Regionalization of thoracic surgery improves short-term cancer esophagectomy outcomes

Abstract

Background: Some studies have found that outcomes from cancer esophagectomy are better at higher-volume centers than at lower-volume centers. Reports on outcomes following systematic centralization have largely demonstrated subsequent improvements, but these originate in nationalized healthcare systems that are not very comparable to the heterogeneous private-payer systems that predominate in the United States. We examined how regionalization of thoracic surgery to Centers of Excellence (CoE) within our American integrated healthcare system changed overall care for our patients, and whether it changed outcomes.

Methods: We conducted a retrospective chart review of 461 consecutive patients undergoing cancer esophagectomy between 2009-2016, spanning the 2014 shift to regionalization. High-volume was defined as ≥5 esophagectomies per year. We compared characteristics of the surgeon, hospital, and operation pre- and post-regionalization using Chi-square or Fisher's exact test for categorical variables and Kruskal-Wallis test for age. We evaluated their associations with patient outcomes with hierarchical linear and logistic mixed models, which adjusted for clustering within surgeon and facility levels and relevant covariates.

Results: While there was no difference in their baseline demographics, patients undergoing esophagectomy post-regionalization were much more likely to have their surgery performed at a designated Center of Excellence (78.8% of cases versus 34.2%, P<0.001), at a high-volume hospital (92.1% from 75.7%, P<0.001), by a high-volume surgeon (78.8% from 58.8%, P<0.001), by a board-certified thoracic surgeon (82.5% from 64.0%, P<0.001), and by minimally-invasive, versus open, approach (60.8% from 22.1%, P<0.001). Post-regionalization patients were in higher American Society of Anesthesiologists classes (P=0.03) and trended toward higher-stage disease (P=0.14), indicative of the inclusion of higher-complexity patients. Despite that, regionalization was associated with improved short-term outcomes, most notably: average minimally-invasive esophagectomy (MIE) operative time decreased by 2 hours (-135.9 minutes, 95% CI: -172.2, -99.7 minutes); length of stay (LOS) decreased by 2.3 days (95% CI: -3.4, -1.2 days); and 30-day complication rate decreased significantly, from 50.7% to 30.2% (OR 0.45, 95% CI: 0.25, 0.79). Regionalization was the only variable significantly and independently associated with all three outcomes in our adjusted multivariable models. Mortality, both at 30 and 90 days, decreased modestly but was low pre-regionalization, and the difference did not reach significance.

Conclusions: Regionalization of thoracic surgery in our hospital system resulted in esophagectomies being performed by more experienced surgeons at higher-volume centers, with a concomitant improvement in short-term outcomes. Patients undergoing esophagectomy, particularly MIE, post-regionalization benefited significantly from decreased LOS and perioperative complication rate. Our results suggest that, in a large integrated healthcare system, regionalization significantly improves overall outcomes for patients undergoing cancer esophagectomy.

Keywords: Esophagectomy; esophageal neoplasms; low-volume & high-volume hospitals; thoracic surgery.

Figure 1

Esophagectomy case distribution across facilities by year. CoE, Center of Excellence.

Figure 2

Effect of regionalization on esophagectomy annual case distribution and operating sites, by Center of Excellence designation. CoE, Centers of Excellence; #, number.

Figure 3

Effect of regionalization on esophagectomy surgical approach, overall and by Center of Excellence designation. CoE, Centers of Excellence; MIE, minimally-invasive esophagectomy; OE, open esophagectomy.

Figure 4

Effect of regionalization on esophagectomy cases surgeon specialty, overall and by surgical approach. CoE, Centers of Excellence; MIE, minimally-invasive esophagectomy; OE, open esophagectomy.

Figure 5

Effect of regionalization on esophagectomy complication rates, by Center of Excellence designation and overall. CoE, Centers of Excellence.

Figure 6

Effect of regionalization on esophagectomy complication rates, by surgical approach. CoE, Centers of Excellence; MIE, minimally-invasive esophagectomy; OE, open esophagectomy.