Elsevier

European Journal of Cancer

Volume 64, September 2016, Pages 32-43
European Journal of Cancer

Original Research
High lung cancer surgical procedure volume is associated with shorter length of stay and lower risks of re-admission and death: National cohort analysis in England

https://doi.org/10.1016/j.ejca.2016.05.021Get rights and content

Highlights

  • This study addresses whether length of stay, re-admission risk and mortality risk in resected lung cancer patients vary between hospitals with small and large procedure volumes.

  • Hospitals with high procedure volume had better mortality outcomes despite adverse case mix, but there were only smaller differences in terms of length of stay and re-admission.

  • The new study contributes to the on-going discussion about the desirability of centralisation of cancer services and provides new information on length of stay and re-admission risks.

Abstract

It is debated whether treating cancer patients in high-volume surgical centres can lead to improvement in outcomes, such as shorter length of hospital stay, decreased frequency and severity of post-operative complications, decreased re-admission, and decreased mortality.

The dataset for this analysis was based on cancer registration and hospital discharge data and comprised information on 15,738 non-small-cell lung cancer patients resident and diagnosed in England in 2006–2010 and treated by surgical resection. The number of lung cancer resections was computed for each hospital in each calendar year, and patients were assigned to a hospital volume quintile on the basis of the volume of their hospital.

Hospitals with large lung cancer surgical resection volumes were less restrictive in their selection of patients for surgical management and provided a higher resection rate to their geographical population. Higher volume hospitals had shorter length of stay and the odds of re-admission were 15% lower in the highest hospital volume quintile compared with the lowest quintile. Mortality risks were 1% after 30 d and 3% after 90 d. Patients from hospitals in the highest volume quintile had about half the odds of death within 30 d than patients from the lowest quintile.

Variations in outcomes were generally small, but in the same direction, with consistently better outcomes in the larger hospitals. This gives support to the ongoing trend towards centralisation of clinical services, but service re-organisation needs to take account of not only the size of hospitals but also referral routes and patient access.

Introduction

Lung cancer is one of the most frequent types of cancer and the leading cause of cancer death globally [1], [2]. There has been notable progress in lung cancer prevention, as evidenced by declining incidence rates in males [3], and treatment for lung cancer has become more active and more effective [4], [5], [6]. Surgical resection remains the preferred treatment option for medically fit patients with early-stage disease [7], [8], [9], [10].

Lung cancer surgery is highly specialised and increasingly centralised [5]. There is evidence that patient survival is better when surgical care is provided by a multidisciplinary team in hospitals with high-volume practices, and analysis of surgical data from England in patients diagnosed in 2004–2008 showed lower death rates in patients operated in large-volume hospitals [11]. It remains to be addressed whether treating patients in high-volume surgical centres can lead to improvement in other relevant outcomes, such as shorter length of hospital stay, decreased frequency and severity of post-operative complications, decreased re-admission to hospital, and improved patient experience and satisfaction. The present study extends earlier work on patients undergoing lung cancer surgery in England to examine other outcomes, specifically length of stay in hospital after lung cancer resection, and risks of re-admission and death within 30 and 90 d of surgery.

Section snippets

Study population and main predictor variables

The principles of data extraction and linkages were as described previously [9], [11]. The dataset for the analysis comprised information on 15,738 non-small-cell lung cancer patients who were resident and diagnosed in England in 2006–2010 and treated by potentially curative surgical resection as part of their initial care. The majority of resections were lobectomy (85%), 10% were pneumonectomy and 5% were other procedures. This is a complete and population-based ascertainment of surgically

Patients

Table 1 gives an overview of the study cohort of 15,738 lung cancer patients diagnosed in the period 2006–2010 in England and treated with surgical resection.

Hospital volume in relation to covariates

Table 1 shows the marginal distributions of the variables in the analysis and cross-tabulations between the quintile of lung cancer surgical procedure volume (the principal independent variable) and covariates. A high annual hospital volume was strongly associated with a high geographical resection rate (χ2 = 538.2, p < 0.0001). There was

Interpretation of the results of adjusted analyses and two-level analyses

The principal findings of these analyses are as follows:

  • 1

    Hospitals with large lung cancer surgical resection volumes are less conservative in their selection of patients for surgical management, and they provide a higher resection rate to their geographical population.

  • 2

    With adjustment for case mix, high-volume hospitals have shorter length of stay, with approximately 0.3 d difference between the extreme quintiles of hospital volume. The error of this estimate is large, however, particularly when

Conflict of interest statement

None.

Acknowledgement

The study was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas' National Health Service (NHS) Foundation Trust and King's College London and by the UK National Cancer Analysis and Registration Service, Public Health England. The views expressed are those of the authors and not necessarily those of NHS, NIHR, Public Health England, or the Department of Health. The study was covered by Section 251 of the National Health Service Act

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