Abstract Background Quality assurance is acknowledged as a crucial factor in the assessment of oncological surgical care. The aim of this study was to develop a composite measure of multiple outcome parameters defined as ‘textbook outcome’, to assess quality of care for patients undergoing oesophagogastric cancer surgery. Methods Patients with oesophagogastric cancer, operated on with the intent of curative resection between 2011 and 2014, were identified from a national database (Dutch Upper Gastrointestinal Cancer Audit). Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. Hospital variation in textbook outcome was analysed after adjustment for case-mix factors. Results In total, 2748 patients with oesophageal cancer and 1772 with gastric cancer were included in this study. A textbook outcome was achieved in 29·7 per cent of patients with oesophageal cancer and 32·1 per cent of those with gastric cancer. Adjusted textbook outcome rates varied from 8·5 to 52·4 per cent between hospitals. The outcome parameter ‘at least 15 lymph nodes examined’ had the greatest negative impact on a textbook outcome both for patients with oesophageal cancer and for those with gastric cancer. Conclusion Most patients did not achieve a textbook outcome and there was wide variation between hospitals.
In 2011, the Dutch Upper Gastrointestinal Cancer Audit (DUCA) group began nationwide registration of all patients undergoing surgery with the intention of resection for oesophageal or gastric cancer. The aim of this study was to describe the initiation and implementation of this process along with an overview of the results.The DUCA is part of the Dutch Institute for Clinical Auditing. The audit provides (surgical) teams with reliable, weekly updated, benchmarked information on process and (case mix-adjusted) outcome measures. To accomplish this, a web-based registration was designed, based on a set of predefined quality measures.Between 2011 and 2014, a total of 2786 patients with oesophageal cancer and 1887 with gastric cancer were registered. Case ascertainment approached 100 per cent for patients registered in 2013. The percentage of patients with oesophageal cancer starting treatment within 5 weeks of diagnosis increased significantly over time from 32·5 per cent in 2011 to 41·0 per cent in 2014 (P < 0·001). The percentage of patients with a minimum of 15 examined lymph nodes in the resected specimen also increased significantly for both oesophageal cancer (from 50·3 per cent in 2011 to 73·0 per cent in 2014; P < 0·001) and gastric cancer (from 47·5 per cent in 2011 to 73·6 per cent in 2014; P < 0·001). Postoperative mortality remained stable (around 4·0 per cent) for patients with oesophageal cancer, and decreased for patients with gastric cancer (from 8·0 per cent in 2011 to 4·0 per cent in 2014; P = 0·031).Nationwide implementation of the DUCA has been successful. The results indicate a positive trend for various process and outcome measures.
309 Background: In 2011, the Dutch Upper GI Cancer Audit (DUCA) group started with a nationwide registration of all patients who underwent surgery for esophageal or gastric cancer. The aim of this study was to describe the initiation and implementation of the DUCA and to provide an overview of the results. Methods: The DUCA is part of the Dutch Institute for Clinical Auditing. It provides (surgical) teams with reliable, weekly updated, benchmarked information on process and (casemix-adjusted) outcome measures. A web-based registration was designed, based on a set of predefined quality measures. Results: Between 2011 and 2014, a total of 4672 patients with esophageal or gastric cancer was registered in the DUCA. Case ascertainment has approached 100% for patients registered in 2014. The percentage of patients with esophageal cancer starting treatment within 5 weeks after diagnosis significantly increased over time (33 to 41%) and the percentage of patients with a minimum of 15 lymph nodes in the resected specimen significantly increased for both esophageal cancer (50 to 73%) and gastric cancer (48 to 74%). Postoperative mortality decreased for patients with gastric cancer (8.0% in 2011 to 4.0% in 2014; p = 0.020) and remained stable (around 4%) for patients with esophageal cancer. Conclusions: Nationwide implementation of the DUCA has been successful. Results give a valuable insight in the quality of the surgical care for patients with esophageal or gastric cancer and show a positive trend for various process and outcome measures.
