Facility Volume Research Articles

Average treatment effect of facility hepatopancreatobiliary cancer volume on survival of non-resected pancreatic adenocarcinoma

To examine the average treatment effect of hepato-pancreato-biliary (HPB) cancer volume on survival outcomes of patients with non-resected pancreatic adenocarcinoma (PDAC). We queried the National Cancer Database (2004-2018) for patients with HPB malignancies (PDAC, pancreatic neuroendocrine neoplasms, hepatocellular carcinoma, biliary tract cancers). We determined the 25th, 50th, and 75th percentiles based on the total annual HPB volume. We then identified patients with non-resected PDAC. We utilized inverse probability (IP)-weighted Cox regression to estimate the effect of facility volume on overall survival (OS). We identified 710,988 patients with HPB malignancies. The 25th, 50th, and 75th percentiles of total annual HPB volume were 32, 71, and 177 cases/year, respectively. We included a total of 196,150 patients with non-resected PDAC. Patients treated at ≥25th, ≥50th, and ≥75th percentile facilities had improved median OS compared to those treated at facilities below these thresholds (5.8 vs. 4.2months, 6.5 vs. 4.5months, 7.5 vs. 4.8months, respectively; p<0.001 for all). Treatment at facilities ≥25th, ≥50th, and ≥75th percentile resulted in lower hazards of death than treatment at lower-percentile facilities (HR: 0.87, 95% CI: 0.84-0.90; HR: 0.87, 95% CI: 0.83-0.91; HR: 0.85, 95% CI: 0.79-0.91, respectively). Our data suggest that consolidation of care of patients with PDAC to high-volume centers may be beneficial even in the nonoperative setting.

Impact of Facility Case Volume on Radiation Schema and Outcomes in Palliative Radiation of Osseous Metastases

<h3>Purpose/Objective(s)</h3> To compare how facility volume impacts palliative RT practices in patients with osseous metastases, radiation schema used, and outcomes of the applied therapies by analyzing the percentage of remaining life spent receiving RT (PRLSRT) and RT completion rates. <h3>Materials/Methods</h3> A retrospective analysis was conducted using the National Cancer Database (2010-2016). Facilities were grouped and analyzed according to case volume of patients treated with palliative RT for bone mets. Facilities were grouped by case volume (<10, 10-24, 25-49, 50-74, 75-99, 100-149, ≥150). Patterns of palliative RT schemes (extended fractionation (>10 fx), hypofractionation (5 or fewer), and single fraction (8 Gy)) and outcomes were evaluated for facilities based on case volume. PRLSRT and course completion rates were calculated. <h3>Results</h3> 52,864 patient cases from 1,312 facilities were included. Higher facility case volume was associated with facility type (Academic > Comprehensive Community > Integrated Network > Community Cancer Program), higher population areas, higher distance traveled for treatment, lower comorbidity, younger age, and private insurance. Higher volume facilities were associated with the use of higher dose per fraction, resulting in increased use of single fraction, hypofractionation, and less use of extended fractionation regimens (see Table 1). The use of shorter courses at high volume centers resulted in increased radiation completion rates, and remaining life spent receiving radiation. <h3>Conclusion</h3> For palliative treatment of osseous metastases, facilities with higher case volumes favor shorter courses of RT and have better outcomes measured by PRLSRT and higher rates of treatment completion. It should be considered whether facility volume and experience influence the adoption of hypofractionation for palliative treatment of bone mets and how to improve adoption of shorter courses among all volume facilities.

Disparities in overall survival (OS) outcomes based on treating facility volume in pancreatic neuroendocrine tumors.

150 Background: Pancreatic neuroendocrine tumors (pNETs) comprise less than 5% of all pancreatic tumors and 7% of all neuroendocrine tumors (NETs). There has been considerable progress in understanding the biology of pNETs and numerous therapeutic options emerged, especially with the collaboration of various specialties in the multidisciplinary setting. In this this study, we sought to analyze the association of facility volume, treatment modalities offered, and different risk adjusted outcomes in pNETs. Methods: We extracted data from National Cancer Data Base (NCDB) that covers 70% of all newly diagnosed cancer cases in the U.S and Puerto Rico. Patients with pNETs diagnosed between 2004 &amp; 2017 were included and classified into tertiles based on hospital volume. Volume–outcome relationship was determined by using Cox regression adjusting for patient demographics, comorbidities, tumor characteristics, insurance type and therapy received. Kaplan Meier estimates of OS were compared with log-rank test. The primary predictor of interest was the facility volume defined as number of pNETs treated/year. A total of 7202 patients with pathologically confirmed pNETS were treated at 840 facilities. The median annual facility volume was 5patients/year. Facilities were classified into (T:mean cases/year) T1: &lt; 3; T2:4-8; T3:≥9 cases/year. Results: A total of 7202 pNET patients were treated at 840 facilities. The median annual facility volume was 5 patients/year. Facilities were classified into (T: mean cases/year) T1:&lt;3; T2:4-8; T3:≥9 cases/year. The unadjusted median OS by facility volume was: T1: 71 months (m), T2: 136 m, and T3: not-reached (p &lt; 0.001). On multivariable analysis, compared with patients treated at T3 facilities, patients treated at lower-tertile facilities had higher risk of death [T2 hazard ratio (HR), 1.17 (95% CI, 1.03-1.33); T1 HR, 1.45 (CI, 1.30-1.67), p &lt; 0.0001] and such a difference in OS was more pronounced in stage IV disease (Table). Patients at T3 facilities (vs T1) were more likely to receive surgical resection of the primary tumor (75 vs 49%), lymph node dissection performed at the time of surgery (70 vs 42%), and a better R0 resection (72 vs 46%) (p &lt; 0.01). Conclusions: Patients who were treated for pNETs at high-volume centers (&gt; 9cases/year) had significantly higher OS and were more likely to receive surgical resection along with lymph node dissection and R0 resection. There was a 45% increased risk of death in patients treated at low volume centers (&lt; 3/year) as compared to high-volume centers (&gt; 9/year). While OS difference was noticed in all stages, the difference was more pronounced in stage IV disease demonstrating the importance of multi-disciplinary approach in pNETs management and incorporating such quality measures in low-volume facilities.[Table: see text]

