R, Shaheen A, Dixon E, Buie W. Elective resection of colon cancer by high‐volume surgeons is associated with decreased morbidity and mortality. Journal of Gastrointestinal Surgery 2011;15:541‐50. - PubMed
Elferink 2010A {published data only}
    1. Elferink M, Wouters M, Krijnen P, Lemmens V, Jansen‐Landheer M, Velde C, Siesling S, Tollenaar R. Disparities in quality of care for colon cancer between hospitals in the Netherlands. European Journal of Surgical Oncology 2010;36:S64‐S73. - PubMed
Elferink 2010B {published data only}
    1. Elferink M, Krijnen P, Wouters M, Lemmens V, Jansen‐Landheer M, Velde C, Langendijk J, Marijnen C, Siesling S, Tollenaar R. Variation in treatment and outcome of patients with rectal cancer by region, hospital type and volume in the Netherlands. European Journal of Surgical Oncology 2010;36:S74‐S82. - PubMed
Engel 2005A {published data only}
    1. Engel A, Oomen J, Knol D, Cuesta M. Operative mortality after colorectal resection in the Netherlands. British Journal of Surgery 2005;92:1526‐1532. - PubMed
Engel 2005B {published data only}
    1. Engel J, Kerr J, Eckel R, Gunther B, Heiss M, Heitland W, Siewert JR, Jauch KW, Holzel, D. Influence of hospital volume on local recurrence and survival in a population sample of rectal cancer patients. European Journal of Surgical Oncology 2005;31(5):512‐20. - PubMed
Finlayson 2003 {published data only}
    1. Finalyson E, Goodney P, Birkmeyer J. Hospital volume and operative mortality in cancer. Archives of Surgery 2003;138:721‐25. - PubMed
Gort 2010 {published data only}
    1. Gort M, Otter R, Plukker J, Broekhius M. Actionable indicators for short and long term outcomes in rectal cancer. European Journal of Cancer 2010;46:1808‐14. - PubMed
Grabham 1996 {published data only}
    1. Grabham JA, Coleman MG, Moss S, Thompson MR, Lane RHS. Wessex colorectal cancer audit: anastomotic leakage following elective anterior resection. British Journal of Surgery 1996;83(Suppl. 1):22‐3.
Hannan 2002 {published data only}
    1. Hannan E, Radzyner M, Rubin D, Dougherty J, Brennan M. The influence of hospital and surgeon volume on in‐hospital mortality for colectomy, gastrectomy and lung lobectomy in patients for cancer.. Surgery 2002;131:6‐15. - PubMed
Harling 2005 {published data only}
    1. Harling H, Bulow S, Moller LN, Jorgensen T, Group DCC. . Hospital volume and outcome of rectal cancer surgery in Denmark 1994‐1999.. Colorectal Disease 2005;7(1):90‐5. - PubMed
Harmon 1999 {published data only}
    1. Harmon JW, Tang DG, Gordon TA, Bowman HM, Choti MA, Kaufman HS, et al. Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection. Annals of Surgery 1999;230:404‐11. - PMC - PubMed
Hodgson 2003 {published data only}
    1. Hodgson DC, Zhang W, Zaslavsky AM, Fuchs CS, Wright WE, Ayanian JZ. Relation of hospital volume to colostomy rates and survival for patients with rectal cancer. 2003;95(10):708‐716. Journal of the National Cancer Institute 2003;95(10):708‐16. - PubMed
Kressner 2009 {published data only}
    1. Kressner M, Bohe M, Cedermark B, Dahlberg M, Damber L, Lindmark G, Ojerskog B, Sjodahl R, Johansson R, Påhlman L. The Impact of Hospital Volume on Surgical Outcome in Patients with Rectal Cancer. Diseases of the colon and rectum 2009;52(9):1542‐49. - PubMed
Kuwabara 2009 {published data only}
    1. Kuwabara K, Matsuda S, Fushimi K, Ishikawa K, Horiguchi H, Fujimori K. Impact of hospital case volume on the quality of laparoscopic colectomy in Japan. Journal of Gastrointestinal Surgery 2009;13:1619‐26. - PubMed
Larson 2008 {published data only}
    1. Larson D, Marcello P, Larach S, Wexner S, Park A, Marks J, Senagore A, Thorson A, Young‐Fadok T, Green E, Sargent D, Nelson H. Surgeon volume does not predict outcomes in the setting of technical credentialing. Annals of Surgery 2008;248:746‐50. - PubMed
Lin 2006 {published data only}
    1. Lin H, Xirasagar S, Lee H Chai C. Hospital volume and inpatient mortality after cancer‐related gastrointestinal resections: The experience of an Asian country. Annals of Surgical Oncology 2006;13(9):1182‐88. - PubMed
