Currently, there are no comprehensive breast sarcoma guidelines in the UK. There is therefore a need for guidelines to clarify surgical management, which we have based on data from our regional audit, current evidence, and consensus between West of Scotland Breast Cancer and Scottish Sarcoma Managed Clinical Networks. Methods and results: From 2007 to 2019, 46 patients were treated with breast sarcoma in the West of Scotland. Sarcoma Centre versus Peripheral Hospitals: Incomplete excision rate was 0% at sarcoma centre and 50% at peripheral hospitals (p = 0.0002, Odds Ratio 43). For angiosarcoma, 0% positive margin at the sarcoma centre versus 62.5% at the peripheral unit (p = 0.0036, odds ratio 39.3). Tumours treated at the sarcoma centre were larger than those treated at peripheral hospitals (92.5 versus 39.7 mm, p = 0.0009). WLE (wide local excision) versus mastectomy: Out of eight WLE patients, seven (87.5%) had positive margins, with 6 of these patients proceeding to mastectomy (i.e. 75% WLE patients ultimately had a mastectomy). The positive margin rate was significantly higher in WLE (87.5%) than in mastectomy (10.3%) (p = 0.0001, odds ratio 60.7). Survival: No difference was noted between the sarcoma centre and peripheral hospitals for overall survival (p = 0.43), stratified for tumours <5 cm (p = 0.16), and disease-free survival (p = 0.45). Conclusions: Our data strongly suggest that specific guidelines are needed for breast sarcoma, and that managing these patients according to breast carcinoma protocols in peripheral hospitals is sub-optimal. We recommend centralisation of breast sarcoma patient care to a specialist sarcoma centre, with WLE not recommended as a firstline surgical option given both the high rates of incomplete excision and subsequent need for completion mastectomy.

We sought to evaluate whether provider volume or other factors are associated with chemotherapy guideline compliance in elderly patients with epithelial ovarian cancer (EOC).
We queried the SEER-Medicare database for patients ≥66 years, diagnosed with FIGO stage II-IV EOC from 2004 to 2013 who underwent surgery and received chemotherapy within 7 months of diagnosis. We compared NCCN guideline compliance (6 cycles of platinum-based doublet) and chemotherapy-related toxicities across provider volume tertiles. Factors associated with guideline compliance and chemotherapy-related toxicities were assessed using logistic regression. Overall survival (OS) was compared across volume tertiles and Cox proportional-hazards model was created to adjust for case-mix.
1924 patients met inclusion criteria. The overall rate of guideline compliance was 70.3% with a significant association between provider volume and compliance (64.5% for low-volume, 72.2% for medium-volume, 71.7% for high-volume, p = .02). In the multivariate model, treatment by low-volume providers and patient age ≥ 80 years were independently associated with worse chemotherapy-guideline compliance. In the survival analysis, there was a significant difference in median OS across provider volume tertiles with median survival of 32.8 months (95%CI 29.6, 36.4) low-volume, 41.9 months (95%CI 37.5, 46.7) medium-volume, 42.1 months (95%CI 38.8, 44.2) high-volume providers, respectively (p < .01). After adjusting for case-mix, low-volume providers were independently associated with higher rates of mortality (aHR 1.25, 95%CI: 1.08, 1.43).
In a modern cohort of elderly Medicare patients with advanced EOC, we found higher rates of non-compliant care and worse survival associated with treatment by low-volume Medicare providers. Urgent efforts are needed to address this volume-outcomes disparity.

To assess European Association of Urology guideline adherence on the surgical management of patients with T1 renal tumours and the effects of centralisation of care.
Retrospective data from all kidney tumours that underwent radical nephrectomy (RN) or partial nephrectomy (PN) in the period 2012-2016 from the British Association of Urological Surgeons Nephrectomy Audit were retrieved and analysed. We assessed total surgical hospital volume (HV; RN and PN performed) per centre, PN rates, complication rates, and completeness of data. Descriptive analyses were performed, and confidence intervals were used to illustrate the association between hospital volume and proportion of PN. Chi- squared and Cochran-Armitage trend tests were used to evaluate differences and trends.
In total, 13 045 surgically treated T1 tumours were included in the analyses. Over time, there was an increase in PN use (39.7% in 2012 to 44.9% in 2016). Registration of the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) complexity score was included in March 2016 and documented in 39% of cases. Missing information on postoperative complications appeared constant over the years (8.5-9%).  A clear association was found between annual HV and the proportion of T1 tumours treated with PN rather than RN (from 18.1% in centres performing <25 cases/year [lowest volume] to 61.8% in centres performing ≥100 cases/year [high volume]), which persisted after adjustment for PADUA complexity. Overall and major (Clavien-Dindo grade ≥III) complication rate decreased with increasing HV (from 12.2% and 2.9% in low-volume centres to 10.7% and 2.2% in high-volume centres, respectively), for all patients including those treated with PN.
Closer guideline adherence was exhibited by higher surgical volume centres. Treatment of T1 tumours using PN increased with increasing HV, and was accompanied by an inverse association of HV with complication rate. These results support the centralisation of kidney cancer specialist cancer surgical services to improve patient outcomes.

