Abstract：
Current literature has identified textbook outcome (TO) as a quality metric after cancer surgery. We studied whether TO after pancreatic resection has a stronger association with long-term survival than individual hospital case volume.
Patients undergoing surgery for pancreatic adenocarcinoma from 2010 to 2015 were identified from the National Cancer Database. Hospitals were stratified by volume (low less than 6, medium 6 to 19, and high 20 cases or more per year), and overall survival data were abstracted. We defined TO as adequate lymph node count, negative margins, length of stay less than the 75th percentile, appropriate systemic therapy, timely systemic therapy, and without a mortality event or readmission within 30 days. The association of TO and case volume was assessed using a multivariable Cox regression model for survival.
Overall, 7270 patients underwent surgery, with 30.7%, 48.7%, and 20.6% performed at low-, medium-, and high-volume hospitals, respectively. Patients treated at low-volume hospitals were more likely to be Black, be uninsured or on Medicaid, have higher Charlson comorbidity scores, and be less likely to achieve TO (23.4% TO achievement vs 37.5% achievement at high-volume hospitals). However, high hospital volume was no longer associated with overall survival once TO was added to the multivariable model stratified by volume status. Achievement of TO corresponded to a 31% decrease in mortality (hazard ratio 0.69; p < 0.001), independent of hospital volume.
Improved long-term survival after pancreatic resection was associated with TO rather than high hospital volume. Quality improvement efforts focused on TO criteria have the potential to improve outcomes irrespective of case volume.
Patients undergoing surgery for pancreatic adenocarcinoma from 2010 to 2015 were identified from the National Cancer Database. Hospitals were stratified by volume (low less than 6, medium 6 to 19, and high 20 cases or more per year), and overall survival data were abstracted. We defined TO as adequate lymph node count, negative margins, length of stay less than the 75th percentile, appropriate systemic therapy, timely systemic therapy, and without a mortality event or readmission within 30 days. The association of TO and case volume was assessed using a multivariable Cox regression model for survival.
Overall, 7270 patients underwent surgery, with 30.7%, 48.7%, and 20.6% performed at low-, medium-, and high-volume hospitals, respectively. Patients treated at low-volume hospitals were more likely to be Black, be uninsured or on Medicaid, have higher Charlson comorbidity scores, and be less likely to achieve TO (23.4% TO achievement vs 37.5% achievement at high-volume hospitals). However, high hospital volume was no longer associated with overall survival once TO was added to the multivariable model stratified by volume status. Achievement of TO corresponded to a 31% decrease in mortality (hazard ratio 0.69; p < 0.001), independent of hospital volume.
Improved long-term survival after pancreatic resection was associated with TO rather than high hospital volume. Quality improvement efforts focused on TO criteria have the potential to improve outcomes irrespective of case volume.
摘要：
目前的文献已将教科书结果（TO）确定为癌症手术后的质量指标。我们研究了胰腺切除术后的TO与长期生存率是否比单个医院病例量具有更强的相关性。
从国家癌症数据库中确定了2010年至2015年接受胰腺腺癌手术的患者。医院按数量进行了分层（每年低6例，中6至19例，高20例或更多），并提取总生存数据.我们将TO定义为足够的淋巴结计数，负边距，住院时间少于第75百分位数，适当的全身治疗，及时的全身治疗,并且在30天内没有死亡事件或再入院。使用多变量生存Cox回归模型评估TO和病例体积的关联。
总的来说，7270名患者接受了手术，30.7%，48.7%,20.6%的表现在低位，medium-,和大量的医院，分别。在低容量医院接受治疗的患者更有可能是黑人，没有保险或医疗补助，Charlson合并症得分较高,并且不太可能实现TO（在高容量医院中实现23.4％的TO与37.5％的成就）。然而,一旦将TO加入到按容量状态分层的多变量模型中,高住院容量不再与总生存期相关.实现TO对应于死亡率下降31%（危险比0.69；p<0.001），独立于医院容量。
胰腺切除术后长期生存率的提高与TO相关，而不是高住院量。无论案例数量如何，以TO标准为重点的质量改进工作都有可能改善结果。
从国家癌症数据库中确定了2010年至2015年接受胰腺腺癌手术的患者。医院按数量进行了分层（每年低6例，中6至19例，高20例或更多），并提取总生存数据.我们将TO定义为足够的淋巴结计数，负边距，住院时间少于第75百分位数，适当的全身治疗，及时的全身治疗,并且在30天内没有死亡事件或再入院。使用多变量生存Cox回归模型评估TO和病例体积的关联。
总的来说，7270名患者接受了手术，30.7%，48.7%,20.6%的表现在低位，medium-,和大量的医院，分别。在低容量医院接受治疗的患者更有可能是黑人，没有保险或医疗补助，Charlson合并症得分较高,并且不太可能实现TO（在高容量医院中实现23.4％的TO与37.5％的成就）。然而,一旦将TO加入到按容量状态分层的多变量模型中,高住院容量不再与总生存期相关.实现TO对应于死亡率下降31%（危险比0.69；p<0.001），独立于医院容量。
胰腺切除术后长期生存率的提高与TO相关，而不是高住院量。无论案例数量如何，以TO标准为重点的质量改进工作都有可能改善结果。