Defining Facility Volume Threshold for Optimization of Short- and Long-Term Outcomes in Patients Undergoing Resection of Perihilar Cholangiocarcinoma

BackgroundWe determined the minimum threshold (Tmin) of annual facility case volume to optimize outcomes for patients with resected perihilar cholangiocarcinoma. MethodsWe identified patients with localized perihilar cholangiocarcinoma who underwent resection within the National Cancer Database (2010–2017). We used marginal structural logistic regression models to estimate the average treatment effect of receiving care in facilities meeting/exceeding Tmin on 90-day mortality and other postoperative outcomes. ResultsA total of 2471 patients underwent resection for perihilar cholangiocarcinoma at 471 facilities. There was no effect of total hepatopancreatobiliary, surgical hepatopancreatobiliary, total hepatobiliary, surgical hepatobiliary, or total perihilar cholangiocarcinoma case volume on 90-day mortality. A Tmin of seven perihilar cholangiocarcinoma resections/year resulted in lower odds of 90-day mortality (IP-weighted OR = 0.49, 95% CI: 0.66–0.87). A total of two facilities met the Tmin. Patients receiving treatment at Tmin facilities had lower odds of length of stay ≥ 7 days (IP-weighted OR = 0.85, 95% CI: 0.75–0.97) and positive surgical resection margins (IP-weighted OR = 0.40, 95% CI: 0.47–0.55). Additionally, undergoing surgery at Tmin facilities resulted in higher (≥ 4 nodes) lymph node yields (IP-weighted OR = 1.94, 95% CI: 1.21–3.11) but no change in the odds of nodal positivity. There was no effect of undergoing surgery at Tmin facilities on 30-day mortality or re-admission. ConclusionsResection of perihilar cholangiocarcinoma is infrequently performed at a high number of facilities. A Tmin of ≥ 7 resections/year resulted in lower 90-day mortality and improved postoperative outcomes. Our data suggest that regionalization of care for patients with perihilar cholangiocarcinoma could potentially improve outcomes in the USA.

Effect of facility volume on giant pituitary adenoma neurosurgical outcomes.

Giant pituitary adenomas (PAs), defined as 4 cm or greater at their maximum diameter, are commonly treated with neurosurgical intervention as the first-line therapy. However, existing studies are from high-volume institutions whose outcomes may not be representative of many cancer centers. In the present study, the authors use a large cancer registry to evaluate demographics, national treatment trends, and outcomes by facility volume to address knowledge gaps for this uncommon tumor. The National Cancer Database was queried for adult patients with PAs who had undergone resection from 2004 to 2016. Univariate and multivariate logistic regression modeling was used to evaluate the prognostic impact of covariates on short-term outcomes including 30-day readmission (30R), 30-day mortality (30M), 90-day mortality (90M), and prolonged length of inpatient hospital stay (LOS). Propensity score matching was used for validation. Among the 39,030 patients who met the study inclusion criteria, 3696 giant PAs were identified. These tumors had higher rates of subtotal resection (55% vs 24%, p < 0.001), adjunctive radiotherapy (15% vs 5%, p < 0.001), and hormonal therapy (8% vs 4%, p < 0.001) than nongiant PAs. The giant PAs also had worse 30M (0.6% vs 3.1%, p < 0.001), 90M (1.0% vs 5.0%, p < 0.001), 30R (4.0% vs 6.3%, p < 0.001), and LOS (22.2% vs 42.1%, p < 0.001). On multivariate analysis for giant PA, decreased tumor size, younger age, race other than African American, lower comorbidity score, and high-volume facility (HVF; defined as ≥ 2.5 giant PA cases per year) were statistically significant predictors of favorable outcomes. Specifically, 30M, 90M, 30R, and LOS were decreased by 50%, 43%, 55%, and 32%, respectively, when giant PAs were treated at HVFs (each p < 0.05). HVFs more often used the endoscopic approach (71% vs 46%, p < 0.001) and less adjuvant radiotherapy (11% vs 16%, p < 0.001). Propensity score matching validated 30M, 30R, and LOS outcome differences in a cohort of 1056 patients. This study provides evidence of superior outcomes when giant PAs are treated at HVFs. These results likely reflect the relation between physician experience and outcomes for these uncommon tumors, which suggests the need for institutional collaboration as a potential goal in their surgical management.