Abstract Background To standardize outcome reporting in esophageal surgery, the Esophageal Complications Consensus Group (ECCG) developed a standardized platform. Recently, this group published outcomes of 2704 patients that underwent an esophagectomyin 24 high-volume hospitals in the period 2015–2016. The aim of this study was to report postoperative morbidity and mortality in the Netherlands using the definitions of the ECCG. Methods All patients who underwent esophagectomy for cancer of the esophagus or esophagogastric junction in the Netherlands in 2016 were selected from the Dutch Upper gastrointestinal Cancer Audit (DUCA). Patient outcomes including postoperative complications, 30-day/in-hospital mortality readmission rate were reported according to the definitions of the ECCG platform (Low et al. Ann Surg 2017). Outcomes of the DUCA were compared with the recently published outcomes of the ECCG with Chi-square analysis. Results Some 797 patients were included from 22 hospitals. In 1 patient, the postoperative outcome was unkown. In 17 patients readmission status was unknown. Some 168 (21%) patients had an ASA score of ≥ III and 250 (31%) patients a Charlson comorbidity score of ≥ 2. In total, 498 patients (63%) had at least one postoperative complication (versus ECCG: 57%, P = 0.07). The most common complications were pneumonia (21% DUCA versus 15% ECCG, P < 0.01), anastomotic/staple-line failure or localized conduit necrosis (18% DUCA versus 11% ECCG, P < 0.01) and atrial dysrhythmia requiring treatment (13% DUCA versus 15% ECCG, P = 0.28). Readmissions occurred in 105 of 780 patients (13% DUCA versus 11% ECCG, P = 0.13). The 30-day/in-hospital mortality was 2.5% for the DUCA group and 2.4% for the ECCG group (P = 0.88). Conclusion The registration of complications according to the ECCG platform in the national audit promotes the use of uniform definitions and allows international comparison of outcomes. The overall complication rate, readmission rate and mortality in the Netherlands were comparable with the outcomes of the ECGG. However, anastomotic leakage and pneumonia were more frequently reported in the Netherlands. Disclosure All authors have declared no conflicts of interest.
305 Background: There is a known volume-outcome association for complex surgial procedures such as oncologic gastric resections. The aim of this study was to describe the process of centralization for gastric cancer surgery in the Netherlands in relation to other types of upper gastrointestinal (GI) cancer resections and to investigate whether the quality of gastric cancer surgery is affected by the overall experience with those related complex surgical procedures. Methods: Data on all patients (n = 4251) who underwent surgical treatment for non metastatic invasive gastric cancer between 2005-2013 were obtained from the Netherlands Cancer Registry. Annual hospital volume categories were based on the overall volume of gastrectomies, esophagectomies and pancreatectomies together (composite hospital volume). Volume-outcome analyses were performed for lymph node yield, 30-day mortality, and overall survival. Results: The percentage of gastric cancer patients who underwent a resection in a hospital with a volume of at least 20 gastrectomies per year increased. At the same time, the percentage of gastric cancer patients who underwent surgery in hospitals with an annual composite hospital volume of at least 20 upper GI cancer resections, such as esophageal and pancreatic cancer resections, increased. A higher composite hospital volume was associated with a higher lymph node yield, a lower 30-day mortality, and an increased overall survival. Conclusions: In the Netherlands, an increasing proportion of gastric cancer resections is performed in hospitals that are high volume centers for esophagectomies and pancreatectomies for cancer. Experience with these complex surgical procedures has a favorable effect on the outcomes of gastric cancer surgery.
Background: The highest blood pressure and its complications are found in black people compared to white subjects. Enhanced vascular contractility, attenuated vasodilation, and higher creatine kinase (CK) activity are all reported to be involved in the pathogenesis. This study aimed to assess whether normotensive whites and blacks differ in vascular contractile responses. Methods: Consecutive white and black women < 50 years old, scheduled for elective abdominal operations were eligible for inclusion. Women with bleeding disorders, inflammatory disease, diabetes, malignant disease, and smokers were excluded. Sample size calculation was based on maximum vasoconstriction with KPSS-noradrenaline (10–5 M) as the main outcome, assuming a 30% (Sd 10 %) higher force in black people, needing least 5 patients in each group. As secondary outcomes, we studied passive and active tension-diameter relations, bradykinin (up to 10–6 M), and sodium nitroprusside (up to 10–4 M) -induced vasodilation using a Mulvany-Alpern myograph. Finally, we added dinitro-fluorobenzene (DNFB, up to 10–6 M), a specific irreversible CK inhibitor, to assess the CK mediated contribution to potassium-mediated vasoconstriction. Results: Of 101 patients 66 were eligible. Three out of 33 white women were hypertensive vs 21 of 33 (64%) black women (odds of being normotensive and black 0.10 [0.03to 0.33] as compared to whites). Five normotensive blacks and 6 normotensive whites fulfilled inclusion criteria for the vessel study. Maximal contraction induced by KSS with noradrenaline was similar in both ethnic groups (9.98 ± 2.51 vs 10.21 ± 2.39 mN, whites vs blacks. vasodilation responses to bradykinin and SNP. The CK inhibitor DNFB reduced the contractile response in resistance vessels to 10% in whites, as in earlier studies in white women, and to 12% in blacks (p > 0.05). Conclusion: Selected normotensive black patients have similar vascular reactivity and intravascular CK activity as normotensive whites. These findings are in line with our earlier findings in a population study that black subjects with relatively low CK have lower blood pressures.
