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1.
PLoS One ; 19(6): e0303586, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38875301

RESUMO

INTRODUCTION: Literature regarding the impact of esophagectomy approach on hospitalizations costs and short-term outcomes is limited. Moreover, few have examined how institutional MIS experience affects costs. We thus examined utilization trends, costs, and short-term outcomes of open and minimally invasive (MIS) esophagectomy as well as assessing the relationship between institutional MIS volume and hospitalization costs. METHODS: All adults undergoing elective esophagectomy were identified from the 2016-2020 Nationwide Readmissions Database. Multiple regression models were used to assess approach with costs, in-hospital mortality, and major complications. Additionally, annual hospital MIS esophagectomy volume was modeled as a restricted cubic spline against costs. Institutions performing > 16 cases/year corresponding with the inflection point were categorized as high-volume hospitals (HVH). We subsequently examined the association of HVH status with costs, in-hospital mortality, and major complications in patients undergoing minimally invasive esophagectomy. RESULTS: Of an estimated 29,116 patients meeting inclusion, 10,876 (37.4%) underwent MIS esophagectomy. MIS approaches were associated with $10,600 in increased incremental costs (95% CI 8,800-12,500), but lower odds of in-hospital mortality (AOR 0.76; 95% CI 0.61-0.96) or major complications (AOR 0.68; 95% CI 0.60, 0.77). Moreover, HVH status was associated with decreased adjusted costs, as well as lower odds of postoperative complications for patients undergoing MIS operations. CONCLUSION: In this nationwide study, MIS esophagectomy was associated with increased hospitalization costs, but improved short-term outcomes. In MIS operations, cost differences were mitigated by volume, as HVH status was linked with decreased costs in the setting of decreased odds of complications. Centralization of care to HVH centers should be considered as MIS approaches are increasingly utilized.


Assuntos
Procedimentos Cirúrgicos Eletivos , Esofagectomia , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos , Esofagectomia/economia , Esofagectomia/mortalidade , Humanos , Estados Unidos , Masculino , Feminino , Pessoa de Meia-Idade , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Idoso , Procedimentos Cirúrgicos Eletivos/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/economia , Custos Hospitalares , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Resultado do Tratamento , Hospitais com Baixo Volume de Atendimentos/economia
2.
J Am Coll Surg ; 233(1): 21-27.e1, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33752982

RESUMO

BACKGROUND: The US News & World Report (USNWR) annual ranking of the best hospitals for gastroenterology and gastrointestinal surgery offers direction to patients and healthcare providers, especially for recommendations on complex medical and surgical gastrointestinal (GI) conditions. The objective of this study was to examine the outcomes of complex GI cancer resections performed at USNWR top-ranked, compared to non-ranked, hospitals. STUDY DESIGN: Using the Vizient database, data for patients who underwent esophagectomy, gastrectomy, and pancreatectomy for malignancy between January and December 2018 were reviewed. Perioperative outcomes were analyzed according to USNWR rank status. Primary outcome was in-hospital mortality. Secondary outcomes include length of stay, mortality index (observed-to-expected mortality ratio), rate of serious complication, and cost. Secondary analysis was performed for outcomes of patients who developed serious complications. RESULTS: There were 3,054 complex GI cancer resections performed at 42 top-ranked hospitals vs 3,608 resections performed at 198 non-ranked hospitals. The mean annual case volume was 73 cases at top-ranked hospitals compared to 18 cases at non-ranked hospitals. Compared with non-ranked hospitals, top-ranked hospitals had lower in-hospital mortality (0.96% vs 2.26%, respectively, p < 0.001) and lower mortality index (0.71 vs 1.53, respectively). There were no significant differences in length of stay, rate of serious complications, or direct cost between groups. In patients who developed serious morbidity, top-ranked hospitals had a lower mortality compared with non-ranked hospitals (8.2% vs 16.8%, respectively, p < 0.01). CONCLUSIONS: Within the context of complex GI cancer resection, USNWR top-ranked hospitals performed a 4-fold higher case volume and were associated with improved outcomes. Patients with complex GI-related malignancies may benefit from seeking surgical care at high-volume regional USNWR top-ranked hospitals.


Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia , Gastrectomia , Pancreatectomia , Neoplasias Pancreáticas/cirurgia , Neoplasias Gástricas/cirurgia , Adolescente , Adulto , Idoso , Bases de Dados Factuais/estatística & dados numéricos , Custos Diretos de Serviços/estatística & dados numéricos , Neoplasias Esofágicas/epidemiologia , Neoplasias Esofágicas/mortalidade , Esofagectomia/efeitos adversos , Esofagectomia/economia , Esofagectomia/mortalidade , Esofagectomia/estatística & dados numéricos , Feminino , Gastrectomia/efeitos adversos , Gastrectomia/economia , Gastrectomia/mortalidade , Gastrectomia/estatística & dados numéricos , Mortalidade Hospitalar , Hospitais/normas , Hospitais/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/normas , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreatectomia/efeitos adversos , Pancreatectomia/economia , Pancreatectomia/mortalidade , Pancreatectomia/estatística & dados numéricos , Neoplasias Pancreáticas/epidemiologia , Neoplasias Pancreáticas/mortalidade , Neoplasias Gástricas/epidemiologia , Neoplasias Gástricas/mortalidade , Estados Unidos/epidemiologia , Adulto Jovem
3.
J Thorac Cardiovasc Surg ; 161(3): 822-832.e6, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33451846