114. Surgeon volume is associated with complications after lumbar fusion

114. Surgeon volume is associated with complications after lumbar fusion

Characteristics of High-Volume Lung Segmentectomy Hospitals: A Propensity Score-Matched Analysis

BackgroundSegmental resection continues to gain favor in the treatment of early-stage non-small cell lung cancer, but there is limited data on outcomes as related to facility volume. The purpose of this study is to better define the relationship between segmentectomy outcomes, survival, and facility volume. MethodsA retrospective cohort analysis was completed using the National Cancer Database. Patients with stage I disease undergoing segmentectomy 2004 to 2015 were included. Facility volume was determined per year; facilities performing higher than the median number of segmental resections were deemed high-volume and retained that classification for the remainder of the study. Propensity-score matching was used to compare 5-year survival and outcomes. ResultsSix hundred eighty-one centers performing 2481 segmentectomies were included. High-volume centers had higher utilization of minimally invasive approaches and lower conversion rates. There was no difference in readmission or 30-day mortality, but 90-day mortality differed between groups (1.2% vs. 2.6%, P = .03). High-volume centers were more likely to sample lymph nodes (88.5% vs. 80.7%, P < .01), and patients were less likely to have positives margins (1.3% vs. 2.7%, P = .03). Patients were no more likely to be upstaged based on facility volume (4.6% vs. 3.3%, P = .21). Overall, 5-year survival was better for patients treated at high-volume centers in the full cohort (69.5% vs. 66.4%, P = .014) but in propensity score-matched analysis this survival difference became non-significant (68.0% vs. 67.9% (P = .172). ConclusionSegmentectomy performed at high-volume centers is associated with more frequent use of minimally invasive approach, more frequent negative margins, and improved 90-day survival.

Numerical simulation study on the influence of artificial reefs on the instantaneous collision with seabed based on the explicit finite element method

The deposition of artificial reef (AR) is a complicated systematic project. The instantaneous impact and subsidence between ARs and seabed will reduce the effective volume of AR. This study presents the effects of ARs on seabed subsidence based on explicit finite element method. The cut-opening ratio on reef bottom, weights and incident angles of ARs were used as the influencing factors, and the respective terminal velocities were used as the initial conditions to simulate the instantaneous collision process. The research results showed that the subsidence effect of ARs with a larger volume ratio (0.50) and material density (7896 kg/m3) in the seabed will be more obvious, and the rate of effective facility volume can be reduced to 79.1%. The change of incident angle affected the deformation region after AR subsidence. The indexes of the subsidence ratio and the rate of effective facility volume should be used simultaneously to measure the extent of subsidence. In addition, the maximum stress monitoring results of AR in subsidence process verified that the current strength standard of 25 MPa can meet the safety needs of AR deposition. This study aims to provide a scientific reference for the structural design and release scheme of AR.

Facility level volume of surgical lymph node assessment for patients with vulvar cancer: A multi-institutional database analysis (368)

<b>Objectives:</b> To investigate surgical lymph node assessment (LND) facility level volume for patients with vulvar cancer using a large hospital-based database and evaluate the potential impact on perioperative and survival outcomes. <b>Methods:</b> The National Cancer Database was accessed, and patients who were diagnosed between 2004 and 2016 with a pathologically confirmed invasive vulvar malignancy, who received all treatment at the reporting facility and underwent surgical lymph node assessment (LND) (including lymph node sampling, dissection, or sentinel lymph node biopsy) were identified. Annual LND volume was calculated for facilities that reported at least 12 cases. High-volume facilities were defined as those performing at least ten LND annually. The impact of facility volume on perioperative and survival outcomes was examined in a cohort of patients with apparent stage IB squamous cell carcinoma, and available data on lymph node status from the pathology report. Clinical-pathologic and demographic characteristics of patients managed in low and high-volume facilities were compared with the Chi-square test while overall survival (OS) was compared with the log-rank test. A Cox model was constructed to control for a priori selected confounders. <b>Results:</b> A total of 376 facilities performed at least 12 cases of LND in vulva cancer patients between 2004 and 2016. The median annual facility volume was 2.9 cases; 10^th and 90^th percentiles were 1.81 and 6.41 cases, respectively. Only eight facilities performed at least ten vulvar cancer LND cases annually. The analysis cohort included 10821 patients with apparent stage IB SCC who met the inclusion criteria; 990 (9.1%) were managed at high-volume centers. There was no difference between patients managed in low and high-volume facilities in terms of patient age, insurance status, and presence of comorbid conditions. Rate of lymph node metastases (22.4% vs 24%, p=0.24) and 90-day mortality (1.5% vs 1.4%, p=0.66) were comparable between low and high-volume facilities. The rate of prolonged hospital stay (defined as >3 days) was higher in low-volume facilities (26.2% vs 21.2%, p<0.001); however, the rate of unplanned re-admission 30 days from discharge was lower (5.2% vs 7.8%, p<0.001). There was no difference in OS between low and high-volume facilities (median OS: 106.9 and 108.9 months, respectively, p=0.21). However, patients who had negative lymph nodes who were managed at highvolume facilities had better OS (p=0.024); 5-year OS rates were 80% and 75%, respectively. After controlling for patient age, race, insurance status, presence of comorbid conditions, history of another tumor, tumor size, and status of lymph nodes, there was no difference in OS between low and high-volume centers (HR: 0.93; 95% CI: 0.83, 1.04). <b>Conclusions:</b> The majority of institutions in the United States perform very few LND for vulvar cancer. Although facility volumes do not appear to affect OS, lymph node assessments appear to be more accurate at high-volume centers.

