Differences in organization of care are associated with mortality, severe complication and failure to rescue in emergency colon cancer surgery.

BACKGROUND: Emergency colon cancer surgery is associated with increased mortality and complication risk, which can be due to differences in the organization of hospital care. This study aimed. OBJECTIVE: To explore which structural factors in the preoperative, perioperative and postoperative periods influence outcomes after emergency colon cancer surgery. METHODS: An observational study was performed in 30 Dutch hospitals. Medical records from 1738 patients operated in the period 2012 till 2015 were reviewed on the type of referral, intensive care unit (ICU) level, surgeon specialization and experience, duration of surgery and operating room time, blood loss, stay on specialized postoperative ward, complication occurrence, reintervention and day of surgery and linked to case-mix data available in the Dutch Colorectal Audit. Multivariate logistic regression analysis was used to estimate the influence of these factors on 30-day mortality, severe complication and failure to rescue (FTR), after adjustment for case-mix. RESULTS: Patients operated by a non-Gastro intestinal/oncology specialized surgeon have significantly increased mortality (Odds Ratio (OR) 2.28 [95% confidence interval (95% CI) 1.23-4.23]) and severe complication risk (OR 1.61 [95% CI 1.08-2.39]). Also, duration of stay in the operating room was significantly associated with increased risk on severe complication (OR 1.03 [95% CI 1.01-1.06]). Patients admitted to a non-specialized ward have significantly increased mortality (OR 2.25 [95% CI 1.46-3.47]) and FTR risk (OR 2.39 [95% CI 1.52-3.75]). A low ICU level (basic ICU) was associated with a lower severe complication risk (OR 0.72 [95% CI 0.52-1.00]). Surgery on Tuesday was associated with a higher mortality risk (OR 2.82 [95% CI 1.24-6.40]) and a severe complication risk (OR 1.77, [95% CI 1.19-2.65]). CONCLUSION: This study identified a non-specialized surgeon and ward, operating room, time and day of surgery to be risk factors for worse outcomes in emergency colon cancer surgery.

Do Outcomes in Elective Colon and Rectal Cancer Surgery Differ by Weekday? An Observational Study Using Data From the Dutch ColoRectal Audit.

BACKGROUND: Previous studies showing higher mortality after elective surgery performed on a Friday were based on administrative data, known for insufficient case-mix adjustment. The goal of this study was to investigate the risk of adverse events for patients with colon and rectal cancer by day of elective surgery using clinical data from the Dutch ColoRectal Audit. PATIENTS AND METHODS: Prospectively collected data from the 2012-2015 Dutch ColoRectal Audit (n=36,616) were used to examine differences in mortality, severe complications, and failure to rescue by day of elective surgery (Monday through Friday). Monday was used as a reference, analyses were stratified for colon and rectal cancer, and case-mix adjustments were made for previously identified variables. RESULTS: For both colon and rectal cancer, crude mortality, severe complications, and failure-to-rescue rates varied by day of elective surgery. After case-mix adjustment, lower severe complication risk was found for rectal cancer surgery performed on a Friday (odds ratio, 0.84; 95% CI, 0.72-0.97) versus Monday. No significant differences were found for colon cancer surgery performed on different weekdays. CONCLUSIONS: No weekday effect was found for elective colon and rectal cancer surgery in the Netherlands. Lower severe complication risk for elective rectal cancer surgery performed on a Friday may be caused by patient selection.

Evaluation of a Completion Total Mesorectal Excision in Patients After Local Excision of Rectal Cancer: A Word of Caution.