RESUMO

OBJECTIVES: To (1) measure 4 physiologic metrics before esophagectomy, (2) use these in an index to predict composite postoperative outcome after esophagectomy, and (3) compare predictive accuracy of this index to that of the Fried Frailty Index and Modified Frailty Index. METHODS: Grip strength (kilograms), 30-second chair sit-stands (number), 6-minute walk distance (meters), and normalized psoas muscle area (cm2/m) were measured for 77 consenting patients from January 1, 2018, to April 1, 2019. Imbalanced random forest classification estimated probability of a composite postoperative outcome, which included mortality, respiratory complications, anastomotic leak, delirium, length of stay ≥14 days, discharge to nursing facility, and readmission. G-mean error was used to compare predictive accuracy among indexes. RESULTS: Median grip strength was 38 kg (25th-75th percentiles, 31-44), number of sit-stands 11 (10-14), psoas muscle area to height ratio 6.9 cm2/m (6.0-8.2), and 6-minute walk distance 407 m (368-451). There was generally weak correlation between these metrics, with the highest between 30-second sit-stands and 6-minute walk distance (r = 0.57). Age, degree of patient-reported exhaustion, and the 4 objective metrics comprised the Esophageal Vitality Index, which had a lower G-mean error of 32% (31-33) than the Fried Frailty Index, 37% (37-38), and the Modified Frailty Index, 48% (47-48). CONCLUSIONS: The Esophageal Vitality Index, an objective, simple assessment consisting of grip strength, 30-second chair sit-stands, 6-minute walk, and psoas muscle area to height ratio outperformed commonly used frailty indexes in predicting postesophagectomy mortality and morbidity. The index provides a robust picture of patients' fitness for surgery beyond the qualitative "eyeball" test.


Assuntos
Técnicas de Apoio para a Decisão , Esofagectomia , Fragilidade/diagnóstico , Indicadores Básicos de Saúde , Idoso , Composição Corporal , Tomada de Decisão Clínica , Esofagectomia/efeitos adversos , Esofagectomia/mortalidade , Tolerância ao Exercício , Feminino , Fragilidade/complicações , Fragilidade/fisiopatologia , Estado Funcional , Força da Mão , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Estudos Prospectivos , Músculos Psoas/diagnóstico por imagem , Músculos Psoas/fisiopatologia , Medição de Risco , Fatores de Risco , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Teste de Caminhada , Caminhada
4.
J Surg Res ; 255: 355-360, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32599455

RESUMO

BACKGROUND: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) calculator is a useful tool used by physicians to better inform patients on the surgical risk of postoperative complications. It makes use of the NSQIP database to derive the chance for several adverse outcomes to occur postoperatively given certain patient's factors. The aim of this study was to assess its applicability in a series of patients undergoing an Ivor Lewis esophagectomy. METHODS: Data from 100 consecutive patients who underwent an Ivor Lewis esophagectomy between September 2013 and November 2017 at our institution were reviewed. Each patient was assessed using the ACS NSQIP surgical risk calculator. Actual events in this group were compared with their particular NSQIP-assessed risk. Logistic regression models were used to compare surgical risk calculator estimates binary outcomes such as incidence of postoperative complications such as cardiac events, renal events, surgical site infection, and death. Mixed linear model was used for length of stay (LOS) duration versus observed LOS. C-statistic was for predictive accuracy each binary outcome and intraclass correlation was used for LOS. RESULTS: C-statistic values were higher than the cutoff (0.75) for surgical site infection and death. The ACS NSQIP risk calculator was poorly predictive of other reported outcomes by the calculator such as cardiac or renal complications. Corroboration between observed LOS and predicted LOS was weak (8 d versus 11 d, respectively, intraclass coefficient 0.04). CONCLUSIONS: This study suggests that the risk calculator is useful for identifying risk of death or surgical site infection but poor at discriminating likelihood of other reported outcomes occurring, such as pneumonia, acute renal failure and cardiac complications for patients who underwent an Ivor Lewis esophagectomy. Estimations for procedure-specific complications for esophagectomy may need reevaluated.


Assuntos
Esofagectomia/mortalidade , Tempo de Internação , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Feminino , Florida/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade
5.
World J Surg ; 44(7): 2305-2313, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32123980