The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty.

Introduction:This study seeks to evaluate (1) the relationship between hospital and surgeon volumes of shoulder arthroplasty and complication rates and (2) patient demographics/socioeconomic factors that may affect access to high-volume shoulder arthroplasty care.Methods:Adults older than 40 years who underwent shoulder arthroplasty between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database using International Classification of Disease 9/10 and Current Procedural Terminology codes. Medical/surgical complications were compared across surgeon and facility volumes. The effects of demographic factors were analyzed to determine the relationship between such factors and surgeon/facility volume in shoulder arthroplasty.Results:Seven thousand seven hundred eighty-five patients were included. Older, Hispanic/African American, socially deprived, nonprivately insured patients were more likely to be treated by low-volume facilities. Low-volume facilities had higher rates of readmission, urinary tract infection, renal failure, pneumonia, and cellulitis than high-volume facilities. Low-volume surgeons had patients with longer hospital lengths of stay.Discussion:Important differences in patient socioeconomic factors exist in access to high-volume surgical care in shoulder arthroplasty, with older, minority, and underinsured patients markedly more likely to receive care by low-volume surgeons and facilities. This may highlight an area of potential focus to improve access to high-volume care.

HIPEC is associated with improved survival in stage III-IV ovarian cancer patients undergoing complete cytoreductive surgery: An NCDB-based analysis (561)

<b>Objectives:</b> To determine if hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with improved survival in patients undergoing cytoreductive surgery (CRS) for newly diagnosed stage III or stage IV ovarian cancer at Commission on Cancer (CoC)-accredited cancer programs in the United States. <b>Methods:</b> The National Cancer Database was queried for patients with stage III or stage IV ovarian cancer undergoing CRS+HIPEC between 2004 and 2017. A control population of patients from 38 HIPEC-performing institutions undergoing CRS only was obtained using propensity score matching and adjusted for facility volume, age, Charlson-Deyo-Comorbidity-Index (CDCI), and stage. All patients in this study underwent complete cytoreduction to no gross residual (NGR) disease. Univariate survival analyses were performed using the log-rank test and adjusted for covariates using Cox proportional hazards regression. All analyses were performed using IBM SPSS Statistics 27. <b>Results:</b> A total of 66 patients who underwent CRS+HIPEC and had available survival data were identified. An additional 66 patients who underwent CRS only at HIPEC performing institutions were included in all comparisons based on propensity score match parameters. Demographics for the CRS+HIPEC group versus the CRS only group revealed no significant difference between median age (58 vs 61 years old) or median CDCI (score 0 vs 0), while significant differences were observed in primary CRS (46% vs 76%) (p<0.001), interval CRS (54% vs 24%) (p<0.001), stage III (65% vs 82%) (p=0.007), and stage IV (35% vs 18%) (p=0.007). Patients undergoing CRS+HIPEC had a significantly higher median overall survival (OS) of 42.1 months (95% CI: 31.8-52.4 months) compared to patients undergoing CRS only, who had a median OS of 34.9 months (95% CI: 23.4-46.4 months, p=0.015). Fifty percent of patients undergoing CRS+HIPEC were still alive at 60 months compared to 30.3% of patients undergoing CRS only. On multivariable analysis, patients undergoing CRS+HIPEC were 38.9% less likely to die compared to those who underwent CRS alone (HR of death: 0.611, 95% CI 0.402-0.928, p=0.021). Fig. 1 <b>Conclusions:</b> On retrospective review of patients undergoing complete CRS for newly diagnosed stage III or stage IV ovarian cancer at CoC-accredited cancer programs in the United States, we found CRS+HIPEC to be associated with significantly improved survival compared to CRS only. These findings are especially notable given the higher proportion of stage IV patients in the CRS+HIPEC group. Thus, stage IV patients who respond well to neoadjuvant chemotherapy and can undergo complete interval CRS should also be considered for HIPEC.

Early-Stage Glottic Carcinoma in the United States: Demographics and Treatment Choice.