Manchon‐Walsh 2011 {published data only}
    1. Manchon‐Walsh P, Borras J, Espinas J, Aliste L and Catalonian Rectal Cancer Group. Variability in the quality of rectal cancer care in public hospitals in Catalonia (Spain): Clinical audit as a basis for action. European Journal of Surgical Oncology 2011;37:325‐33. - PubMed
Martling 2002 {published data only}
    1. Martling A, Cedermark B, Johansson H, Rutqvist LE, Holm T. The surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer. British Journal of Surgery 2002;89(8):1008‐13. - PubMed
Marusch 2001A {published data only}
    1. Marusch F, Koch A, Schmidt U, Pross M, Gastinger I, Lippert H. Hospital caseload and the results achieved in patients with rectal cancer. British Journal of Surgery 2001;88:1397‐402. - PubMed
Marusch 2001B {published data only}
    1. Marusch F, Koch A, Schmidt, Zippel R, Lehmann M, Czarnetzki H, Knoop M, Geissler S, Pross M, Gastinger I, Lippert H. Effect of caseload on the short‐term outcome of colon surgery: results of a multicenter study. International Journal of Colorectal disease 2001;16:362‐69. - PubMed
Marwan 2010 {published data only}
    1. Marwan K, Staples M, Thursfield V, Bell S. The rate of abdominoperineal resections for rectal cancer in the state of Victoria, Australia. Diseases of the Colon and Rectum 2010;53(12):1645‐51. - PubMed
McArdle 2004 {published data only}
    1. McArdle CS, Hole DJ. Influence of volume and specialisation on survival following surgery for colorectal disease. British Journal of Surgery 2004;91:610‐17. - PubMed
McGrath 2005 {published data only}
    1. McGrath DR, Leong DC, Gibberd R, Armstrong B, Spigelman AD. Surgeon and hospital volume and the management of colorectal cancer patients in Australia. Australian and New Zealand Journal of Surgery 2005;75:901‐10. - PubMed
Mella 1997 {published data only}
    1. Mella J, Biffin A, Radcliffe A, Stamatakis J, Steele R. Population‐based audit of colorectal cancer management in two UK health regions. British Journal of Surgery 1997;84:1731‐36. - PubMed
Meyerhardt 2003 {published data only}
    1. Meyerhardt J, Catalano P, Schrag D, Ayanian J, Haller D, Mayer R, MacDonald J, Benson A, Fuchs C. Association of hospital procedure volume and outcomes in patients with colon cancer at high risk of recurrence. Annals of Internal Medicine 2003;139(8):649‐57. - PubMed
Meyerhardt 2004 {published data only}
    1. Meyerhardt J, Tepper J, Niedzwiecki D, Hollis D, Schrag D, Ayanian J, O'Connel M, Weeks J, Mayer R, Willet C, MacDonald J, Benson A, Fuchs C. Imppact of hospital procedure volume on surgical operation and long term outcomes in high risk curatively resected rectal cancer: findings from the Intergroup 0114 study. Journal of Clinical Oncology 2004;22:166‐74. - PubMed
Morris 2007 {published data only}
    1. Morris M, Platell C. Surgical volume influences survival in patients undergoing resections for stage II colon cancer. Australian and New Zealand Journal of Surgery 2007;77:902‐6. - PubMed
Mroczkowski 2011 {published data only}
    1. Mroczkowski P, Kube R, Ptok H, Schmidt U, Has S, Kockerling F, Gastinger I, Lippert H. Low‐volume center vs. high‐volume:the role of a quality assurance program in colon cancer surgery. Colorectal Disease 2011;13:276‐283. - PubMed
Ng 2006 {published data only}
    1. Ng VV, Tytherleigh MG, Fowler L, Farouk R. Subspecialisation and its effect on the management of rectal cancer. Annals of Royal College of Surgeons England 2006;88:181‐4. - PMC - PubMed
Parry 1999 {published data only}
    1. Parry JM, Collins S, Mathers J, Scott NA, Woodman CB. Influence of volume of work on the outcome of treatment for patients with colorectal cancer. British Journal of Surgery 1999;86:475‐81. - PubMed
Platell 2003 {published data only}
    1. Platell C, Lim D, Nazreem T, Ji‐Li T, Wong K. Does surgical subspecialization influence survival in patients with colorectal cancer. World Journal of Gastroenterology 2003;9(5):961‐64. - PMC - PubMed