RESUMO

BACKGROUND: Assessment of preoperative physiological status is crucial for optimizing clinical outcomes in patients undergoing surgery for esophageal carcinoma (EC). We aimed to evaluate the prognostic impact of pulmonary dysfunctions and their relationships with other physiological factors, especially sarcopenia, in EC patients receiving esophagectomy. METHODS: In total, 411 EC patients who underwent esophagectomy between 2006 and 2016 were retrospectively reviewed. Preoperative pulmonary functions were evaluated based on %vital capacity (%VC) and forced expiratory volume (FEV) 1.0%. The thresholds were set as the lowest quartile (99% for %VC and 68.6% for FEV1.0%) in this cohort. RESULTS: One hundred and two patients (24.8%) had low %VC (%VC < 99%), which was significantly associated with age, comorbidity, sarcopenia and postoperative complications, while not correlating with pathological variables. The overall survival (OS) of patients in the low %VC group was significantly poorer than that of those in the high %VC group (P < 0.001), especially in those with pStage 0-II diseases (P < 0.001). In contrast, survival was not stratified by FEV1.0% (P = 0.80). Notably, patients with both low %VC and sarcopenia showed very poor 5-year OS (30.3%). Multivariate analysis revealed low %VC to be independently associated with poor OS (P = 0.03). In the cause-specific survival analyses, low %VC was an independent predictor of deaths from non-EC-related causes (P = 0.03). CONCLUSIONS: Preoperative low %VC was independently associated with poor survival outcomes, especially when present in combination with sarcopenia, due to an increased risk of death from non-EC-related causes. Preoperative spirometry testing is useful for predicting long-term outcomes in EC patients undergoing esophagectomy.


Assuntos
Carcinoma/cirurgia , Neoplasias Esofágicas/cirurgia , Esofagectomia/mortalidade , Indicadores Básicos de Saúde , Complicações Pós-Operatórias/etiologia , Sarcopenia/etiologia , Capacidade Vital , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma/mortalidade , Neoplasias Esofágicas/mortalidade , Feminino , Seguimentos , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Sarcopenia/epidemiologia , Análise de Sobrevida
6.
Cancer Med ; 9(2): 440-446, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31749330

RESUMO

BACKGROUND: Standard treatment for locally advanced esophageal cancer usually includes a combination of chemotherapy, radiation, and surgery. In squamous cell carcinoma (SCC), recent studies have indicated that esophagectomy after chemoradiation does not significantly improve survival but may reduce recurrence at the cost of treatment-related mortality. This study aims to evaluate the cost-effectiveness of chemoradiation with and without esophagectomy. METHODS: We developed a decision tree and Markov model to compare chemoradiation therapy alone (CRT) versus chemoradiation plus surgery (CRT+S) in a cohort of 57-year-old male patients with esophageal SCC, over 25 years. We used information on survival, cancer recurrence, and side effects from a Cochrane meta-analysis of two randomized trials. Societal utility values and costs of cancer care (2017, USD) were from medical literature. To test robustness, we conducted deterministic (DSA) and probabilistic sensitivity analyses (PSA). RESULTS: In our base scenario, CRT resulted in less cost for more quality-adjusted life years (QALYs) compared to CRT+S ($154 082 for 1.32 QALYs/patient versus $165 035 for 1.30 QALYs/patient, respectively). In DSA, changes resulted in scenarios where CRT+S is cost-effective at thresholds between $100 000-$150 000/QALY. In PSA, CRT+S was dominant 17.9% and cost-effective at willingness-to-pay of $150 000/QALY 38.9% of the time, and CRT was dominant 30.6% and cost-effective 61.1% of the time. This indicates that while CRT would be preferred most of the time, variation in parameters may change cost-effectiveness outcomes. CONCLUSIONS: Our results suggest that more data is needed regarding the clinical benefits of CRT+S for treatment of localized esophageal SCC, although CRT should be cautiously preferred.


Assuntos
Quimiorradioterapia/economia , Análise Custo-Benefício , Neoplasias Esofágicas/economia , Carcinoma de Células Escamosas do Esôfago/economia , Esofagectomia/economia , Quimiorradioterapia/mortalidade , Terapia Combinada , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/terapia , Carcinoma de Células Escamosas do Esôfago/patologia , Carcinoma de Células Escamosas do Esôfago/terapia , Esofagectomia/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Taxa de Sobrevida
7.
Semin Thorac Cardiovasc Surg ; 32(2): 347-354, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31866573

RESUMO

Social determinants of health have been associated with poor outcomes in esophageal cancer. Primary language and immigration status have not been examined in relation to esophageal cancer outcomes. This study aims to investigate the impact of these variables on stage of presentation, treatment, and outcomes of esophageal cancer patients at an urban safety-net hospital. Clinical data of patients with esophageal cancer at our institution between 2003 and 2018 were reviewed. Demographic, tumor, and treatment characteristics were obtained. Outcomes included median overall survival, stage-specific survival, and utilization of surgical and perioperative therapy. Statistical analysis was conducted using Chi-square test, Fisher's exact tests, Kaplan-Meier method, and logistic regression. There were 266 patients; 77% were male. Mean age was 63.9 years, 23.7% were immigrants, 33.5% were uninsured/Medicaid, and 16.2% were non-English speaking. Adenocarcinoma was diagnosed in 55.3% and squamous cell in 41.0%. More patients of non-Hispanic received esophagectomies when compared to those of Hispanic origin (64% vs 25%, P = 0.012). Immigrants were less likely to undergo esophagectomy compared to US-born patients (42% vs 76%, P = 0.001). Patients with adenocarcinoma were more likely than squamous cell carcinoma patients to undergo esophagectomy (odds ratio = 4.40, 95% confidence interval 1.61-12.01, P = 0.004). More commercially/privately insured patients (75%) received perioperative therapy compared to Medicaid/uninsured (54%) and Medicare (49%) patients (P = 0.030). There was no association between demographic factors and the utilization of perioperative chemoradiation for patients with operable disease. Approximately 23% of patients with operable disease were too frail or declined to undergo surgical intervention. In this small single-center study, race and primary language were not associated with median survival for patients treated for esophageal cancer. US-born patients experienced higher surgical utilization and privately insured patients were more likely to receive perioperative therapy. Many patients with operable cancer were too frail to undergo a curative surgery. Studies should expand on the relationships between social determinants of health and nonclinical services on delivery of care and survival of vulnerable populations with esophageal cancer.