Limited investigation of factors potentially contributing to treatment choice in early-stage glottic carcinoma (EGC) has been performed with large-scale data. The National Cancer Database (NCDB) represents >72% of all new cancer cases in the United States. We hypothesized that NCDB variables may lend insight into treatment decisions between surgery and radiation for EGC. The NCDB was queried for all cases of T1-2 N0 M0 glottic carcinoma from 2004 to 2016. We used multivariable logistic regression analysis to examine factors associated with first-line treatment modality:radiation therapy (RT) versus surgery. All reported odds ratios (OR) were adjusted for age, gender, race, insurance, residence in a metropolitan area, region, and facility volume. 34,991 EGC patients received treatment: 6,687 (19%) surgery; 20,289 (58%) RT; and 8,015 (23%) surgery and RT. OR for receiving RT (vs. surgery alone) were >2 for: more advanced T stage cancers (OR 2.5 [95%CI: 2.3, 2.7]), treatment at non-academic facilities (OR 2.8, [95%CI: 2.6, 3.0]), and shorter travel distances to treatment centers (OR 2.2, [95%CI: 2.0, 2.4]). Surgery was more likely with treatment in the western US, higher income, private insurance, living in a metropolitan (vs. non-metropolitan) area, female gender, older age, and low facility volume. Hispanic ethnicity, education level, and race were not associated with treatment type in the multivariable model. Most patients in the NCDB receive first-line treatment with radiation for EGC, and this decision is associated with various tumor, patient, and treatment facility characteristics. 4 Laryngoscope, 133:901-907, 2023.

The Influence of Facility Volume and Type on Skull Base Chordoma Treatment and Outcomes

To evaluate the influence of facility case volume and type on skull base chordoma treatment and overall survival (OS). The 2004-2016 National Cancer Database was queried for skull base chordoma patients receiving definitive treatment. Facilities were categorized into 2 cohorts by calculating the mean number of patients treated per facility and using cutoff numbers that were 0.5 SD above and below the computed mean to separate the groups. As, by definition of the inclusion criteria, all included facilities treated at least 1 patient, low-volume facilities were defined as treating 1 patient, and high-volume facilities were defined as treating ≥7 patients; mid-volume facilities (facilities treating ≥2 but ≤6 patients) were excluded. Differences in treatment course, outcomes, and OS by facility type were assessed. The study included 658 patients (44.8% female, 79.5% White). The 187 unique facilities were categorized into 95 low-volume facilities (treating 1 patient during timeline) and 26 high-volume facilities (treating ≥7 patients during timeline). Kaplan-Meier log-rank analysis demonstrated a significant positive association between facility volume and OS (P < 0.001) and an improvement in OS in patients at academic facilities (P = 0.018). On Cox proportional hazards multivariate regression after adjusting for sex, age, Charlson-Deyo comorbidity index, and insurance type, high-volume facilities and academic facilities were associated with a lower mortality risk than low-volume facilities and nonacademic facilities (P < 0.001 and P = 0.03, respectively). Higher facility case volume and academic facility type appear to be associated with improved survival outcomes in treatment of skull base chordomas.

Facility Volume as a Prognosticator of Survival in Locally Advanced Papillary Thyroid Cancer.

To evaluate the influence of facility case-volume on survival in patients with locally advanced papillary thyroid cancer (PTC), and to identify prognostic case-volume thresholds for facilities managing this patient population. Retrospective database study. The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for locally advanced PTC. Using K-means clustering and multivariable Cox proportional-hazards (CPH) regression, two groups with distinct spectrums of facility case-volumes were generated. Multivariable CPH regression and Kaplan-Meier analysis assessed for the influence of facility case-volume and the prognostic value of its stratification on overall survival (OS). Of 48,899 patients treated at 1304 facilities, there were 34,312 (70.2%) females and the mean age was 48.0 ± 16.0 years. Increased facility volume was significantly associated with reduced all-cause mortality (HR 0.996; 95% CI, 0.992-0.999; p=0.008). Five facility clusters were generated, from which two distinct cohorts were identified: low (LVF; <27 cases/year) and high (HVF; ≥27 cases/year) facility case-volume. Patients at HVFs were associated with reduced mortality compared to those at LVFs (HR 0.791; 95% CI, 0.678-0.923, p=0.003). Kaplan-Meier analysis of propensity score-matched N0 and N1 patients demonstrated higher OS in HVF cohorts (all p < 0.001). Facility case-volume was an independent predictor of improved OS in locally advanced PTC, indicating a possible survival benefit at high-volume medical centers. Specifically, independent of a number of sociodemographic and clinical factors, facilities that treated ≥27 cases per year were associated with increased OS. Patients with locally advanced PTC may, therefore, benefit from referrals to higher-volume facilities. 4 Laryngoscope, 133:443-450, 2023.

Hospital Operative Volume and Esophagectomy Outcomes in the Veterans Affairs System.