Ptok 2007 {published data only}
    1. Ptok H, Marusch F, Kuhn R, Gastinger I, Lippert H, the study group " Colon/Rectum carcinoma (Primary Tumour). Influence of hospital volume on the frequency of abdominoperineal resections and long‐term oncological outcomes in low rectal cancer. European Journal of Surgical Oncology 2007;33:854‐61. - PubMed
Purves 2005 {published data only}
    1. Purves H, Pietrobon R, Hervey S, Guller U, Miller W, Ludwig K. Relationship between surgeon caseload and sphincter preservation in patients with rectal cancer. Diseases of the Colon and Rectum 2005;48:195‐202. - PubMed
Rabeneck 2004 {published data only}
    1. Rabeneck L, Davila, J, Thompson M, El‐Serag H. Surgical volume and long‐term survival following surgery for colorectal cancer in the veterans affairs health‐care system. American Journal of Gastroenterology 2004;99(4):668‐75. - PubMed
Rogers 2006 {published data only}
    1. Rogers Jr SO, Wolf RE, Zaslavsky AM, Wright WE, Ayanian JZ. Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery. Annals of Surgery 2006;244:1003‐11. - PMC - PubMed
Schrag 2002 {published data only}
    1. Schrag D, Panageas KS, Riedel E, Cramer LD, Guillem JG, Bach PB, et al. Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection. Annals of Surgery 2002;236:583‐92. - PMC - PubMed
Schrag 2003 {published data only}
    1. Shrag D, Panageas K, Riedel E, Hsieh L, Bach P, Guillem J, Begg C. Surgeon volume compared to hospital volume as a predictor of outcome following primary colon cancer resection. Journal of Surgical Oncology 2003;83:68‐79. - PubMed
Simons 1997 {published data only}
    1. Simons A, Ker R, Groshen S, Gee C, Anthone G, Ortega A, Vukasin P, Ross R, Beart R. Variations in treatment of rectal cancer. Diseases of colon and rectum 1997;40(6):641‐46. - PubMed
Simunovic 2000 {published data only}
    1. Simunovic M, To T, Baxter N, Balshem A, Ross E, Cohen Z, McLeod R, Engstrom P, Sigurdson E. Hospital procedure volume and teaching status do not influence treatment and outcome measures of rectal cancer surgery in a large general population. Journal of Gastrointestinal Surgery 2000;4(3):324‐30. - PubMed
Simunovic 2006 {published data only}
    1. Simunovic M, Rempell E, Theriault M, Coates A, Whelan T, Holowarty E, Langer B, Levine M. Influence of hospital characteristics on operative death and survival of patients after major cancer surgery in Ontario. Canadian Journal of Surgery 2006;49(4):251‐58. - PMC - PubMed
Sjovall 2007 {published data only}
    1. Sjovall A, Holm T, Singnomklao T, Granath F, GlimeliusF, Glimelius B, Cedermark B. Colon cancer management and outcome in relation to individual hospitals in a defined population. British Journal of Surgery 2007;94(4):491‐99. - PubMed
Smith 2003 {published data only}
    1. Smith J, King P, Lane R, Thompson M. Evidence of the effect of specialization on the management, surgical outcome and survival from colorectal cancer in Wessex.. British Journal of Surgery 2003;90:583‐92. - PubMed
Urbach 2004 {published data only}
    1. Urbach DR, Baxter NN. Does it matter what a hospital is "high‐volume" for? Specificity of hospital volume‐outcome associations for surgical procedures: analysis of administrative data. British Medical Journal 2004;328:737‐40. - PMC - PubMed
Wibe 2005 {published data only}
    1. Wibe A, Eriksen MT, Syse A, Tretli S, Myrvold HE, Soreide O, et al. Effect of hospital caseload on long‐term outcome after standardisation of rectal cancer surgery at a national level. British Journal of Surgery 2005;92:217‐24. - PubMed
Zhang 2007 {published data only}
    1. Zhang W, Ayanian J, Zaslavsky A. Patient characteristics and hospital quality for colorectal cancer surgery. International Journal for quality and healthcare 2007;19:11‐20. - PubMed

References to studies excluded from this review

Beart 1995 {published data only}
    1. Beart R, Steele G, Menck H, Chmiel J, Ocweija K. Management and survival of patients with adenocarcinoma of the colon and rectum:a national survey of the commission on cancer. Journal of the American College of Surgeons 1995;181:235‐236. - PubMed
