Skip to main content

Advertisement

Log in

Esophageal Cancer Surgery: Spontaneous Centralization in the US Contributed to Reduce Mortality Without Causing Health Disparities

  • Gastrointestinal Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Improvement in mortality has been shown for esophagectomies performed at high-volume centers.

Objective

This study aimed to determine if centralization of esophageal cancer surgery occurred in the US, and to establish its impact on postoperative mortality. In addition, we aimed to analyze the relationship between regionalization of cancer care and health disparities.

Methods

A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000–2014. Adult patients (≥ 18 years of age) diagnosed with esophageal cancer and who underwent esophagectomy were included. Yearly hospital volume was categorized as low (< 5 procedures), intermediate (5–20 procedures), and high (> 20 procedures). Multivariable analyses on the potential effect of hospital volume on patient outcomes were performed, and the yearly rate of esophagectomies was estimated using Poisson regression.

Results

A total of 5235 patients were included. Esophagectomy at low- [odds ratio (OR) 2.17] and intermediate-volume (OR 1.62) hospitals, compared with high-volume hospitals, was associated with a significant increase in mortality. The percentage of esophagectomies performed at high-volume centers significantly increased during the study period (29.2–68.5%; p < 0.0001). The trend towards high-volume hospitals was different among the different US regions: South (7.7–54.3%), West (15.0–67.6%), Midwest (37.3–67.7%), and Northeast (55.8–86.8%) [p < 0.0001]. Overall, the mortality rate of esophagectomy dropped from 10.0 to 3.5% (p = 0.006), with non-White race, public insurance, and low household income patients also showing a significant reduction in mortality.

Conclusions

A spontaneous centralization for esophageal cancer surgery occurred in the US. This process was associated with a decrease in the mortality rate, without contributing to health disparities.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Arnold M, Laversanne M, Brown LM, et al. Predicting the future burden of esophageal cancer by histological subtype: international trends in incidence up to 2030. Am J Gastroenterol. 2017;112(8):1247–1255.

    Article  PubMed  Google Scholar 

  2. Sauvanet A, Mariette C, Thomas P, et al. Mortality and morbidity after resection for adenocarcinoma of the gastroesophageal junction: predictive factors. J Am Coll Surg. 2005;201:253–262.

    Article  PubMed  Google Scholar 

  3. Kassis ES, Kosinski AS, Ross P Jr, et al. Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thorac Surg. 2013;96(6):1919–1926.

    Article  PubMed  Google Scholar 

  4. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128–1137.

    Article  PubMed  Google Scholar 

  5. Gasper WJ, Glidden DV, Jin C, et al. Has recognition of the relationship between mortality rates and hospital volume for major cancer surgery in California made a difference? A follow-up analysis of another decade. Ann Surg. 2009;250(3):472–483.

    PubMed  Google Scholar 

  6. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011;364(22):2128–2137.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Reames BN, Ghaferi AA, Birkmeyer JD, et al. Hospital volume and operative mortality in the modern era. Ann Surg. 2014;260(2): 244–251.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Wouters MW, Karim-Kos HE, le Cessie S, et al. Centralization of esophageal cancer surgery: does it improve clinical outcome?. Ann Surg Oncol. 2009;16(7):1789–1798.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Markar SR, Karthikesalingam A, Thrumurthy S, et al. Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000–2011. J Gastrointest Surg. 2012;16(5):1055–1063.

    Article  PubMed  Google Scholar 

  10. Henneman D, Dikken JL, Putter H, et al. Centralization of esophagectomy: how far should we go?. Ann Surg Oncol. 2014;21(13):4068–4074.

    Article  PubMed  Google Scholar 

  11. Markar S, Gronnier C, Duhamel A, et al. Pattern of postoperative mortality after esophageal cancer resection according to center volume: results from a large european multicenter study. Ann Surg Oncol. 2015;22(8):2615–2623.

    Article  PubMed  Google Scholar 

  12. U.S. Census Bureau. Census Regions and Divisions of the United States. 2017 https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf. Accessed 14 Jun 2017.

  13. Birkmeyer JD, Dimick JB. Potential benefits of the new Leapfrog standards: effect of process and outcomes measures. Surgery. 2004;135(6):569–575.

    Article  PubMed  Google Scholar 

  14. Metzger R, Bollschweiler E, Vallböhmer D, et al. High volume centers for esophagectomy: what is the number needed to achieve low postoperative mortality?. Dis Esophagus. 2004;17(4):310–314.

    Article  CAS  PubMed  Google Scholar 

  15. Fuchs HF, Harnsberger CR, Broderick RC, et al. Mortality after esophagectomy is heavily impacted by center volume: retrospective analysis of the Nationwide Inpatient Sample. Surg Endosc. 2017;31(6):2491–2497.

    Article  PubMed  Google Scholar 

  16. Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117–2127.

    Article  CAS  PubMed  Google Scholar 

  17. Speicher PJ, Englum BR, Ganapathi AM, et al. Traveling to a high-volume center is associated with improved survival for patients with esophageal cancer. Ann Surg. 2017;265(4):743–749.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Disclosure

Francisco Schlottmann, Paula D. Strassle, Anthony G. Charles, and Marco G. Patti have no conflicts of interest to declare.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Francisco Schlottmann MD.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schlottmann, F., Strassle, P.D., Charles, A.G. et al. Esophageal Cancer Surgery: Spontaneous Centralization in the US Contributed to Reduce Mortality Without Causing Health Disparities. Ann Surg Oncol 25, 1580–1587 (2018). https://doi.org/10.1245/s10434-018-6339-3

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-018-6339-3

Keywords

Navigation