Previous studies reported that increased hospital case volume improves outcomes after esophagectomy. Yet, the standard for high and low-volume hospitals varies in the literature. This study attempts to define the relationship between hospital operative volume and 30-day post-operative outcomes of esophagectomy in the Veterans Affairs (VA) system. This is a retrospective review of patients that underwent esophagectomy from 2008 to 2019 utilizing the Veterans Affairs Surgical Quality Improvement Program Database. Receiver operating characteristic (ROC) analysis quantified an inflection point of optimal association between 30-day morbidity and mortality by facility volume. This point was used to separate cohorts for comparison of outcomes using 1:1 propensity score matching (PSM) to account for confounding covariates. Two thousand two hundred and twelve esophagectomies were performed from 2008 to 2019 and ROC analysis identified an inflection point at 43 cases (4 cases/y) where bidirectional operative volume significantly affected outcomes. Subsequent PSM resulted in 1718 cases utilized for analysis (n=859 per cohort). Facility volume ≥4 cases/y was significantly associated with decreased odds of 30-day mortality (odds ratio(OR)=0.57; P=0.03), shorter length of stay (median 13 versus 14d; P=0.04) and longer operative times (6.5 versus 6.0h; P<0.001). VA hospitals that averaged ≥4 esophagectomies/y had significantly lower rates of mortality and length of stay. This volume threshold may serve as a benchmark to determine the optimal setting for esophageal resection. However, our findings also may reflect the benefits of cumulative operating room and multidisciplinary team experience at VA centers in conjunction with dedicated surgeons. Future studies should focus on long-term outcomes after esophagectomy in relation to hospital operative volume.

Geographic Access to High-Volume Care Providers and Survival in Patients with Bone Sarcomas: Nationwide Patterns in the United States.

Clinical practice guidelines recommend centralized care for patients with bone sarcoma. However, the relationship between the distance that patients travel to obtain care, institutional treatment volume, and survival is unknown. We used the National Cancer Database to examine associations between travel distance and survival among 8,432 patients with bone sarcoma diagnosed from 2004 to 2015. Associations were identified using multivariable Cox regression analyses that controlled for sociodemographic, clinical, and hospital-level factors; subgroup analyses stratified patients by histological diagnosis, tumor stage, and pediatric or adult status. Mortality risk was lower among patients who traveled ≥50 miles (≥80.5 km) than among patients who traveled ≤10 miles (≤16.1 km) (hazard ratio [HR], 0.69 [95% confidence interval (CI), 0.63 to 0.76]). Among hospital-level factors, facility volume independently affected survival: mortality risk was lower among patients at high-volume facilities (≥20 cases per year) than at low-volume facilities (≤5 cases per year), with an HR of 0.72 (95% CI, 0.66 to 0.80). The proportion of patients who received care at high-volume facilities varied by distance traveled (p < 0.001); it was highest among patients who traveled ≥50 miles (53%) and lower among those who traveled 11 to 49 miles (17.7 to 78.9 km) (32%) or ≤10 miles (18%). Patients who traveled ≥50 miles to a high-volume facility had a lower risk of mortality (HR, 0.65 [95% CI, 0.56 to 0.77]) than those who traveled ≤10 miles to a low-volume facility. In subgroup analyses, this association was evident among patients with all 3 major histological subtypes; those with stage-I, II, and IV tumors; and adults. This national study showed that greater travel burden was associated with higher survival rates in adults, a finding attributable to patients traveling to receive care at high-volume facilities. Despite the burdens associated with travel, modification of referral pathways to specialized centers may improve survival for patients with bone sarcoma. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Association of facility volume with pathologic complete response and overall survival in patients with non-metastatic breast cancer.

586 Background: High facility volume has been previously shown to be associated with a higher likelihood of pCR among patients with breast cancer following neoadjuvant chemotherapy. However, factors underlying the association of high facility volume with pCR and the impact of facility volume on survival remain unclear. We performed an observational cohort study to investigate the association of overall survival (OS) with facility volume and identify variables associated with high facility volume. Methods: The National Cancer Database (NCDB) was queried for women diagnosed between 2010 and 2017 with non-metastatic breast cancer treated with neoadjuvant chemotherapy followed by surgery. Facility volume was stratified by tertiles of low, intermediate, and high. Logistic and Cox multivariable analyses (MVA) were performed to evaluate factors associated with facility volume and OS, respectively. Propensity score matching was used to reduce selection bias. Results: A total of 105,804 women met our inclusion criteria (low facility volume: n=6,172; intermediate facility volume: n=20,199; high facility volume: n=79,433). The median follow up was 49.2 months (IQR 32.7-71.3). On logistic MVA, both intermediate (adjusted odds ratio [aOR] 1.24, 95% confidence interval [CI] 1.14-1.35, p&lt;0.001) and high (aOR 1.53, 95% CI 1.42-1.65, p&lt;0.001) facility volumes were associated with pCR. On Cox MVA, high (adjusted hazards ratio [aHR] 0.89, 95% CI 0.83-0.96, p=0.001), but not intermediate (aHR 0.97, 95% CI 0.90-1.04, p=0.40), facility volume was associated with improved OS. Similar findings were noted in 18,671 matched pairs between high versus low or intermediate facility volumes (HR 0.90, 95% CI 0.85-0.94, p&lt;0.001). On logistic MVA, patients were more likely to receive treatments at high volume facilities if they were academic (adjusted odds ratio [aOR] 5.47, 95% CI 5.24-5.71, p&lt;0.001), African American (aOR 1.25, 95% CI 1.20-1.30, p&lt;0.001) with private insurance (aOR 1.13, 95% CI 1.04-1.22, p=0.005), and higher tumor grades (grade 2: aOR 1.10, 95% CI 1.03-1.18, p=0.008; grade 3: aOR 1.12, 95% CI 1.05-1.20, p=0.001). Patients were less likely to undergo treatments at high volume facilities if they reside in urban (aOR 0.63, 95% CI 0.60-0.66, p&lt;0.001) or rural (aOR 0.75, 95% CI 0.67-0.85, p&lt;0.001) areas with limited education (aOR 0.90, 95% CI 0.87-0.93, p&lt;0.001), had government-led insurance (aOR 0.87, 95% CI 0.80-0.94, p=0.001), and had time interval of &lt;180 or &gt;240 days between diagnosis and surgery (aOR 0.92, 95% CI 0.90-0.95, p&lt;0.001). Conclusions: To our knowledge, this is the largest study using a nationwide oncology database to report the association of high facility volume with pCR and improved OS, with various patient demographics associated with high facility volume. Our findings suggest an integral role of facility volume on pCR and survival for breast cancer.