Background: According to Dutch guidelines, locally excised, low-risk, pT1 or ypT0-1 rectal cancer should not necessarily be followed by completion total mesorectal excision (cTME) in contrast to rectal cancers with higher T stages or unfavorable features. This study evaluated cTME after local excision at a national level with possible determinants for decision-making. Methods: All patients in the Dutch Colorectal Audit (DCRA) who underwent local excision of rectal cancer between 2012 and 2015 were included. Guideline adherence for performing cTME was determined with univariate and multivariate analyses to identify factors related to noncompliance. Results: According to the guidelines, of 530 included patients, cTME was indicated in 283 (53%), and among those, was performed in 82 (29%). Guideline adherence for performing cTME improved significantly (P<.001), from 10% in 2012 to 44% in 2015. Lower Charlson comorbidity index in patients with high-risk pT1 rectal cancer and younger patients (aged 61-70 years vs ≥80 years) with pT≥2 rectal cancer were associated with increased performance of cTME (odds ratio [OR], 13.50; 95% CI, 1.39-131.32, and OR, 6.25; 95% CI, 1.83-21.31, respectively). Conclusions: In this population-based study from the Netherlands, only a minority of patients underwent cTME after local excision of rectal cancer with pathologic features indicating the need for further treatment according to the guidelines. Although the percentage of patients undergoing cTME increased over time, the study indicated a tendency toward rectal-preserving treatment with potential oncologic risks.

Weekend Effect in Emergency Colon and Rectal Cancer Surgery: A Prospective Study Using Data From the Dutch ColoRectal Audit.

Background: It is unclear whether emergency weekend colon and rectal cancer surgery are associated with worse outcomes (ie, weekend effect) because previous studies mostly used administrative data, which may insufficiently adjust for case-mix. Materials and Methods: Prospectively collected data from the 2012-2015 Dutch ColoRectal Audit (n=5,224) was used to examine differences in 30-day mortality and severe complication and failure-to-rescue rates for emergency weekend (Saturday and Sunday) versus Monday surgery, stratified for colon and rectal cancer. Analyses were adjusted for age, sex, body mass index, Charlson comorbidity index, American Society of Anesthesiologists classification score, tumor stage, presence of metastasis, preoperative complication, additional resection for metastasis or locally advanced tumor, location primary colon tumor, type of rectal surgery (lower anterior resection or abdominal perineal resection), and type of neoadjuvant therapy (short-course radiotherapy or chemoradiotherapy). Results: A total of 5,052 patients undergoing colon cancer surgery and 172 undergoing rectal cancer surgery were included. Patients undergoing colon or rectal cancer surgery during weekends had significantly more preoperative tumor complications compared with those undergoing surgery on a weekday. Additionally, differences in year of surgery and location of primary tumor were found for colon cancer surgery. Emergency colon cancer surgery during the weekend was associated with increased 30-day mortality (odds ratio [OR], 1.66; 95% CI, 1.10-2.50) and severe complications (OR, 1.29; 95% CI, 1.03-1.63) compared with surgery on Monday. Estimates for emergency weekend rectal cancer surgery were similar but not statistically significant, likely explained by small numbers. Conclusions: Weekend emergency colon cancer surgery was associated with higher mortality and severe complication rates. More research is needed to understand which factors explain and contribute to these differences.

Different Risk Factors for Early and Late Colorectal Anastomotic Leakage in a Nationwide Audit.

