Reply

Abstract

We thank Drs Li and de Mol for their insightful letter and comments [1Li W.W.L. de Mol B.A.J.M. Hospital volume as a quality standard in lung cancer surgery: an unfinished debate.Ann Thorac Surg. 2008; 85 (letter): 1840-1841Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar] regarding our recent report on thoracic surgical oncology standards in Ontario [2Sundaresan S. Langer B. Oliver T. Schwartz F. Brouwers M. Stern H. Expert Panel on Thoracic Surgical OncologyStandards for thoracic surgical oncology in a single-payer healthcare system.Ann Thorac Surg. 2007; 84: 693-701Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar] and we offer the following reply. First, Drs Li and de Mol point out that most of the evidence linking a high volume of lung cancer surgery with lower operative mortality are derived from the United States and that the potential for competition between American hospitals may amplify the actual differences in outcomes between them. In our review, we have acknowledged the limitations in the available literature. However, our review assessed the relationship between volume-related and outcome indicators for lung and esophageal resection from studies originating in the United States and, to a lesser extent, in Canada, Great Britain and elsewhere; the results were consistent, although not always statistically significant. Patient outcomes were typically more favorable if the patients were treated by surgeons with higher volumes or in hospitals with higher volumes. It is true that the available literature does not identify a discreet dividing point between high and low volumes, so the numbers in our review were established by a process of combining evidence and applying expert consensus. Second, Drs Li and de Mol correctly state that outcome-related end points are ultimately the most important to patients and the most vital component of assessment of quality of care. It is true that our proposal addresses the structural and process components; data will be carefully collected prospectively to validate or refute the proposal as we move towards regionalization of thoracic surgical oncology in Ontario. In this regard, it is worth briefly summarizing the outcome of a similar effort by Cancer Care Ontario dealing with pancreatic cancer surgery. In 1998, it was recognized that in Ontario there was a wide variability in the postoperative mortality rate between hospitals performing major pancreatic cancer resection and an inverse relationship between hospital volume and mortality rate: 3.4% mortality rate seen in 2 hospitals conducting 42 or more resections per year vs 14.4% seen in 56 hospitals conducting 21 resections or less per year (personal communication, Dr Bernard Langer, Cancer Care Ontario). A Pancreatic Surgery Task Force was formed in 1999 to deal with this issue and pursued a process very similar to the Thoracic Surgical Oncology Standards group. [3Langer B. Stern H. An integrated system-wide strategy for quality improvement in cancer surgery.Br J Surg. 2007; 94: 3-5Crossref PubMed Scopus (10) Google Scholar] The ensuing Pancreatic Cancer Surgery standards document recommended training requirements for surgeons; hospital requirements, resources and organizational aspects; and annual case volumes for pancreatic (≥10) and major hepatopancreatic-biliary tract [HPB] resections (≥25), with a proposed benchmark mortality rate of less than 5%. As of 2001, there was 62% compliance amongst hospitals surveyed. Notable changes included a sharp reduction in the number of hospitals and surgeons conducting major pancreatic cancer surgery, recruitment of surgeons with advanced training, and efforts to consolidate a dedicated HPB service. By 2005, there was a significant rise in the number of resections being done in high-volume centers and, ultimately, a reduction in the province-wide crude 30-day mortality rate from 10.2% to 4.5% (personal communication, Dr Bernard Langer, Cancer Care Ontario). Drs Li and de Mol correctly argue that outcome measures are important to support the standards. We agree that “the proof is in the pudding” and provide here a reference to a strong precedent that applies to complex cancer surgery within our immediate jurisdiction. We believe it reasonable to expect that a similar correlation will soon be established with thoracic cancer surgery in Ontario with careful follow-up and the passage of time. Hospital Volume as a Quality Standard in Lung Cancer Surgery: An Unfinished DebateThe Annals of Thoracic SurgeryVol. 85Issue 5PreviewWe read with great interest the article by Sundaresan and associates [1], proposing quality standards for centers performing thoracic surgical oncology. Regarding lung cancer surgery, the authors attempted to set hospital volume criteria, recommending a target of 150 anatomic pulmonary resections per year for level 1 centers, and at least 50 per year for level 2. We have two comments. First of all, the title of the article states that these standards are meant for countries with single-payer healthcare systems, as implemented in Canada, the Netherlands, and most European countries. Full-Text PDF