Assuntos
Adenocarcinoma/cirurgia , Emigrantes e Imigrantes , Neoplasias Esofágicas/cirurgia , Carcinoma de Células Escamosas do Esôfago/cirurgia , Esofagectomia , Disparidades em Assistência à Saúde/etnologia , Provedores de Redes de Segurança , Determinantes Sociais da Saúde/etnologia , Populações Vulneráveis , Adenocarcinoma/etnologia , Adenocarcinoma/mortalidade , Idoso , Boston/epidemiologia , Quimiorradioterapia Adjuvante , Neoplasias Esofágicas/etnologia , Neoplasias Esofágicas/mortalidade , Carcinoma de Células Escamosas do Esôfago/etnologia , Carcinoma de Células Escamosas do Esôfago/mortalidade , Esofagectomia/efeitos adversos , Esofagectomia/mortalidade , Feminino , Nível de Saúde , Humanos , Seguro Saúde , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Fatores Raciais , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
8.
ANZ J Surg ; 89(11): 1404-1409, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31480100

RESUMO

BACKGROUND: High hospital-volume and service capability are associated with improved mortality following complex cancer surgery. Using a population-based study in Queensland, we assessed differences in mortality following oesophagectomy and pancreaticoduodenectomy, comparing high- and low-volume hospitals stratified by service capability. METHODS: Data on all patients undergoing oesophagectomy and pancreaticoduodenectomy for cancer in Queensland between 2001 and 2015 were obtained from the Queensland Oncology Repository. Hospital service capability was defined using the 2015 Australian Institute of Health and Welfare hospital peer groupings. Hospitals were grouped into 'high-volume (≥6 oesophagectomies or pancreaticoduodenectomies annually) with high service capability'; 'low-volume (<6) with high service capability' and 'low-volume with low service capability'. Multivariate Poisson models were used to estimate differences in 30- and 90-day mortality between hospital groups adjusting for age, sex, socioeconomic status, Charlson and American Society of Anesthesiologists scores, chemotherapy, radiotherapy, stage and time-period. RESULTS: For oesophagectomy, adjusted 90-day mortality was higher in low-volume compared with high-volume hospitals, regardless of service capability (low-volume, high service: incident rate ratio (IRR) 3.86, 95% confidence interval (CI) 1.74-8.57; low-volume, low service: IRR 3.40, 95% CI 1.16-10.00). For pancreaticoduodenectomy, mortality was higher in low-volume compared with high-volume centres regardless of service capability: 30-day mortality (low-volume, high service: IRR 2.32, 95% CI 1.07-5.03; low-volume, low service: IRR 3.92, 95% CI 1.45-10.61); 90-day mortality (low-volume, high service: IRR 2.36, 95% CI 1.29-4.30; low-volume, low service: IRR 3.32, 95% CI 1.64-6.71). CONCLUSION: High hospital resection volumes are associated with lower post-operative mortality following oesophagectomy and pancreaticoduodenectomy regardless of hospital service capability. This data supports centralization of these procedures to high-volume centres.


Assuntos
Neoplasias Gastrointestinais/cirurgia , Mortalidade Hospitalar/tendências , Especialidades Cirúrgicas/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Esofagectomia/mortalidade , Esofagectomia/estatística & dados numéricos , Feminino , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/mortalidade , Pancreaticoduodenectomia/estatística & dados numéricos , Queensland/epidemiologia , Classe Social , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos
9.
J Gastrointest Surg ; 22(11): 1845-1851, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30066065

RESUMO

BACKGROUND: With increasing focus on health care quality and cost containment, volume-based referral strategies have been proposed to improve value in high-cost procedures, such as esophagectomy. While the effect of hospital volume on outcomes has been demonstrated, our goal was to evaluate the economic consequences of volume-based referral practices for esophagectomy. METHODS: The nationwide inpatient sample (NIS) was queried for the years 2004-2013 for all patients undergoing esophagectomy. Patients were stratified by hospital volume quartile and substratified by preoperative risk and age. Clustered multivariable hierarchical logistic regression analysis was used to assess adjusted costs and mortality. RESULTS: In total, 9270 patients were clustered based on annual hospital volume quartiles of < 7, 7 to 22, 23 to 87, and > 87 esophagectomies. After stratification by patient variables, high-volume centers performed esophagectomies in high-risk patients at the same cost as low-volume centers without significant difference in resource utilization. Overall, mortality decreased across volume quartiles (lowest 8.9 versus highest 3.6%, p < 0.0001). The greatest volume-mortality differences were observed among patients aged between 70 and 80 years (lowest 12.2 versus highest 6.2%, p = 0.009). Patients with high preoperative risk also derived mortality benefits with increasing hospital volume (lowest 17.5 versus highest 11.8%, p < 0.0001). CONCLUSIONS: This study demonstrates that the mortality improvements for high-risk patients undergoing esophagectomy at high-volume centers do not come at increased costs. These results suggest that health systems should consider selectively referring high-risk patients to high-volume centers within their region.