BACKGROUND: Anastomotic leakage remains a major complication after surgery for colorectal carcinoma, but its origin is still unknown. Our hypothesis was that early anastomotic leakage is mostly related to technical failure of the anastomosis, and that late anastomotic leakage is mostly related to healing deficiencies. OBJECTIVE: The aim of this study was to assess differences in risk factors for early and late anastomotic leakage. DESIGN: This was a retrospective cohort study. SETTINGS: The Dutch ColoRectal Audit is a nationwide project that collects information on all Dutch patients undergoing surgery for colorectal cancer. PATIENTS: All patients undergoing surgical resection for colorectal cancer in the Netherlands between 2011 and 2015 were included. MAIN OUTCOME MEASURES: Late anastomotic leakage was defined as anastomotic leakage leading to reintervention later than 6 days postoperatively. RESULTS: In total, 36,929 patients were included; early anastomotic leakage occurred in 863 (2.3%) patients, and late anastomotic leakage occurred in 674 (1.8%) patients. From a multivariable multinomial logistic regression model, independent predictors of early anastomotic leakage relative to no anastomotic leakage and late anastomotic leakage relative to no anastomotic leakage included male sex (OR, 1.8; p < 0.001 and OR, 1.2; p = 0.013) and rectal cancer (OR, 2.1; p < 0.001 and OR, 1.6; p = 0.046). Additional independent predictors of early anastomotic leakage relative to no anastomotic leakage included BMI (OR, 1.1; p = 0.001), laparoscopy (OR, 1.2; p = 0.019), emergency surgery (OR, 1.8; p < 0.001), and no diverting ileostomy (OR, 0.3; p < 0.001). Independent predictors of late anastomotic leakage relative to no anastomotic leakage were Charlson Comorbidity Index of ≥II (OR, 1.3; p = 0.003), ASA score III to V (OR, 1.2; p = 0.030), preoperative tumor complications (OR, 1.1; p = 0.048), extensive additional resection because of tumor growth (OR, 1.7; p = 0.003), and preoperative radiation (OR, 2.0; p = 0.010). LIMITATIONS: This was an observational cohort study. CONCLUSIONS: Most risk factors for early anastomotic leakage were surgery-related factors, representing surgical difficulty, which might lead to technical failure of the anastomosis. Most risk factors for late anastomotic leakage were patient-related factors, representing the frailty of patients and tissues, which might imply healing deficiencies. See Video Abstract at http://links.lww.com/DCR/A730.

Laparoscopic conversion in colorectal cancer surgery; is there any improvement over time at a population level?

Conversion of laparoscopic colorectal cancer resection has been associated with worse outcome, but this might have been related to a learning curve effect. This study aimed to evaluate incidence, predictive factors and outcomes of laparoscopic conversion after the implementation phase of laparoscopic surgery at a population level. Patients undergoing elective resection of non-locally advanced, non-metastatic colorectal cancer between 2011 and 2015 were included. Data were extracted from the Dutch Surgical Colorectal Audit. Patients were grouped as laparoscopic completed (LR), laparoscopic converted (CONV) with further specification of timing (within or after 30 min) as registered in the DSCA, and open resection (OR). Uni- and multi-variate analyses were used to determine predictors of conversion and outcome (complicated course and mortality), with evaluation of trends over time. A total of 23,044 patients with colon cancer and 11,324 with rectal cancer were included. Between 2011 and 2015, use of laparoscopy increased from 55 to 84% in colon cancer, and from 49 to 89% in rectal cancer. Conversion rates decreased from 11.8 to 8.6% and from 13 to 8.0%, respectively. Laparoscopic hospital volume was independently associated with conversion rate. Only for colon cancer, the rate of complicated course was significantly higher after CONV compared to OR (adjusted odds ratio 1.486; 95% CI 1.298-1.702), and significantly higher after late (> 30 min) compared to early conversion (adjusted odds ratio 1.341; 1.046-1.719). There was no impact of CONV on mortality in both colon and rectal cancer. The use of laparoscopic colorectal cancer surgery increased to more than 80% at a national level, accompanied by a decrease in conversion which is significantly related to the laparoscopic hospital volume. Conversion was only associated with complicated course in colon cancer, especially when the reason for conversion consisted of an intra-operative complication, without affecting mortality.

Hospital Teaching Status and Patients' Outcomes After Colon Cancer Surgery.

BACKGROUND AND OBJECTIVES: It is increasingly accepted that quality of colon cancer surgery might be secured by combining volume standards with audit implementation. However, debate remains about other structural factors also influencing this quality, such as hospital teaching status. This study evaluates short-term outcomes after colon cancer surgery of patients treated in general, teaching or academic hospitals. METHODS: All patients (n = 23,593) registered in the Dutch Colorectal Audit undergoing colon cancer surgery between 2011 and 2014 were included. Patients were divided into groups based on teaching status of their hospital. Main outcome measures were serious complications, failure to rescue (FTR) and 30-day or in-hospital mortality. Multivariate logistic regression models on these outcome measures and with hospital teaching status as primary determinant were used, adjusted for case-mix, year of surgery and hospital volume. RESULTS: Patients treated in teaching and academic hospitals showed higher adjusted serious complication rates, compared to patients treated in general hospitals (odds ratio 1.25 95% CI [1.11-1.39] and OR 1.23 [1.05-1.46]). However, patients treated in teaching hospitals had lower adjusted FTR rates than patients treated in general hospitals (OR 0.63 [0.44-0.89]). However, for all outcomes there was considerable between-hospitals variation within each type of teaching status. CONCLUSION: On average, patients treated in general hospitals had lower serious complication rates, but patients treated in teaching hospitals had more favorable FTR rates. Given the hospital variation within each hospital teaching type, it is possible to deliver excellent care regardless of the hospital teaching type.