PD39-10 SOCIODEMOGRAPHIC DISPARITIES IN ACCESS TO HIGH-VOLUME PROVIDERS AND FACILITIES FOR SIMPLE PROSTATECTOMY: A NEW YORK STATEWIDE ANALYSIS

You have accessJournal of UrologyCME1 May 2022PD39-10 SOCIODEMOGRAPHIC DISPARITIES IN ACCESS TO HIGH-VOLUME PROVIDERS AND FACILITIES FOR SIMPLE PROSTATECTOMY: A NEW YORK STATEWIDE ANALYSIS Krishna Ravivarapu, Olamide Omidele, Evan Garden, Chih Peng Chin, Micah Levy, Alexander Small, Joseph Sewell Araya, and Michael Palese Krishna RavivarapuKrishna Ravivarapu More articles by this author , Olamide OmideleOlamide Omidele More articles by this author , Evan GardenEvan Garden More articles by this author , Chih Peng ChinChih Peng Chin More articles by this author , Micah LevyMicah Levy More articles by this author , Alexander SmallAlexander Small More articles by this author , Joseph Sewell ArayaJoseph Sewell Araya More articles by this author , and Michael PaleseMichael Palese More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002597.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior studies have demonstrated that patients receiving care from high-volume centers and surgeons are afforded superior postoperative outcomes. Here, we aim to assess potential sociodemographic disparities in access to high-volume surgeons and hospitals for simple prostatectomy (SP) in New York State. Furthermore, we aim to identify predictors of access to high-volume care. METHODS: Using the New York Statewide Planning and Research Cooperative database (SPARCS), we analyzed SP cases from 2009 to 2017. Cases were sorted into low-, medium-, and high-volume facility and provider volume by percentile. Patient, provider, and facility level factors were compared across volume groups. Multivariate analysis controlling for patient-level factors was conducted to identify predictors of access to high-volume surgeons and hospitals. RESULTS: We identified 2,008 SP cases. Low-volume providers were more likely to have less than 15 years of experience compared to high-volume providers (34% vs. 11%, p <0.001). Low-volume providers were also less likely to use a robotic approach compared to high-volume providers (9% vs. 12%, p=0.038). A greater proportion of low-volume facilities were rural (6% vs 0%, p <0.001) and non-teaching (17% vs. 13%, p=0.001) compared to high-volume facilities. A greater proportion of Black patients received care with low-volume providers (18% vs. 8%, p <0.001) and facilities (20% vs. 6%, p <0.001) compared to high-volume groups. A greater proportion of Medicaid patients were associated with low-volume providers (6% vs. 2%, p <0.001) and facilities (8% vs. 1%, p <0.001) compared to high-volume groups. On multivariate analysis, negative predictors of receiving care from high-volume facilities included Black race, Asian race, Medicaid status, and uninsured status (all p <0.05). Negative predictors of access to high-volume providers included Black race, Medicaid status, and uninsured status (all p <0.05). CONCLUSIONS: Sociodemographic disparities exist for access to high-volume care for SP patients in New York State. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e656 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Krishna Ravivarapu More articles by this author Olamide Omidele More articles by this author Evan Garden More articles by this author Chih Peng Chin More articles by this author Micah Levy More articles by this author Alexander Small More articles by this author Joseph Sewell Araya More articles by this author Michael Palese More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP42-11 THE IMPACT OF PSYCHIATRIC DIAGNOSES ON PERIOPERATIVE OUTCOMES FOLLOWING RADICAL CYSTECTOMY IN THE STATE OF FLORIDA