Assuntos
Esofagectomia/economia , Esofagectomia/mortalidade , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Encaminhamento e Consulta , Fatores de Risco , Estados Unidos/epidemiologia
10.
Ann Thorac Surg ; 106(5): 1484-1491, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29944881

RESUMO

BACKGROUND: Postoperative complications result in significantly increased health care expenditures. The objective of this study was to examine 90-day excess costs associated with inpatient complications after esophagectomy and their predictive factors, by using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. METHODS: The study examined patients older than 65 years of age with a diagnosis from 2002 to 2009 and who were undergoing esophagectomy for cancer in the SEER-Medicare database. Quantile regression models were fit at 5% intervals for excess 90-day cost associated with perioperative complications while controlling for baseline characteristics. Excess cost was defined as the difference in total cost for patients with versus without the complication. Analyses were stratified by patients' characteristics to identify factors predictive of excess cost. RESULTS: A total of 1,462 patients were identified in the cohort; 51% had at least one complication. Significant excess cost was associated with pulmonary and mechanical wound complications across all quantiles (p < 0.05). Infectious (0.35 to 0.75 quantiles), intraoperative (0.05 to 0.85 quantiles), and systemic (0.30 to 0.85 quantiles) complications were associated with higher costs. Further, excess costs were significantly elevated in the higher quantiles. At the 0.50 quantile (median) of total cost distribution, excess cost in patients with any complication were significantly higher in patients with the following characteristics: transthoracic esophagectomy, emergency esophagectomy, Charlson Comorbidity Index >0, living in a nonmetropolitan area or poorer community, or treated in larger hospitals; no such difference was identified in patients without complications. CONCLUSIONS: Complications after esophagectomy result in significant excess 90-day cost. Efforts at cost reduction and quality improvement will need to focus on reducing complications, in particular pulmonary and infectious, as well as risk factors for higher complication costs.


Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia/economia , Gastos em Saúde , Tempo de Internação/economia , Medicare/economia , Complicações Pós-Operatórias/economia , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Intervalo Livre de Doença , Neoplasias Esofágicas/economia , Neoplasias Esofágicas/mortalidade , Esofagectomia/efeitos adversos , Esofagectomia/métodos , Esofagectomia/mortalidade , Feminino , Custos Hospitalares , Mortalidade Hospitalar/tendências , Humanos , Modelos Logísticos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Programa de SEER , Análise de Sobrevida , Estados Unidos
11.
Ann Thorac Surg ; 106(3): 916-923, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29738757

RESUMO

Since the 1970s, studies have demonstrated a strong association between operative volume and outcomes such as death and complications, particularly for complex cancer resections such as esophagectomy. The denouement has been to suggest that this operation should be directed toward specialized centers of esophageal cancer care, with operative volume thresholds being the primary basis for evidence-based hospital referral. This article reviews early efforts to centralize esophagectomy, as reported from other countries such as England, Canada, and the Netherlands, as well as the potential effect on access to care from instituting such policies in the United States.


Assuntos
Institutos de Câncer/organização & administração , Neoplasias Esofágicas/cirurgia , Esofagectomia/mortalidade , Esofagectomia/métodos , Avaliação de Resultados em Cuidados de Saúde , Regionalização da Saúde/organização & administração , Canadá , Serviços Centralizados no Hospital/organização & administração , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Hospitais com Alto Volume de Atendimentos , Humanos , Países Baixos , Inovação Organizacional , Melhoria de Qualidade , Análise de Sobrevida , Resultado do Tratamento , Reino Unido , Estados Unidos
12.
J Thorac Cardiovasc Surg ; 155(5): 2221-2230.e1, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29428700

RESUMO

OBJECTIVES: We compared the effectiveness of upfront esophagectomy versus induction chemoradiation followed by esophagectomy for overall survival in patients with clinical T2N0 (cT2N0) esophageal cancer. We also assessed the influence of the diagnostic uncertainty of endoscopic ultrasound on the expected benefit of chemoradiation. METHODS: We created a decision analysis model representing 2 treatment strategies for cT2N0 esophageal cancer: upfront esophagectomy that may be followed by adjuvant therapy for upstaged patients and induction chemoradiation for all patients with cT2N0 esophageal cancer followed by esophagectomy. Parameter values within the model were obtained from published data, and median survival for pathologic subgroups was derived from the National Cancer Database. In sensitivity analyses, staging uncertainty of endoscopic ultrasound was introduced by varying the probability of pathologic upstaging. RESULTS: The baseline model showed comparable median survival for both strategies: 48.3 months for upfront esophagectomy versus 45.9 months for induction chemoradiation and surgery. The sensitivity analysis demonstrated induction chemoradiation was beneficial, with probability of upstaging > 48.1%, which is within the published range of 32% to 65% probability of pathologic upstaging after cT2N0 diagnosis. The presence of any of 3 key variables (size larger than 3 cm, high grade, or lymphovascular invasion) was associated with > 48.1% risk of upstaging, thus conferring a survival advantage to induction chemoradiation. CONCLUSIONS: The optimal treatment strategy for cT2N0 esophageal cancer depends on the accuracy of endoscopic ultrasound staging. High-risk features that confer increased probability of upstaging can inform clinical decision making to recommend induction chemoradiation for select cT2N0 patients.


