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Relation of Surgeon and Hospital Volume to Processes and Outcomes of Colorectal Cancer Surgery

Rogers, Selwyn O. Jr MD, MPH*‡; Wolf, Robert E. MS§; Zaslavsky, Alan M. PhD§; Wright, William E. PhD∥; Ayanian, John Z. MD, MPP†‡§

Annals of Surgery:
doi: 10.1097/01.sla.0000231759.10432.a7
Original Articles
Abstract

Background: Greater hospital volume has been associated with lower mortality after colorectal cancer surgery. The contribution of surgeon volume to processes and outcomes of care is less well understood. We assessed the relation of surgeon and hospital volume to postoperative and overall mortality, colostomy rates, and use of adjuvant radiation therapy.

Methods: From the California Cancer Registry, we studied 28,644 patients who underwent surgical resection of stage I to III colorectal cancer during 1996 to 1999 and were followed up to 6 years after surgery to assess 30-day postoperative mortality, overall long-term mortality, permanent colostomy, and use of adjuvant radiation therapy.

Results: Across decreasing quartiles of hospital and surgeon volume, 30-day postoperative mortality ranged from 2.7% to 4.2% (P<0.001). Adjusting for age, stage, comorbidity, and median income among patients with colorectal cancer who survived at least 30 days, patients in the lowest quartile of surgeon volume had a higher adjusted overall mortality rate than those in the highest quartile (hazard ratio, 1.16; 95% confidence interval, 1.09–1.24), as did patients in the lowest quartile of hospital volume relative to those treated in the highest quartile (hazard ratio, 1.11; 95% confidence interval, 1.05–1.19). For rectal cancer, adjusted colostomy rates were significantly higher for low-volume surgeons, and the use of adjuvant radiation therapy was significantly lower for low-volume hospitals.

Conclusions: Greater surgeon and hospital volumes were associated with improved outcomes for patients undergoing surgery for colorectal cancer. Further study of processes that led to these differences may improve the quality of colorectal cancer care.

In Brief

Relative contributions of surgeon and hospital volume to processes and outcomes of colorectal cancer care are poorly understood. A total of 28,644 patients who had stage I to III colorectal cancer during 1996 to 1999 were followed up 6 years. Greater surgeon and hospital volume were associated with improved outcomes for patients undergoing surgery for colorectal cancer.

Author Information

From the *Department of Surgery, †Division of General Medicine, and ‡Center for Surgery and Public Health, Brigham and Women's Hospital and Harvard Medical School; the §Department of Health Care Policy, Harvard Medical School, Boston, MA; and ∥Cancer Surveillance Section, California Department of Health Services, Sacramento, CA.

Supported by Grant Nos. R01 HS09869 and U01 CA93324 from the Agency for Healthcare Research and Quality and the National Cancer Institute. Dr. Rogers was also supported by the Center for Excellence in Minority Health and Health Disparities, Harvard Medical School. The collection of cancer data used in this study was supported by the California Department of Health Services through the statewide cancer reporting program mandated by California Health and Safety Code Section 103885, the National Cancer Institute's SEER Program, and the Centers for Disease Control and Prevention's National Program of Cancer Registries.

The ideas and opinions expressed herein are those of the authors, and endorsement by the State of California Department of Health Services, the National Cancer Institute, and the Centers for Disease Control and Prevention is not intended nor should be inferred.

Reprints: John Z. Ayanian, MD, MPP, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115. E-mail: ayanian@hcp.med.harvard.edu.

© 2006 Lippincott Williams & Wilkins, Inc.