You have accessJournal of UrologyCME1 May 2022MP42-11 THE IMPACT OF PSYCHIATRIC DIAGNOSES ON PERIOPERATIVE OUTCOMES FOLLOWING RADICAL CYSTECTOMY IN THE STATE OF FLORIDA Bryce Baird, Tiara Taylor, Shalmali Borkar, Laura Geldmaker, Christian Ericson, Emily Brennan, Augustus Anderson, Stephen Boorjian, Shehzad Niazi, Dorin Colibaseanu, Aaron Spaulding, and Timothy Lyon Bryce BairdBryce Baird More articles by this author , Tiara TaylorTiara Taylor More articles by this author , Shalmali BorkarShalmali Borkar More articles by this author , Laura GeldmakerLaura Geldmaker More articles by this author , Christian EricsonChristian Ericson More articles by this author , Emily BrennanEmily Brennan More articles by this author , Augustus AndersonAugustus Anderson More articles by this author , Stephen BoorjianStephen Boorjian More articles by this author , Shehzad NiaziShehzad Niazi More articles by this author , Dorin ColibaseanuDorin Colibaseanu More articles by this author , Aaron SpauldingAaron Spaulding More articles by this author , and Timothy LyonTimothy Lyon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002608.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Psychiatric diagnoses, including anxiety and depression, diagnosed after radical cystectomy (RC) for bladder cancer have been linked to increased risks of suicide, cancer-specific and all-cause mortality. However, the potential impact of psychiatric diagnoses on postoperative healthcare resource utilization are less well-understood. Herein, we sought to identify associations between psychiatric diagnoses and perioperative outcomes following RC within the state of Florida. METHODS: The Florida Hospital Inpatient Data File was queried to identify patients who underwent RC between 2013-2019. The exposure was defined as an ICD-10 code for a mood or anxiety disorder and analyzed as a 3-level variable: no mood or anxiety disorder, either a mood or anxiety disorder, and both a mood and anxiety disorder. Outcomes analyzed included inpatient mortality (death or discharge to hospice), non-home discharge, in-hospital complications, and length of stay. Mixed-effects logistic regression accounting for patients clustered within hospitals were used for categorical outcomes and negative binomial regression models were utilized for continuous outcomes. RESULTS: A total of 4396 RC patients were identified, of whom 306 (7.0%) had a mood disorder, and 389 (8.8%) had an anxiety disorder. After adjusting for age, sex, comorbidity, payer, patient region, surgical approach, and average facility volume, patients with either a mood or anxiety disorder (OR 1.49, 95% CI 1.12-1.98) and both a mood and anxiety disorder (OR 2.79, 95% CI 1.73-4.50) had significantly increased odds of discharge to a non-home facility. Additionally, either a mood or anxiety disorder (IRR 1.13, 95% CI 1.07-1.19) and both a mood and anxiety disorder (IRR 1.12, 95% CI 1.01-1.24) were significantly associated with increased length of stay. There were no significant associations between mood and/or anxiety disorders with inpatient mortality or the presence or number of postoperative complications. CONCLUSIONS: In the state of Florida, patients with mood and/or anxiety disorders undergoing RC for bladder cancer had an increased length of stay and increased odds of discharge to a non-home facility, but no difference in the risk of perioperative complications. Differences in behavioral or socioeconomic factors may underlie the observed differences in outcome. These data may be helpful to guide perioperative resource planning in caring for RC patients with psychiatric diagnoses. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e734 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bryce Baird More articles by this author Tiara Taylor More articles by this author Shalmali Borkar More articles by this author Laura Geldmaker More articles by this author Christian Ericson More articles by this author Emily Brennan More articles by this author Augustus Anderson More articles by this author Stephen Boorjian More articles by this author Shehzad Niazi More articles by this author Dorin Colibaseanu More articles by this author Aaron Spaulding More articles by this author Timothy Lyon More articles by this author Expand All Advertisement PDF DownloadLoading ...

Impact of esthesioneuroblastoma treatment delays on overall patient survival.

To characterize clinical factors associated with esthesioneuroblastoma treatment delays and determine the impact of these delays on overall survival. Retrospective database analysis. The 2004-2016 National Cancer Database was queried for patients with esthesioneuroblastoma managed by primary surgery and adjuvant radiation. Durations of diagnosis-to-treatment initiation (DTI), diagnosis-to-treatment end (DTE), surgery-to-RT initiation (SRT), radiotherapy treatment (RTD), and total treatment package (TTP) were analyzed. The cohort was split into two groups for each delay interval using the median time as the threshold. A total of 814 patients (39.6% female, 88.5% white) with mean ± SD age of 52.6 ± 15.1 years who underwent both esthesioneuroblastoma surgery and adjuvant radiotherapy were queried. Median DTI, DTE, SRT, RTD, and TTP were 34, 140, 55, 45, and 101 days, respectively. A significant association was identified between increased regional radiation dose above 66 Gy and decreased DTI (OR=0.54, 95% CI 0.35-0.83, p=0.01) and increased RTD (OR=3.94, 95% CI 2.36-6.58, p < 0.001) durations. Chemotherapy administration was linked with decreased SRT (OR=0.64, 95% CI 0.47-0.89, p=0.01) and TTP (OR=0.59, 95% CI 0.43-0.82, p=0.001) durations. Cox proportional-hazards analysis revealed that increased RTD was associated with decreased survival (HR=1.80, 95% CI 1.26-2.57, p < 0.005), independent of age, sex, race, regional radiation dose, facility volume, facility type, insurance status, modified Kadish stage, chemotherapy status, Charlson-Deyo comorbidity index, and surgical margins. Delays during, and prolongation of radiotherapy for esthesioneuroblastoma appears to be associated with decreased survival. 4 Laryngoscope, 133:764-772, 2023.