Assuntos
Quimiorradioterapia Adjuvante , Técnicas de Apoio para a Decisão , Neoplasias Esofágicas/terapia , Esofagectomia , Terapia Neoadjuvante , Idoso , Quimiorradioterapia Adjuvante/efeitos adversos , Quimiorradioterapia Adjuvante/mortalidade , Tomada de Decisão Clínica , Pesquisa Comparativa da Efetividade , Bases de Dados Factuais , Endossonografia , Neoplasias Esofágicas/diagnóstico por imagem , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Esofagectomia/efeitos adversos , Esofagectomia/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/efeitos adversos , Terapia Neoadjuvante/mortalidade , Estadiamento de Neoplasias , Seleção de Pacientes , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
13.
Ann Surg Oncol ; 25(6): 1580-1587, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29349529

RESUMO

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.


Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia/mortalidade , Disparidades nos Níveis de Saúde , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Idoso , Esofagectomia/efeitos adversos , Honorários e Preços , Feminino , Mortalidade Hospitalar/etnologia , Mortalidade Hospitalar/tendências , Hospitais com Alto Volume de Atendimentos/tendências , Humanos , Renda , Tempo de Internação , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pobreza , Estudos Retrospectivos , Estados Unidos/epidemiologia
14.
BMC Gastroenterol ; 16(1): 142, 2016 Dec 21.
Artigo em Inglês | MEDLINE | ID: mdl-28003023

RESUMO

BACKGROUND: Body mass index (BMI), resting energy expenditure (REE) and fasting blood glucose (FBG) are major preoperative assessments of patients' nutrition and metabolic state. The relations and effects of these indices on esophageal cancer patients' postoperative short-term and long-term outcomes remain controversial and unclear. We aimed to study the impact of BMI, REE and FBG in esophageal cancer patients undergoing esophagectomy. METHODS: Three hundred and six esophageal cancer patients who underwent esophagectomy were observed retrospectively. Clinical characteristics, postoperative complications and survival analysis were compared among different BMI, REE and FBG groups. RESULTS: There were significant linear relationships between REE, BMI and FBG indices, patients with low BMI tended to have low REE (p < 0.001) and low FBG (p = 0.003). No significant difference was found in case of mortality and postoperative complications among different groups. Low BMI (X 2 = 6.141, p = 0.046), REE (X 2 = 6.630, p = 0.010) and FBG (X 2 = 5.379, p = 0.020) were related to poor survival. FBG ≤90 mg/dL was independently associated with poor survival (HR = 0.695; 95 % CI 0.489-0.987, p = 0.042). BMI and REE came to be stronger prognostic factors on lymph node-negative patients and proved to be independent prognostic indicators (HR = 0.540; 95 % CI 0.304-0.959, p = 0.035 and HR = 0.457; 95 % CI 0.216-0.967, p = 0.041, respectively). CONCLUSIONS: BMI, REE and FBG are important prognostic factors in patients with esophageal cancer undergoing esophagectomy and preoperative evaluation of these indices help to determine the prognosis in these patients.


Assuntos
Metabolismo Basal/fisiologia , Índice de Massa Corporal , Neoplasias Esofágicas/fisiopatologia , Jejum/sangue , Idoso , Glicemia/análise , Neoplasias Esofágicas/sangue , Neoplasias Esofágicas/cirurgia , Esofagectomia/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
15.
Zhonghua Wei Chang Wai Ke Za Zhi ; 19(9): 1009-1013, 2016 Sep 25.
Artigo em Chinês | MEDLINE | ID: mdl-27680069

