Multicenter Stratified Comparison of Hospital Costs Between Laparoscopic and Open Colorectal Cancer Resections: Influence of Tumor Location and Operative Risk.

OBJECTIVE: To compare actual 90-day hospital costs between elective open and laparoscopic colon and rectal cancer resection in a daily practice multicenter setting stratified for operative risk. BACKGROUND: Laparoscopic resection has developed as a commonly accepted surgical procedure for colorectal cancer. There are conflicting data on the influence of laparoscopy on hospital costs, without separate analyses based on operative risk. METHODS: Retrospective analyses using a population-based database (Dutch Surgical Colorectal Audit). All elective resections for a T1-3N0-2M0 stage colorectal cancer were included between 2010 and 2012 in 29 Dutch hospitals. Operative risk was stratified for age (<75 years or ≥75 years) and ASA status (I-II/III-IV). Ninety-day hospital costs were measured uniformly in all hospitals based on time-driven activity-based costing. RESULTS: Total 90-day hospital costs ranged from &OV0556;10474 to &OV0556;20865 in the predefined subgroups. For colon cancer surgery (N = 4202), laparoscopic resection was significant less expensive than open resection in all subgroups, savings because of laparoscopy ranged from &OV0556;409 (<75 years ASA I-II) to &OV0556;1932 (≥75 years ASA I-II). In patients ≥75 years and ASA I-II, laparoscopic resection was associated with 46% less mortality (P = 0.05), 41% less severe complications (P < 0.001), 25% less hospital stay (P = 0.013), and 65% less ICU stay (P < 0.001). For rectal cancer surgery (N=2328), all laparoscopic subgroups had significantly higher total hospital costs, ranging from &OV0556;501 (<75 years ASA I-II) to &OV0556;2515 (≥75 years ASA III-IV). CONCLUSIONS: Laparoscopic resection resulted in the largest cost reduction in patients over 75 years with ASA I-II undergoing colonic resection, and the largest cost increase in patients over 75 years with ASA III-IV undergoing rectal resection as compared with an open approach.

A combined measure of procedural volume and outcome to assess hospital quality of colorectal cancer surgery, a secondary analysis of clinical audit data.

OBJECTIVE: To identify, on the basis of past performance, those hospitals that demonstrate good outcomes in sufficient numbers to make it likely that they will provide adequate quality of care in the future, using a combined measure of volume and outcome (CM-V&O). To compare this CM-V&O with measures using outcome-only (O-O) or volume-only (V-O), and verify 2010-quality of care assessment on 2011 data. DESIGN: Secondary analysis of clinical audit data. SETTING: The Dutch Surgical Colorectal Audit database of 2010 and 2011, the Netherlands. PARTICIPANTS: 8911 patients (test population, treated in 2010) and 9212 patients (verification population, treated in 2011) who underwent a resection of primary colorectal cancer in 89 Dutch hospitals. MAIN OUTCOME MEASURES: Outcome was measured by Observed/Expected (O/E) postoperative mortality and morbidity. CM-V&O states 2 criteria; 1) outcome is not significantly worse than average, and 2) outcome is significantly better than substandard, with 'substandard care' being defined as an unacceptably high O/E threshold for mortality and/or morbidity (which we set at 2 and 1.5 respectively). RESULTS: Average mortality and morbidity in 2010 were 4.1 and 24.3% respectively. 84 (94%) hospitals performed 'not worse than average' for mortality, but only 21 (24%) of those were able to prove they were also 'better than substandard' (O/E<2). For morbidity, 42 hospitals (47%) met the CM-V&O. Morbidity in 2011 was significantly lower in these hospitals (19.8 vs. 22.8% p<0.01). No relationship was found between hospitals' 2010 performance on O-O en V-O, and the quality of their care in 2011. CONCLUSION: CM-V&O for morbidity can be used to identify hospitals that provide adequate quality and is associated with better outcomes in the subsequent year.

Evaluating the validity of quality indicators for colorectal cancer care.