To examine associations between survival and adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines using an observed-to-expected (O/E) ratio for greater adherence as a risk-adjusted hospital measure of quality care in elderly patients treated for larynx cancer.
Retrospective analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data.
Patients diagnosed with larynx cancer from 2004 to 2007 were evaluated using multivariate regression and survival analysis. A fit logistic regression model was used to calculate an O/E ratio for guideline adherence for each hospital using quality indicators derived from NCCN guidelines for recommended treatment and stratified by hospital volume.
Of 1,721 patients treated at 395 hospitals, 43.0% of patients received NCCN guideline-adherent care. Low-volume hospitals (N = 295) treating six or fewer cases treated 765 patients (44.5%), with a mean O/E of 0.96 ± 0.45. Hospitals treating more then six cases with an O/E <1 (N = 32) treated 284 patients (16.5%), with a mean O/E of 0.77 ± 0.18. Hospitals treating more than six cases with an O/E ≥1 (N = 68) treated 672 patients (39.1%), with a mean O/E of 1.17 ± 0.11. Treatment at hospitals with an O/E ≥1 was associated with improved survival (hazard ratio [HR] = 0.83 [95% confidence interval [CI]: 0.70 to 0.98]) and lower mean incremental treatment-related costs (-$3,009 [-$5,226 to -$791]) compared with hospitals with an O/E <1 (HR = 1.00 [0.80 to 1.24]) and the reference group of low-volume hospitals.
A hospital-specific O/E for NCCN treatment guideline adherence, combined with a minimum case volume criterion, is associated with survival and treatment-related costs in elderly patients with larynx cancer, and may be a feasible measure of larynx cancer quality of care.
NA Laryngoscope, 130:672-678, 2020.

A retrospective study was performed to characterize trends in centralization of care and compliance with National Comprehensive Cancer Network (NCCN) guidelines for resected cholangiocarcinoma (CCA), and their impact on overall survival (OS).
Using the National Cancer Database (NCDB) 2004-2015 we identified patients undergoing resection for CCA. Receiver Operating Characteristic (ROC) analyses identified time periods and hospital volume groups for comparison. Propensity score matching provided case-mix adjusted patient cohorts. Cox hazard analysis identified risk factors for OS.
Among the 40,338 patients undergoing resection for CCA, the proportion of patients undergoing surgery at high volume hospitals increased over time (25%-44%, p < 0.001), while the proportion of patients undergoing surgery at low volume hospitals decreased (30%-15%, p < 0.001). Using ROC analyses, a hospital volume of 14 operations/year was the most sensitive and specific value associated with mortality. Surgery at high volume hospitals [HR] = 0.92, 95% CI: 0.88-0.97, p < 0.001) and receipt of care compliant with NCCN guidelines (HR = 0.87, 95% CI: 0.83-0.91, p < 0.001) were independently associated with improved OS.
Both centralization of surgery for CCA to high volume hospitals and increased compliance with NCCN guidelines were associated with significant improvements in overall survival.