To investigate a new composite quality measurement, which comprises a desirable outcome for elective aneurysm surgery, called "Textbook Outcome" (TO).Single-quality indicators in vascular surgery are often not distinctive and insufficiently reflect the quality of care.All patients undergoing elective abdominal aortic aneurysm repair, registered in the Dutch Surgical Aneurysm Audit between 2014 and 2015 were included. TO was defined as the percentage of patients who had abdominal aortic aneurysm-repair without intraoperative complications, postoperative surgical complications, reinterventions, prolonged hospital stay [endovascular aneurysm repair (EVAR) ≤4 d, open surgical repair (OSR) ≤10 d], readmissions, and postoperative mortality (≤30 d after surgery/at discharge). Case-mix adjusted TO rates were used to compare hospitals and to compare individual hospital results for different procedures.Five thousand one hundred seventy patients were included, of whom 4039 were treated with EVAR and 1131 with OSR. TO was achieved in 71% of EVAR and 53% of OSR. Important obstacles for achieving TO were a prolonged hospital stay, postoperative complications, and readmissions. Adjusted TO rates varied from 38% to 89% (EVAR) and from 0% to 97% (OSR) between individual hospitals. Hospitals with a high TO for OSR also had a high TO for EVAR; however, a high TO for EVAR did not implicate a high TO for OSR.TO generates additional information to evaluate the overall quality of the care of elective aneurysm surgery, which subsequently can be used by hospitals to improve the quality of their care.
In de afgelopen jaren zijn er tal van maatregelen genomen
om de kwaliteit van de zorg voor patienten met een slokdarm- of maagcarcinoom
te verbeteren. De combinatie van volumestandaarden,
evidence based richtlijnen en een meetinstrument waarmee processen en
uitkomsten van de zorg kunnen worden geevalueerd, heeft geleid
tot aanzienlijke verbeteringen in de kwaliteit van zorg voor deze groep
patienten. Een dergelijk meetinstrument als de Dutch Upper GI Cancer Audit
(DUCA) biedt bovendien mogelijkheden ten aanzien van multidimensionale en
internationale kwaliteitsevaluatie.
Background Volume‐outcome associations for complex surgical procedures have motivated centralization of care worldwide. The aim of this study was to investigate the association between overall hospital experience with complex upper gastrointestinal (GI) cancer resections and outcomes after gastric cancer surgery. Methods Data on all patients ( n = 4837) who underwent a resection for non metastatic invasive gastric cancer between 2005 and 2014 were obtained from the Netherlands Cancer Registry (NCR). Annual hospital volume categories were based on the combined volume of gastrectomies, esophagectomies, and pancreatectomies (composite hospital volume). Volume‐outcome analyses were performed for lymph node yield, 30‐day mortality, and overall survival. Results The proportion of gastric cancer resections performed in hospitals with an annual composite hospital volume of ≥40 upper GI cancer resections increased from 6% in 2005 to 80% in 2014. A higher composite hospital volume was univariably associated with a higher lymph node yield, lower 30‐day mortality, and increased overall survival. Statistical significance was lost after adjusting for case mix. But, sub group analysis including only elderly patients (≥75 years) showed a significant association between composite hospital volume and 30‐day mortality. Conclusion In the Netherlands, an increasing proportion of gastric cancer resections is performed in hospitals with a high composite hospital volume of gastric, esophageal, and pancreatic cancer resections. Special attention is warranted to referral of elderly patients, as these patients might specifically benefit from this centralization.