Bokey 1997 {published data only}
    1. Bokey E, Chapuis S, Dent O, Newland R, Koorey S, Zelas P, Stewart P. Factors affecting survival after excision of the rectum for cancer. Diseases of the Colon and Rectum 1996;40:3‐10. - PubMed
Callahan 2003 {published data only}
    1. Callahan M, Christos P, Gold H, Mushlin A, Daly J. Influence of surgical subspecialty training on in‐hospital mortality for gastrectomy and colectomy patients. Annals of Surgery 2003;238:629‐39. - PMC - PubMed
Crocetti 1996 {published data only}
    1. Crocetti E, Barchielli A, Buiatti E, Castiglione G, Zappa M. Colorectal cancer survival‐population based rates in the province of Florence. European Journal of Cancer Prevention 1996;5:189‐95. - PubMed
Dahlberg 1998 {published data only}
    1. Dahlberg M, Pahlman L, Bergstrom R, Glimelius B. Improved survival in patients with rectal cancer:a population‐based register study. British Journal of Surgery 1998;85:515‐20. - PubMed
Dorrance 1997 {published data only}
    1. Dorrance H, O'Dwyer P. Effect of surgeon's specialty interest on outcome following curative colorectal cancer surgery. British Journal of Surgery 1997;84(Suppl 1):37.
Easson 2002 {published data only}
    1. Easson A, Cotterchio M, Crosby J, Sutherland H, Dale D, Aronson M, Holowaty E, Gallinger S. A population‐based study of the extent of surgical resection. Annals of Surgical Oncology 2002;94(4):380‐87. - PubMed
Haward 2004 {published data only}
    1. Haward R, Morris E, Monson J, Johnston, Forman D. The long term survival of rectal cancer patients following abdominoperineal and anterior resection: results of a population‐based observational study. European Journal of Surgical Oncology 2005;31:22‐28. - PubMed
Hayanga 2010 {published data only}
    1. Hayanga A, Mukherjee D, Chang D, Kaiser H, Lee T, Gearhart S, Ahuja N, Freischlag J. Teaching hospital status and operative mortality in the United States. Archives of Surgery 2010;145(4):346‐50. - PMC - PubMed
Hermanek 1995 {published data only}
    1. Hermamnek P, Wiebelt H, Staimmer D, Riedel S, and the German Study Group Colo‐rectal Carcinoma (SGCRC). Prognostic factors of rectum carcinoma‐Experience of the German Multicentre Study (SGCRC). Tumori 1995;81:60‐4. - PubMed
Hermanek 1996 {published data only}
    1. Hermanek P, Hohenberger W. The importance of volume in colorectal cancer surgery. European Journal of Surgical Oncology 1996;22:213‐15. - PubMed
Hermanek 1998 {published data only}
    1. Hermanek P. A critical analysis of different results of colon cancer surgery. Lagenbecks Archive der Chirurgie 1998;115:323‐26. - PubMed
Hermanek 1999 {published data only}
    1. Hermanek P. Impact of surgeons's technique on outcome after treatment of rectal carcinoma. Diseases of the Colon and Rectum 1999;42(5):559‐62. - PubMed
Hermanek 2000 {published data only}
    1. Hermanek P, Mansmann U, Staimmer D, Riedl S, Hermanek P. The German Experience. The surgeon as a prognostic factor in colon and rectal cancer surgery. Surgical Oncology Clinics of North America 2000;9(1):33‐49. - PubMed
Hilska 2004 {published data only}
    1. Hilska M, Roberts JR, Kossi Jyrki, Paajanen H, Collan Yrjo, Laato M. The influence of training level and surgical experience on survival in colorectal cancer. Langenbecks Arch Surg 2004;389:524‐31. - PubMed
Ho 2006 {published data only}
    1. Ho V, Heslin M, Yun H, Howard L. Trends in hospital and surgeon volume and operative mortality for cancer surgery. Annals of Surgical Oncology 2006;13(6):851‐58. - PubMed
Holm 1997 {published data only}
    1. Holm T, Johansson H, Cedermark B, Ekuland G. Influence of hospital‐ and surgeon‐related factors on outcome after treatment of rectal cancer with or without preoperative radiotherapy. British Journal of Surgery 1997;84:657‐63. - PubMed
Jestin 2004 {published data only}
    1. Jestin P, Heurgren M, Pahlman L, Glimelius B, Gunnarsson U. Elective surgery for colorectal cancer in a defined Swedish population. European Journal of Surgical Oncology 2004;30:26‐33. - PubMed
