Originally published as JCO Early Release 10.1200/JCO.2007.15.6356 on June 23 2008

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Directing Surgical Quality Improvement Initiatives: Comparison of Perioperative Mortality and Long-Term Survival for Cancer Surgery

Karl Y. Bilimoria, David J. Bentrem, Joseph M. Feinglass, Andrew K. Stewart, David P. Winchester, Mark S. Talamonti, Clifford Y. Ko

From the Department of Surgery; Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University; Cancer Programs, American College Surgeons, Chicago; Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL; Department of Surgery, University of California, Los Angeles; and VA Greater Los Angeles Healthcare System, Los Angeles, CA

Corresponding author: Karl Y. Bilimoria, MD, MS, Cancer Programs, American College of Surgeons, 633 N St Clair St, 25th Floor, Chicago, IL 60611; e-mail: k-bilimoria{at}northwestern.edu

Purpose Quality-improvement initiatives are being developed to decrease volume-based variability in surgical outcomes. Resources for national and hospital quality-improvement initiatives are limited. It is unclear whether quality initiatives in surgical oncology should focus on factors affecting perioperative mortality or long-term survival. Our objective was to determine whether differences in hospital surgical volume have a larger effect on perioperative mortality or long-term survival using two methods.

Patients and Methods From the National Cancer Data Base, 243,103 patients who underwent surgery for nonmetastatic colon, esophageal, gastric, liver, lung, pancreatic, or rectal cancer were identified. Multivariable modeling was used to evaluate 60-day mortality and 5-year conditional survival (excluding perioperative deaths) across hospital volume strata. The number of potentially avoidable perioperative and long-term deaths were calculated if outcomes at low-volume hospitals were improved to those of the highest-volume hospitals.

Results Risk-adjusted perioperative mortality and long-term conditional survival worsened as hospital surgical volume decreased for all cancer sites, except for liver resections where there was no difference in survival. When comparing low- with high-volume hospitals, the hazard ratios for perioperative mortality were substantially larger than for long-term survival. However, the number of potentially avoidable deaths each year in the United States, if outcomes at low-volume hospitals were improved to the level of highest-volume centers, was significantly larger for long-term survival.

Conclusion Although the magnitude of the hazard ratios implies that quality-improvement efforts should focus on perioperative mortality, a larger number of deaths could be avoided by focusing quality initiatives on factors associated with long-term survival.

published online ahead of print at www.jco.org on June 23, 2008.

Supported by the American College of Surgeons, Clinical Scholars in Residence program and a research fellowship from the Department of Surgery, Feinberg School of Medicine, Northwestern University (both to K.Y.B.); and American Cancer Society Grant No. ACS IRG 93-037-12 (D.B.).

Presented at the Annual Meeting of the Society of Surgical Oncology, March 13-16, 2008 Chicago, IL.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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