BACKGROUND: Quality indicators (QI) have been developed to measure quality of colorectal cancer care in the Netherlands. The aim of this study is to evaluate if these QI consistently assess the quality of colorectal cancer care in a hospital (internal consistency) and if these QI correlate with each other (construct validity). METHODS: The performance of 85 hospitals participating in the Dutch Surgical Colorectal Audit between the 1st of January 2010 and 31st of December 2010, were evaluated on nine QI: three process indicators for colon cancer, three process indicators for rectal cancer and three outcome indicators. Consistency between all process indicators was assessed, and correlations between all process and outcome indicators were evaluated for colon and rectal cancer care separately. RESULTS: Hospital performance on the nine QI ranged widely. There was little consistency between the process indicators in assessing hospital performance. Most evaluated process indicators for colorectal cancer care did not correlate with each other, but were associated with better hospital specific patient outcomes. CONCLUSION: QI on colorectal cancer care do provide complementary information. Individual QI are not suitable as a surrogate measure for the quality of colorectal cancer care. More comprehensive measures are needed for true assessment of hospital performance.

Successful and safe introduction of laparoscopic colorectal cancer surgery in Dutch hospitals.

OBJECTIVE: To investigate the safety of laparoscopic colorectal cancer resections in a nationwide population-based study. BACKGROUND: Although laparoscopic techniques are increasingly used in colorectal cancer surgery, little is known on results outside trials. With the fast introduction of laparoscopic resection (LR), questions were raised about safety. METHODS: Of all patients who underwent an elective colorectal cancer resection in 2010 in the Netherlands, 93% were included in the Dutch Surgical Colorectal Audit. Short-term outcome after LR, open resection (OR), and converted LR were compared in a generalized linear mixed model. We further explored hospital differences in LR and conversion rates. RESULTS: A total of 7350 patients, treated in 90 hospitals, were included. LR rate was 41% with a conversion rate of 15%. After adjustment for differences in case-mix, LR was associated with a lower risk of mortality (odds ratio 0.63, P < 0.01), major morbidity (odds ratio 0.72, P < 0.01), any complications (odds ratio 0.74, P < 0.01), hospital stay more than 14 days (odds ratio 0.71, P < 0.01), and irradical resections (odds ratio 0.68, P < 0.01), compared to OR. Outcome after conversion was similar to OR (P > 0.05). A large variation in LR and conversion rates among hospitals was found; however, the difference in outcome associated with operative techniques was not influenced by hospital of treatment. CONCLUSIONS: Use of laparoscopic techniques in colorectal cancer surgery in the Netherlands is safe and results are better in short-term outcome than open surgery, irrespective of the hospital of treatment. Outcome after conversion was similar to OR.

['Clinical auditing', a novel tool for quality assessment in surgical oncology]. / 'Clinical auditing', een nieuw kwaliteitsinstrument in de chirurgische oncologie.

OBJECTIVE: To determine whether systematic audit and feedback of information about the process and outcomes improve the quality of surgical care. DESIGN: Systematic literature review. METHOD: Embase, PubMed, and Web of Science databases were searched for publications on 'quality assessment' and 'surgery'. The references of the publications found were examined as well. Publications were included in the review if the effect of auditing on the quality of surgical care had been investigated. RESULTS: In the databases 2415 publications were found. After selection, 28 publications describing the effect of auditing, whether or not combined with a quality improvement project, on guideline adherence or indications of outcomes of care were included. In 21 studies, a statistically significant positive effect of auditing was reported. In 5 studies a positive effect was found, but this was either not significant or statistical significance was not determined. In 2 studies no effect was observed. 5 studies compared the combination of auditing with a quality improvement project with auditing alone; 4 of these reported an additional effect of the quality improvement project. CONCLUSION: Audit and feedback of quality information seem to have a positive effect on the quality of surgical care. The use of quality information from audits for the purpose of a quality improvement project can enhance the positive effect of the audit.