RESUMO

OBJECTIVE: To investigate the application of bundles of intervention in the treatment of esophageal carcinoma anastomotic leak. METHODS: From January 2014 to May 2015, 44 cases of esophageal carcinoma anastomotic fistula were treated by bundles of intervention (through the collection of a series of evidence-based treatment and care measures for the treatment of diseases) in Department of Thoracic Surgery, Huai'an First Hospital, Nanjing Medical University (bundles of intervention group), and 68 patients with esophageal carcinoma postoperative anastomotic leak from December 2013 to January 2012 receiving traditional therapy were selected as the control group. The clinical and nutritional indexes of both groups were compared. RESULTS: There were no significant differences in general data and proportion of anastomotic leak between the two groups. Eleven patients died during hospital stay, including 3 cases in bundles of intervention group(6.8%) and 8 cases in control group (11.8%) without significant difference(P = 0.390). In bundles of intervention group, 1 case died of type III( intrathoracic anastomotic leak, 2 died of type IIII( intrathoracic anastomotic leak. In control group, 2 cases died of type III( cervical anastomotic leak, 2 died of type III( intrathoracic anastomotic leak and 4 of type IIII( intrathoracic anastomotic leak. The mortality of bundles of intervention group was lower than that of control group. The duration of moderate fever [(4.1±2.4) days vs. (8.3±4.4) days, t=6.171, P=0.001], the time of antibiotic use [(8.2±3.8) days vs.(12.8±5.2) days, t=5.134, P = 0.001], the healing time [(21.5±12.7) days vs.(32.2±15.8) days, t=3.610, P=0.001] were shorter, and the average hospitalization expenses[(63±12) thousand yuan vs. (74±19) thansand yuan, t=3.564, P=0.001] was lower in bundles of intervention group than those in control group. Forty-eight hours after occurrence of anastomotic leak, the levels of hemoglobin, albumin and prealbumin were similar in both groups. However, at the time of fistula healing, the levels of hemoglobin [(110.6±10.5) g/L vs.(103.8±11.1) g/L, t=3.090, P=0.002], albumin [(39.2±5.2) g/L vs.(36.3±5.9) g/L, t=2.543, P=0.013] and prealbumin [(129.3±61.9) g/L vs.(94.1±66.4) g/L, t=2.688, P=0.008] were significantly higher in bundles of intervention group. CONCLUSION: In the treatment of postoperative esophageal carcinoma anastomotic leak, application of bundles of intervention concept can significantly improve the nutritional status and improve the clinical outcomes.


Assuntos
Fístula Anastomótica/terapia , Carcinoma/complicações , Fístula Esofágica/terapia , Neoplasias Esofágicas/complicações , Esofagectomia/efeitos adversos , Esofagectomia/mortalidade , Pacotes de Assistência ao Paciente/estatística & dados numéricos , Resultado do Tratamento , Fístula Anastomótica/mortalidade , Anti-Infecciosos/uso terapêutico , Carcinoma/cirurgia , Fístula Esofágica/complicações , Fístula Esofágica/mortalidade , Neoplasias Esofágicas/cirurgia , Feminino , Febre/epidemiologia , Febre/etiologia , Hemoglobinas/metabolismo , Custos Hospitalares/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estado Nutricional , Pacotes de Assistência ao Paciente/mortalidade , Pré-Albumina/metabolismo , Albumina Sérica/metabolismo
16.
Ann Surg Oncol ; 23(8): 2673-8, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27020584

RESUMO

BACKGROUND: Invasive esophageal cancers have been managed historically with esophagectomy. Low-risk T1b patients are being proposed for nonsurgical management. The purpose of this study was to evaluate the ability of endoscopic mucosal resections (EMR) to identify low-risk T1b patients and to review surgical treatment outcomes for T1b cancer. METHODS: All esophageal cancer patients, in an institutional review board-approved prospective database, between 2000 and 2013 with clinical stage (cT1bN0), pathological stage (pT1bN0), and no neoadjuvant therapy were retrospectively reviewed. RESULTS: Fifty-one patients, 38 pT1b and 13 cT1b, were assessed. All cT1b had preoperative EMR and five were found to be understaged at esophagectomy. pT1bN0 patients had a mean age of 66 years, mean BMI of 30, and 95 % had adenocarcinoma. Thirty-eight pT1bN0 patients underwent esophagectomy with a median hospital length of stay (LOS) of 9 days. Complications occurred in 14 patients, but 71 % were minor (Accordion score 1-2). In-hospital 30- and 90-day mortality was zero. EMR specimens were re-reviewed to assess low-risk criteria. Degree of differentiation and the presence of lymphovascular invasion could be assessed in all EMR specimens; however, assessment of submucosal invasion limited to the superficial submucosal layer could not be determined in the majority of cases. Kaplan-Meier 5-year overall survival in pT1bN0 patients was 78.7 %. CONCLUSIONS: Clinical staging of superficial esophageal cancer can be inaccurate especially in submucosal tumors. EMR should be routinely used for preoperative staging. Healthy patients with clinical tumor stage greater than cT1a should undergo multidisciplinary review and be considered for surgical resection.


Assuntos
Adenocarcinoma/patologia , Carcinoma de Células Escamosas/patologia , Ressecção Endoscópica de Mucosa/mortalidade , Neoplasias Esofágicas/patologia , Esofagectomia/mortalidade , Adenocarcinoma/cirurgia , Idoso , Carcinoma de Células Escamosas/cirurgia , Neoplasias Esofágicas/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Taxa de Sobrevida
18.
J Thorac Cardiovasc Surg ; 150(5): 1254-60, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26412319