Kapiteijn 1998 {published data only}
    1. Kapiteijn E, Marijnen C, Colenbrander A. Local recurrence in patients with rectal cancer diagnosed between 1988 and 1992. European Journal of Surgical Oncology 1998;24:528‐35. - PubMed
Kee 1999 {published data only}
    1. Kee F, Wilson R, Harper C, Patterson C, McCallion K, Houston R, Moorehead R, Sloan J, Rowlands B. Influence of hospital and clinician workload on survival from colorectal cancer:cohort study. British Medical Journal 1999;318:1381‐86. - PMC - PubMed
Luna‐Perez 1999 {published data only}
    1. Luna‐Perez P, Huelga A, Almendaro S, Rodriguez‐Coria D, Macouzet J, Gallardo S. The surgeon as a prognostic factor for local recurrence and survival in the anal sphincter preservation for mid‐rectal cancer. Revista de Investigacion Clinica 1999;51:205‐13. - PubMed
Machado 2000 {published data only}
    1. Machado M, Goldman S, Jarhult J. Improved results in rectal cancer surgery‐an effect of specialisation. Colorectal Disease 2000;2:264‐69. - PubMed
Mander 2002 {published data only}
    1. Mander B, Bokey E, Chapuis P, Dent O, Bisset I, Newland R. The impact of subspecialization on survival in patients undergoing potentially curative resection of colonic carcinoma. Colorectal disease 2002;Suppl 1:11.
Martling 2000 {published data only}
    1. Martling A, Holm T, Rutquist L, Moran B, Heald R, Cedermark B, for the Stockholm Colorectal Cancer Study group and the Basingstoke Bowel Research Project. Effect of a training programme on outcome of rectal in the County of Stockholm. Lancet 2000;356:93‐6. - PubMed
Matthiessen 2006 {published data only}
    1. Matthiessen P, Hallbook O, Rutegard J, Sjodahl R. Population‐based study of risk factors for postoperative death after anterior resection of the rectum. British Journal of Surgery 2006;93:498‐503. - PubMed
McArdle 1991 {published data only}
    1. McArdle C, Hole D. Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival. British Medical Journal 1991;302:1501‐505. - PMC - PubMed
McArdle 2002 {published data only}
    1. McArdle C, Hole D. Outcome following surgery for colorectal cancer: analysis by hospital after adjustment for case‐mix and deprivation. British Journal of Cancer 2002;86:331‐35. - PMC - PubMed
Miller 2004 {published data only}
    1. Miller E, Woosley J, Martin C, Sandler R. Hospital‐to‐hospital variation in lymph node detection after colorectal resection. Cancer 2004;101(5):1065‐71. - PubMed
Mohner 1990 {published data only}
    1. Mohner M, Slisow W. Influence of regional‐centralised treatment on the end results demonstrated in rectum carcinoma in GDR. Zentralblatt Chirurgie 1990;115:801‐12. - PubMed
Paquette 2010 {published data only}
    1. Paquette I, Kemp J, Finlayson S. Patient and Hospital Factors Associated With Use of Sphincter‐Sparing Surgery for Rectal Cancer. Diseases of the colon & rectum 2010;53(2):115‐20. - PubMed
Pata 2008 {published data only}
    1. Pata G, Casella C, Nascimbeni R, Cirillo L, Salerni B. Modifiable risk factors in colorectal surgery: central role of surgeon's volume. Annali Italiani Chirurgia 2008;79:427‐33. - PubMed
Porter 1998 {published data only}
    1. Porter G, Soskolne C, Yakimets W, Newman S. Surgeon‐related factors and outcome in rectal cancer. Annals of Surgery 1998;227(2):157‐67. - PMC - PubMed
Read 2002 {published data only}
    1. Read T, Myerson R, Fleshman J, Fry R, Birnbaum E, Walz B, Kodner I. Surgeon specialty is associated with outcome in rectal cancer treatment. Diseases of the Colon and Rectum 2002;45(7):904‐14. - PubMed
Renzulli 2006 {published data only}
    1. Renzulli P, Lowry A, Maibach R, Egeli R, Metzger U, Laffer U. The influence of the surgeon's and the hospital's caseload on survival and local recurrence after colorectal cancer surgery. Surgery 2006;139(3):296‐304. - PubMed
Schrag 2000 {published data only}
    1. Schrag D, Cramer L, Bach P, Cohen A, Warren J, Begg C. Influence of hospital procedure volume on outcomes following surgery for colon cancer. JAMA 2000;284(23):3028‐35. - PubMed