OBJECTIVE: To examine the rates of adherence to guidelines for pelvic lymph node dissection (PLND) in patients treated with radical cystectomy (RC) and to identify predictors of omitting PLND.
METHODS: We relied on 66,208 patients treated with RC between 2004 and 2013 within the National Inpatients Sample (NIS) database. We examined the rates of PLND according to year of surgery, patient and hospital characteristics. Univariate and multivariate logistic regression analyses assessed the probability of PLND use, after adjusting for year of surgery, age, gender, race, comorbidities, hospital location, teaching status and hospital surgical volume.
RESULTS: Overall, PLND was performed on 54,223 (81.9%) RC patients. The rates PLND at RC significantly increased over the study period from 72.3% in 2004 to 85.9% in 2013, (p < 0.001). Barriers to PLND at RC consisted of female gender (OR: 1.31; 95% CI 1.25-1.38; p < 0.001), African American race (OR: 1.21; 95% CI 1.10-1.32; p < 0.001), intermediate (OR: 1.78; 95% CI 1.68-1.88; p < 0.001) or low surgical volume institutions (OR: 2.59; 95% CI 2.44-2.74; p < 0.001), non-teaching institution status (OR: 1.21; 95% CI 1.15-1.27; p < 0.001) and rural hospital location (OR: 1.13; 95% CI 1.01-1.25; p = 0.03).
CONCLUSIONS: It is encouraging to note increasing rates of PLND at RC over time. Both patients and hospital characteristics influence PLND rates. More efforts should be aimed at reducing inequalities in PLND at RC due to these highly modifiable variables.

Hospital volume is frequently used as a structural metric for assessing quality of care, but its utility in patients admitted with acute heart failure (HF) is not well characterized. Accordingly, we sought to determine the relationship between admission volume, process-of-care metrics, and short- and long-term outcomes in patients admitted with acute HF.
Patients enrolled in the Get With The Guidelines-HF registry with linked Medicare inpatient data at 342 hospitals were assessed. Volume was assessed both as a continuous variable, and quartiles based on the admitting hospital annual HF case volume, as well: 5 to 38 (quartile 1), 39 to 77 (quartile 2), 78 to 122 (quartile 3), 123 to 457 (quartile 4). The main outcome measures were (1) process measures at discharge (achievement of HF achievement, quality, reporting, and composite metrics); (2) 30-day mortality and hospital readmission; and (3) 6-month mortality and hospital readmission. Adjusted logistic and Cox proportional hazards models were used to study these associations with hospital volume.
A total of 125 595 patients with HF were included. Patients admitted to high-volume hospitals had a higher burden of comorbidities. On multivariable modeling, lower-volume hospitals were significantly less likely to be adherent to HF process measures than higher-volume hospitals. Higher hospital volume was not associated with a difference in in-hospital (odds ratio, 0.99; 95% confidence interval [CI], 0.94-1.05; P=0.78) or 30-day mortality (hazard ratio, 0.99; 95% CI, 0.97-1.01; P=0.26), or 30-day readmissions (hazard ratio, 0.99; 95% CI, 0.97-1.00; P=0.10). There was a weak association of higher volumes with lower 6-month mortality (hazard ratio, 0.98; 95% CI, 0.97-0.99; P=0.001) and lower 6-month all-cause readmissions (hazard ratio, 0.98; 95%, CI 0.97-1.00; P=0.025).
Our analysis of a large contemporary prospective national quality improvement registry of older patients with HF indicates that hospital volume as a structural metric correlates with process measures, but not with 30-day outcomes, and only marginally with outcomes up to 6 months of follow-up. Hospital profiling should focus on participation in systems of care, adherence to process metrics, and risk-standardized outcomes rather than on hospital volume itself.

OBJECTIVE: To develop an observed-to-expected ratio (O/E) for adherence to National Comprehensive Cancer Network (NCCN) ovarian cancer treatment guidelines as a risk-adjusted hospital measure of quality care correlated with disease-specific survival.
METHODS: Consecutive patients with stages I-IV epithelial ovarian cancer were identified from the California Cancer Registry (1/1/96-12/31/06). Using a fit logistic regression model, O/E for guideline adherence was calculated for each hospital and distributed into quartiles stratified by hospital annual case volume: lowest O/E quartile or annual hospital case volume <5, middle two O/E quartiles and volume ≥5, and highest O/E quartile and volume ≥5. A multivariable logistic regression model was used to characterize the independent effect of hospital O/E on ovarian cancer-specific survival.
RESULTS: Overall, 18,491 patients were treated at 405 hospitals; 37.3% received guideline adherent care. Lowest O/E hospitals (n=285) treated 4661 patients (25.2%), mean O/E=0.77±0.55 and median survival 38.9months (95%CI=36.2-42.0months). Intermediate O/E hospitals (n=85) treated 8715 patients (47.1%), mean O/E=0.87±0.17 and median survival of 50.5months (95% CI=48.4-52.8months). Highest O/E hospitals (n=35) treated 5115 patients (27.7%), mean O/E=1.34±0.14 and median survival of 53.8months (95% CI=50.2-58.2months). After controlling for other variables, treatment at highest O/E hospitals was associated with independent and statistically significant improvement in ovarian cancer-specific survival compared to intermediate O/E (HR=1.06, 95% CI=1.01-1.11) and lowest O/E (1.16, 95% CI=1.10-1.23) hospitals.
CONCLUSIONS: Calculation of hospital-specific O/E for NCCN treatment guideline adherence, combined with minimum case volume criterion, as a measure of ovarian cancer quality of care is feasible and is an independent predictor of survival.