Level of Digitization in Dutch Hospitals and the Lengths of Stay of Patients with Colorectal Cancer.

A substantial amount of research has been published on the association between the use of electronic medical records (EMRs) and quality outcomes in U.S. hospitals, while limited research has focused on the Western European experience. The purpose of this study is to explore the association between the use of EMR technologies in Dutch hospitals and length of stay after colorectal cancer surgery. Two data sets were leveraged for this study; the HIMSS Analytics Electronic Medical Record Adoption Model (EMRAMSM) and the Dutch surgical colorectal audit (DSCA). The HIMSS Analytics EMRAM score was used to define a Dutch hospital's electronic medical records (EMR) capabilities while the DSCA was used to profile colorectal surgery quality outcomes (specifically total length of stay (LOS) in the hospital and the LOS in ICU). A total of 73 hospitals with a valid EMRAM score and associated DSCA patients (n = 30.358) during the study period (2012-2014) were included in the comparative set. A multivariate regression method was used to test differences adjusted for case mix, year of surgery, surgical technique and for complications, as well as stratifying for academic affiliated hospitals and general hospitals. A significant negative association was observed to exist between the total LOS (relative median LOS 0,974, CI 95% 0.959-0,989) of patients treated in advanced EMR hospitals (high EMRAM score cohort) versus patients treated at less advanced EMR care settings, once the data was adjusted for the case mix, year of surgery and type of surgery (laparoscopy or laparotomy). Adjusting for complications in a subgroup of general hospitals (n = 39) yielded essentially the same results (relative median LOS 0,934, CI 95% 0,915-0,954). No consistent significant associations were found with respect to LOS on the ICU. The findings of this study suggest advanced EMR capabilities support a healthcare provider's efforts to achieve desired quality outcomes and efficiency in Western European hospitals.

Identifying best performing hospitals in colorectal cancer care; is it possible?

BACKGROUND: Comparing outcomes across hospitals to learn from best performing hospitals can be valuable. However, reliably identifying best performance is challenging. This study assesses the possibility to distinguish best performing hospitals on single outcomes and consistency of performance on different outcomes. METHODS: Data were derived from the Dutch ColoRectal Audit 2013-2015. Outcomes considered were textbook outcome (colon), (circumferential) resection margins, (serious) complications, mortality, and 'failure to rescue'. To include uncertainty in rankings, random effect logistic regression models were used to calculate expected ranks (ERs), for each hospital and outcome. Rankability was calculated for each outcome, as a measure of reliability of ranking. Furthermore, correlation between ERs on different outcomes was assessed. Correlation was considered weak <0.40, moderate between 0.40 - 0.59 and strong >0.60. RESULTS: The study included 32 143 patients; of whom 11 373 were treated in 2015 across 84 hospitals, 8181 colon and 3192 rectal cancer patients. In this one-year period 'Postoperative complications' had the highest rankability for colon (57%) and rectal (41%) surgery. No (group of) hospital(s) had the highest ER(s) on all outcomes. Correlation between ERs of outcomes was moderate in 2 (of 25) and strong in 4 (of 25) combinations. Rankability of colorectal mortality increased from 14% in 2015 to 35% when data over 2013-2015 were used. CONCLUSION: The highest reliability of identifying best performance based on an outcome was 57%. However, the balance between reliability and relevance of outcomes is vulnerable. No (group of) hospital(s) could be identified as best performer on all outcomes. Performance was not consistent on outcomes.