Shankar 2001 {published data only}
    1. Shankar P, Achuthan R, Haray P. Colorectal subspecialization in a DGH. The way forward!. Colorectal Disease 2001;3:396‐401. - PubMed
Singh 1995 {published data only}
    1. Singh S, Morgan BF, Broughton M, Caffarey S, Topham C, Marks CG. A 10 year prospective audit of outcome of surgical treatment for colorectal carcinoma. British Journal of Surgery 1995;82:1486‐90. - PubMed
Smedh 2001 {published data only}
    1. Smedh K, Olsson L, Johansson H, Aberg C, Andersom M. Reduction of postoperative morbidity and mortality in patients with rectal cancer following the introduction of a colorectal unit. British Journal of Surgery 2001;88:273‐77. - PubMed
Stocchi 2001 {published data only}
    1. Stocchi L, Nelson H, Sargent D, O'Connell M, Tepper J, Krook J, Beart R and the North Central Cancer Treatment Group. Impact of surgical and pathologic variables in rectal cancer: A United States Community and Co‐operative Group Report. Journal of Clinical Oncology 2001;19(18):3895‐902. - PubMed
Syk 2010 {published data only}
    1. Syk E, Glimelius B, Nilsson P. Factors Influencing Local Failure in Rectal Cancer:Analysis of 2315 Patients From a Population‐Based Series. Diseases of the Colon and Rectum 2010;53:744‐52. - PubMed
Ubhi 1995 {published data only}
    1. Ubhi S, Kent J. Which surgeons in a district general hospital should treat patients with carcinoma of the rectum?. Journal of the Royal College of Surgeons of Edinburgh 1995;40:52‐4. - PubMed
Yasunaga 2009a {published data only}
    1. Yasunaga H, Matsuyama Y, Ohe K and Japan Surgical Society. Effects of hospital and surgeon volumes on operating times, postoperative complications, and length of stay following laparoscopic colectomy. Surgery Today 2009;39:955‐61. - PubMed
Yasunaga 2009b {published data only}
    1. Yasunaga H, Matsuyama Y, Ohe K and Japan Surgical Society. Volume‐outcome relationship in rectal cancer surgery: A new perspective. Surgery Today 2009;39:663‐68. - PubMed

Additional references

ACPGBI 2007
    1. ACPGBI. Guidelines for the management of colorectal cancer. 3rd Edition. The Association of Coloproctologists of Great Britain and Ireland, 2007.
Birkmeyer 2001
    1. Birkmeyer J, Finlayson E, Birkmeyer C. Volume standards for high‐risk surgical procedures: potential benefits of the Leapfrog initiative. Surgery 2001;130:415‐422. - PubMed
Chowdhury 2007
    1. Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. British Journal of Surgery 2007;94:145‐161. - PubMed
Deeks 2001
    1. Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta‐analysis. Statististical methods for examining heterogeneity and combining results from several studies in meta‐analysis. In: Egger M, Davey Smith G,Altman DG (eds), editor(s). Systematic Reviews in Healthcare: Meta‐analysis in context. 2nd Edition. London: British Medical Journal Publication Group, 2001.
Dent 1998
    1. Dent D. Cancer surgery: why some survival benefits may be artefactual. British Journal of Surgery 1998;85:433‐434. - PubMed
Dube 1997
    1. Dube S, Heyen F, Jenicek M. Adjuvant chemotherapy in colorectal carcinoma: results of a meta‐analysis. Diseases of the Colon and Rectum 1997;40(1):35‐41. - PubMed
Dudley 2000
    1. Dudley R A, Johansen, K L, Brand R, Rennie, D J, Milstein, A. Selective referral to high‐volume hospitals. JAMA 2000;283(9):1159‐1166. - PubMed
Feinstein 1985
    1. Feinstein A, Sosin D, Wells C. Stage migration and new diagnostic techniques as source of misleading statistics for survival in cancer. New England Journal of Medicine 1985;312(25):1604‐1608. - PubMed
Fong 2005
    1. Fong Y, Gonen M, Rubin D, Radzyner M, Brennan M F. Long‐term survival is superior after resection for cancer in high‐volume centres. Annals of Surgery 2005;242(4):540‐544. - PMC - PubMed
Globocan 2002 [Computer program]
    1. Ferlay J, Bray F, Pisani P, Parkin DM. Globocan 2002. Cancer incidence, mortality and prevalence worldwide. Lyon: IARC press, 2004.