BACKGROUND: Multidisciplinary team (MDT) conferences have been introduced into standard cancer care, though evidence that it benefits the patient is weak. We used the national Swedish Rectal Cancer Register to evaluate predictors for case discussion at a MDT conference and its impact on treatment.
METHODS: Of the 6760 patients diagnosed with rectal cancer in Sweden between 2007 and 2010, 78% were evaluated at a MDT. Factors that influenced whether a patient was discussed at a preoperative MDT conference were evaluated in 4883 patients, and the impact of MDT evaluation on the implementation of preoperative radiotherapy was evaluated in 1043 patients with pT3c-pT4 M0 tumours, and in 1991 patients with pN+ M0 tumours.
RESULTS: Hospital volume, i.e. the number of rectal cancer surgical procedures performed per year, was the major predictor for MDT evaluation. Patients treated at hospitals with < 29 procedures per year had an odds ratio (OR) for MDT evaluation of 0.15. Age and tumour stage also influenced the chance of MDT evaluation. MDT evaluation significantly predicted the likelihood of being treated with preoperative radiotherapy in patients with pT3c-pT4 M0 tumours (OR 5.06, 95% CI 3.08-8.34), and pN+ M0 (OR 3.55, 95% CI 2.60-4.85), even when corrected for co-morbidity and age.
CONCLUSIONS: Patients with rectal cancer treated at high-volume hospitals are more likely to be discussed at a MDT conference, and that is an independent predictor of the use of adjuvant radiotherapy. These results indirectly support the introduction into clinical practice of discussing all rectal cancer patients at MDT conferences, not least those being treated at low-volume hospitals.

OBJECTIVE: After endovascular aortic aneurysm repair (EVAR), the Society for Vascular Surgery recommends a computed tomography (CT) scan ≤30 days, followed by annual imaging. We sought to describe long-term adherence to surveillance guidelines among United States Medicare beneficiaries and determine patient and hospital factors associated with incomplete surveillance.
METHODS: We analyzed fee-for-service Medicare claims for patients receiving EVAR from 2002 to 2005 and collected all relevant postoperative imaging through 2011. Additional data included patient comorbidities and demographics, yearly hospital volume of abdominal aortic aneurysm repair, and Medicaid eligibility. Allowing a grace period of 3 months, complete surveillance was defined as at least one CT or ultrasound assessment every 15 months after EVAR. Incomplete surveillance was categorized as gaps for intervals >15 months between consecutive images as or lost to follow-up if >15 months elapsed after the last imaging.
RESULTS: Our cohort comprised 9695 patients. Median follow-up duration was 6.1 years. A CT scan ≤30 days of EVAR was performed in 3085 (31.8%) patients and ≤60 days in 60.8%. The median time to the postoperative CT was 38 days (interquartile range, 25-98 days). Complete surveillance was observed in 4169 patients (43.0%). For this group, the mean follow-up time was shorter than for those with incomplete surveillance (3.4 ± 2.74 vs 6.5 ± 2.1 years; P < .001). Among those with incomplete surveillance, follow-up became incomplete at 3.3 ± 1.9 years, with 57.6% lost to follow-up, 64.1% with gaps in follow-up (mean gap length, 760 ± 325 days), and 37.6% with both. A multivariable analysis showed incomplete surveillance was independently associated with Medicaid eligibility (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.29-1.55; P < .001), low-volume hospitals (HR, 1.12; 95% CI, 1.05-1.20; P < .001), and ruptured abdominal aortic aneurysm (HR, 1.51; 95% CI, 1.24-1.84; P < .001).
CONCLUSIONS: Postoperative imaging after EVAR is highly variable, and less than half of patients meet current surveillance guidelines. Additional studies are necessary to determine if variability in postoperative surveillance affects long-term outcomes.