RESUMO

OBJECTIVES: Postoperative readmission is an increasingly scrutinized quality metric that affects patient satisfaction and cost. Even more important is its implication for short-term prognosis. The purpose of this study is to characterize postesophagectomy readmissions and determine their relationship with subsequent 90-day mortality. METHODS: Data were extracted for esophagectomy patients from the linked SEER-Medicare Registry (2000-2009), which provides longitudinal information about Medicare beneficiaries who have cancer. We assessed demographics, comorbidities, 30-day readmission, and 90-day mortality. Readmitting facility and diagnoses were identified. A hierarchic multivariable regression model clustered at the hospital level assessed the relationship between readmission within 30 days of discharge and 90-day mortality. RESULTS: We identified 1543 patients discharged alive after esophagectomy. Among patients discharged alive, the readmission rate was 319 of 1543 (20.7%); 107 of 319 (33.5%) readmissions were to facilities that did not perform the index operation. Mortality rate at 90 days among patients discharged alive was 98 of 1543 (6.4%). Readmission was associated with a 4-fold increase in mortality (16.3% vs 3.8%, P < .001). Using multivariable regression, readmission was the strongest predictor of mortality (odds ratio 6.64, P < .001), with a stronger association than age, Charlson score, and index length of stay. Readmission diagnoses with the highest mortality rates were those associated with pulmonary, gastrointestinal, and cardiovascular diagnoses. CONCLUSIONS: Patients readmitted within 30 days of discharge after esophagectomy are at exceptionally high risk for early mortality. Early recognition of life-threatening readmission diagnoses is essential to providing optimal care.


Assuntos
Esofagectomia/mortalidade , Medicare , Readmissão do Paciente , Programa de SEER , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Comorbidade , Esofagectomia/efeitos adversos , Feminino , Humanos , Modelos Lineares , Masculino , Análise Multivariada , Razão de Chances , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
19.
J Surg Oncol ; 112(5): 517-23, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26374192

RESUMO

BACKGROUND AND OBJECTIVE: Our objective was to compare clinical outcomes, costs, and resource use based on operative approach, transthoracic (TT) or transhiatal (TH), for resection of esophageal cancer. METHODS: This cohort analysis utilized the Surveillance, Epidemiology, and End Results--Medicare linked data from 2002 to 2009. Only adenocarcinomas of the lower esophagus were examined to minimize confounding. Medicare data was used to determine episode of care costs and resource use. Propensity score matching was used to control for identified confounders. Kaplan-Meier method and Cox-proportional hazard modeling were used to compare long-term survival. RESULTS: 537 TT and 405 TH resections were identified. TT and TH esophagectomy had similar complication rates (46.7% vs. 50.8%), operative mortality (7.9% vs 7.1%), and 90 days readmission rates (30.5% vs. 32.5%). However, TH was associated with shorter length of stay (11.5 vs. 13.0 days, P = 0.006) and nearly $1,000 lower cost of initial hospitalization (P = 0.03). No difference in 5-year survival was identified (33.5% vs. 36%, P = 0.75). CONCLUSIONS: TH esophagectomy was associated with lower costs and shorter length of stay in an elderly Medicare population, with similar clinical outcomes to TT. The TH approach to esophagectomy for distal esophageal adenocarcinoma may, therefore, provide greater value (quality/cost).


Assuntos
Adenocarcinoma/cirurgia , Neoplasias Esofágicas/cirurgia , Esofagectomia/economia , Complicações Pós-Operatórias , Toracotomia/economia , Adenocarcinoma/economia , Adenocarcinoma/mortalidade , Idoso , Neoplasias Esofágicas/economia , Neoplasias Esofágicas/mortalidade , Esofagectomia/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Gradação de Tumores , Estadiamento de Neoplasias , Prognóstico , Estudos Retrospectivos , Programa de SEER , Taxa de Sobrevida , Toracotomia/mortalidade
20.
J Surg Oncol ; 112(1): 51-5, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26186718

RESUMO

INTRODUCTION: Care of the esophagectomy patient requires significant resources. We sought to determine which patient and provider variables contribute to resource utilization and their association with clinical outcomes. METHODS: 6,737 patients undergoing esophagectomy were identified from the University Healthsystem Consortium (UHC). Linear and logistic regression models were used to determine whether characteristics, including age, severity of illness (SOI) and procedural volume were associated with mortality, length of stay (LOS), discharge disposition, readmission rates, and cost. RESULTS: Older patients were twice as likely to suffer post-operative death (OR 2.12; 95%CI 1.7-2.7), three times more likely to be discharged to extended care facilities (31.9% vs. 10.6%, P < 0.001), and cost 8.4% more ($27,628 vs. $25,481, P < 0.001). Similarly, patients with higher SOI were more likely to suffer post- operative death (OR 14.6; 4.7-45.9), be readmitted (OR 1.3; 1.1-1.6), and have longer hospital stays (RR 1.3; 1.8-2.1). Patients with the highest index hospital costs were five times more likely to be discharged to an extended care facility (P < 0.001). CONCLUSION: Older patients and those with a higher SOI have higher perioperative mortality, readmission rates, hospital costs, and require more post- operative care. With increasingly scrutinized health care costs, these data provide guidance for more careful patient selection.


Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia/economia , Esofagectomia/mortalidade , Custos de Cuidados de Saúde , Recursos em Saúde/estatística & dados numéricos , Índice de Gravidade de Doença , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Neoplasias Esofágicas/economia , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Feminino , Seguimentos , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Estadiamento de Neoplasias , Readmissão do Paciente/estatística & dados numéricos , Prognóstico , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo
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