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Is It Time to Centralize High-risk Cancer Care in the United States? Comparison of Outcomes of Esophagectomy Between England and the United States

Munasinghe, Aruna BSc, MBBS, FRCS, ChM*; Markar, Sheraz R. MBBChir, MSc, MA, MRCS*,†; Mamidanna, Ravikrishna MBBS, MRCS*; Darzi, Ara W. MD, FRCS, FMedSci, FRS*; Faiz, Omar D. MS, FRCS; Hanna, George B. PhD, FRCS, MErgS*; Low, Donald E. MD, FACS

doi: 10.1097/SLA.0000000000000805
Original Articles

Objective: To determine the difference in in-hospital mortality and length of hospital stay (LOS) after esophagectomy between the United States and England.

Background: Since 2001, complex procedures such as esophagectomy have been centralized in England, but in the United States no formal plan for centralization exists.

Methods: Patients who underwent esophagectomy for cancer between 2005 and 2010 were identified from the Nationwide Inpatient Sample (United States) and the Hospital Episodes Statistics (England). In-hospital mortality and LOS were compared.

Results: There were 7433 esophagectomies performed in 66 English hospitals and 5858 resections in 775 US hospitals; median number of resections per center per year was 17.5 in England and 2 in the United States. In-hospital mortality was greater in US hospitals (5.50% vs 4.20%, P = 0.001). In multiple regression analysis, predictors of mortality included patient age, comorbidities, hospital volume, and surgery performed in the United States [odds ratio (OR) = 1.20 (1.02–1.41), P = 0.03]. Median LOS was greater in the English hospitals (15 vs 12 days, P < 0.001). However, when subset analysis was done on high-volume centers in both health systems, mortality was significantly better in US hospitals (2.10% vs 3.50%, P = 0.02). LOS was also seen to decrease in the US high-volume centers but not in England.

Conclusions: The findings from this international comparison suggest that centralization of high-risk cancer surgery to centers of excellence with a high procedural volume translates into an improved clinical outcome. These findings should be factored into discussions regarding future service configuration of major cancer surgery in the United States.

International comparison of in-hospital mortality after esophagectomy was undertaken using administrative data sets from the United States and England. Overall mortality was higher in the United States. However, when only high-volume centers were compared, US mortality was lower than that seen in English centers, supporting the concept of centralizing high-risk cancer surgery.

*Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, Praed Street, London, UK

Virginia Mason Medical Center, Seattle, WA; and

St Mark's Hospital and Academic Institute, Watford Road, Harrow, UK.

Reprints: Donald E. Low, MD, FACS, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98111. E-mail: Donald.Low@vmmc.org.

Disclosure: This study was supported in part by Cancer Research UK, Biomedical Research Centre, and Ryan-Hill Research Foundation. The authors declare no conflicts of interest.

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