Grade Working Group 2004
    1. Grade Working Group. Grading quality of evidence and strength of recommendations. British Medical Journal 2004;328(7454):1490‐1494. - PMC - PubMed
Gruen 2009
    1. Gruen R L, Pitt V, Green S, Parkhill A, Campbell D, Jolley D. The Effect of Provider Case Volume on Cancer Mortality: Systematic Review and Meta‐Analysis. CA. A Cancer Journal for Clinicians 2009;59:192‐211. - PubMed
Hahn 2002
    1. Hahn S, Williamson PR, Hutton JL. Investigation of within‐study selective reporting in clinical research:follow up of applications submitted to a local research ethics committee. Journal of evaluation in Clinical Practice 2002;8(3):353‐59. - PubMed
Hall 2009
    1. Hall BL, Bilimoria KY, Ko CY. Investigations using clinical data registries: Observational studies and risk adjustment. Surgery 2009;145(6):602‐610. - PubMed
Haynes 1995
    1. Haynes SR, Lawler PG. An assessment of the consistency of ASA physical status classification allocation. Anaesthesia 1995;50:195–199. - PubMed
Heald 1988
    1. Heald RJ. The "Holy Plane" of rectal surgery. Journal of the Royal Society of Medicine 1988;81:503‐508. - PMC - PubMed
Higgins 2003
    1. Higgins JPT, Thompson SG, Deeks JJ Altman DG. Measuring inconsistency in meta‐analyses. British Medical Journal 2003;327:557‐560. - PMC - PubMed
Higgins 2008
    1. Higgins JPT, Deeks JJ. Chapter 7: Selecting studies and collecting data. In: Higgins JPT, Green S editor(s). Cochrane handbook for systematic reviews of interventions. 5.0.2. The Cochrane Collaboration, 2009.
Hogan 2009
    1. Hogan AM, Kennelly R, Winter DC. Volume‐outcome analysis in rectal cancer: A plea for enquiry, evidence and evolution. European Journal of Surgical Oncology 2009;35(2):111‐2. - PubMed
Ihse 2003
    1. Ihse I. The volume‐outcome relationship in cancer surgery:A hard sell. Annals of Surgery 2003;238(6):777‐781. - PMC - PubMed
Iversen 2006A
    1. Iversen L, Harling H, Laurberg S, Wille‐Jorgensen P. Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of the evidence. Part I: short term outcome. Colorectal Disease 2006;9:28‐37. - PubMed
Iversen 2006B
    1. Iversen L, Harling H, Laurberg, Wille‐Jorgensen P. Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of the evidence. Part II: long term outcome. Colorectal Disease 2006;9:38‐46. - PubMed
Iversen 2007
    1. Iversen LH, Norgaard M, Jepsen P, Jacobson J, Christen sen MM, et al. Trends in colorectal cancer survival in northern Denmark: 1985‐2004. Colorectal Disease 2007;9(3):210. - PubMed
Kapiteijn 2001
    1. Kapiteijn E, Marijnen CAM, Nagtegaal ID, Putter H, Steup WH, Wiggers T, Rutten HJT, Pahlman L, Glimelius B, Krieken HJM, Leer JWH, Velde CJH. Preoperative Radiotherapy combined with total mesorectal excision for resectable rectal cancer. The New England Journal of Medicine 2001;345(9):638‐646. - PubMed
Keating 2003
    1. Keating J, Pater P, Lolohea S, Wickremesekera K. The epidemiology of colorectal cancer: what can we learn from the New Zealand Cancer Registry?. New Zealand Medical Journal 2003;116:U437. - PubMed
Killeen 2005
    1. Killeen S, O'Sullivan M, Coffey J, Kirwan W, Redmond H. Provider and outcomes for oncological procedures. British Journal of Surgery 2005;92:389‐402. - PubMed
Lee 1957
    1. Lee JAH, Morrison SL, Morris JN. Fatality from three common surgical conditions in teaching and non‐teaching hospitals. Lancet 1957;11:285‐291. - PubMed
Leyland 2001
    1. Leyland A, Goldstein H. Multilevel Modelling of Health StatisticsSeries: Wiley series in probability and statistics. Vol. Leyland, A.H. and Goldstein, H., eds. (2001) Multilevel Modelling of Health Statistics. Series: Wiley series in probability and statistics, Chichester: Wiley, 2001.
