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

Abstract

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. 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. 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. 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. 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. 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). 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. Impact de la charge de travail et de la spécialité des chirurgiens sur le résultat clinique après une opération du cancer colorectal Un important fonds de recherches s'est concentré sur l'étude des effets du volume de cas traités par les prestataires de soins de santé et de la spécialisation sur les résultats des patients, notamment les résultats de la chirurgie du cancer colorectal. Toutefois, il existe des preuves contradictoires concernant le rôle de ces caractéristiques des prestataires de soins de santé dans la gestion du cancer colorectal. Examiner la littérature disponible concernant les effets du volume hospitalier, du nombre de cas et de la spécialisation des chirurgiens sur les résultats des opérations du cancer colorectal, du cancer du côlon et du cancer rectal. Nous avons effectué une recherche dans le registre Cochrane des essais contrôlés (CENTRAL) et dans LILACS en utilisant des termes de recherche sous forme de texte libre (ainsi que des termes MESH). Nous avons également effectué une recherche dans Medline (de janvier 1990 à septembre 2011), Embase (de janvier 1990 à septembre 2011) et dans des registres des essais cliniques, des résumés de conférences scientifiques, des listes bibliographiques d'études incluses, et avons contacté des experts du domaine. Les études observationnelles et non randomisées qui comparaient les résultats des opérations du cancer colorectal, du cancer du côlon et du cancer rectal (survie globale sur 5 ans, survie spécifique de la maladie à cinq ans, mortalité opératoire, taux de récurrence locale à 5 ans, taux de fuites anastomotiques, taux de stomies permanentes et taux d'excisions abdomino‐périnéales du rectum) entre les hôpitaux et chirurgiens à volume élevé/spécialisés et les hôpitaux et chirurgiens à faible volume/spécialisés. Deux auteurs de la revue ont, indépendamment, extrait les...