Lipworth 1963
    1. Lipworth L, Lee JAH, Morris JN. Case‐fatality in teaching and non‐teaching hospitals 1956‐59. Medical Care 1963;1:71‐76.
Luft 1979
    1. Luft HS, Bunker JP, Enthoven AC. Should Operations be regionalized?. The New England Journal of Medicine 1979;301:1364‐1369. - PubMed
Luft 1987
    1. Luft H, Hunt S, Maerki S. The volume‐outcome relationship: Practice‐makes‐perfect or Selective‐referral pattern. Health Services Research 1987;22(2):157‐182. - PMC - PubMed
Mamounas 1999
    1. Mamounas E, Wienand S, Wolmark N, Bear HD, Atkins JN, Song K, Jones J, Rockette H. Comparative efficacy of adjuvant chemotherapy in patients with Dukes' B versus Dukes' C colon cancer: results from four National Surgical Adjuvant Breast and Bowel Project adjuvant studies (C‐01,C‐02,C‐03 and C‐04). Journal of Clinical Oncology 1999;17(5):1349‐1355. - PubMed
Midgley 2000
    1. Midgley RS, Kerr DJ. ABC of colorectal cancer: adjuvant therapy. British Medical Journal 2000;321:1208‐1211. - PMC - PubMed
Newcastle‐Ottawa Scale
    1. Wells GA, Shea B, O'connell, Petersen J, Welch V, LososM, Tugwell P. The Newcastle‐Ottawa scale for assessing the quality of non‐randomised studies in meta‐analysis. http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm.
Panageas 2003A
    1. Panageas K, Schrag D, Riedel E, Bach P, Begg C. The effect of clustering of outcomes on the association of procedure volume and surgical outcomes. Annals of Internal Medicine 2003;139(8):658‐665. - PubMed
Parmar 1998
    1. Parmar MK, TorriV, Stewart L. Extracting summary statistics to perform meta‐analyses of the published literature for survival endpoints. Statistics in Medicine 1998;17(24):2815‐34. - PubMed
Ranta 1997
    1. Ranta S, Hynynen M, Tammisto T. A survey of the ASA physical status classification: significant variation in allocation among Finnish anaesthesiologists.. Acta Anaesthesiologica Scandinavica 1997;41:629‐632. - PubMed
Salz 2008
    1. Salz T, Sandler RS. The effect of Hospital and Surgeon Volume on outcomes for Rectal Cancer Surgery. Clinical Gastroenterology and Hepatology 2008;6:1185‐93. - PMC - PubMed
Sant 2009
    1. Sant M, Allemani C, Santaquilani M, Knijn A, Marchesi F, Capocaccia R. Eurocare‐4. Survival of cancer patients diagnosed in 1995‐1999. Results and commentary. European Journal of Cancer 2009;45:931‐991. - PubMed
Skegg 2002
    1. Skegg DC, McCredie MR. Comparison of cancer mortality and incidence in New Zealand and Australia. New Zealand Medical Journal 2002;115:205‐208. - PubMed
Soljak 2002
    1. Soljak M. Volume of procedures and outcome of treatment. British Medical Journal 2002;325:787‐788. - PMC - PubMed
Stiller 1994A
    1. Stiller C. Centralised treatment, entry to trials and survival. British Journal of Cancer 1994;70:352‐362. - PMC - PubMed
Swedish Rectal Cancer Trial 1997
    1. Swedish Rectal Cancer Trial. Improved survival with preoperative radiotherapy in resectable rectal cancer. The New England Journal of Medicine 1997;336(14):980‐987. - PubMed
Verdecchia 2007
    1. Verdecchia A, Franciscia S, Brenner H, Gatta G, Micheli A, Mangone L, Kunkler I. Recent cancer survival in Europe: a 2000–02 period analysis of EUROCARE‐4 data. Lancet Oncology 2007;8(9):784‐96. - PubMed
Wille‐Jørgensen 2001
    1. Wille‐Jørgensen P, Grinsted P, Harling H, Pihl J. Status for incidence, prognosis and diagnostics in colorectal cancer [Status for forekomst, prognose og diagnostik af kolorektal cancer]. Kræft i Tyktarm og Endetarm. Diagnostik og Screening. Vol. 3, Copenhagen: Statens Institut for Medicinsk Teknologivurdering, 2001:45‐94. [ISBN:87‐90951‐56‐3]

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