Archive for the ‘Esophageal Cancer’ Category

Transparency of Value in the Care of Patients Undergoing Lung Cancer and Esophageal Cancer Surgery

Posted on October 6th, 2013 in Esophageal Cancer, General, Lung Cancer | No Comments »

Medicine is evolving where the focus expands to not just state of the art technology and procedures to care for our patients, but also what value can medicine provide to patients.  That value is defined by not just the overarching goals of therapy, i.e. cure of cancer, resolution of infection, amelioration of pain, but also by the effects on quality of life, function after surgery, and most importantly, what immediate outcomes are important to patients and their families.

For a potential patient and their family, transparency in provider outcomes is key.  The patient-centered outcomes of the UC Davis General Thoracic Surgery Program are tracked by several quality databases and evaluation organizations including the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®), the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database and the LeapFrog Group.  These bodies compare medical institutions outcomes to national benchmarks and determine how individual institutions rank.  For example, in the case of ACS NSQIP, comparisons determine if an institution’s results in eight measured outcomes are in line with its national peers (As Expected), underperform its peers (Needs Improvement) or out perform its peers (Exemplary).

Below are our UC Davis Thoracic Surgery Program Outcomes as measured by the most recent national quality assurance measures:

2012 ACS NSQIP®

Mortality Exemplary
Pneumonia Exemplary
Ventilator > 48 hours Exemplary
Morbidity As Expected
Unplanned Intubation As Expected
Deep Venous Thrombosis As Expected
Urinary Tract Infection As Expected
Return to the Operating Room As Expected

 

Where Mortality is the rate of surviving the hospital experience after an operation; pneumonia is a lung infection acquired during the hospitalization; ventilator > 48hrs refers to the time on a breathing machine after an operation; morbidity is the accumulative complications after an operation; unplanned intubation is the need for a breathing tube to be put back in after an operation; deep venous thrombosis is a blood clot in the arms or legs that may develop after an operation; urinary tract infection is an infection often from a bladder catheter that is placed for an operation; return to the operating room is an unplanned re-operation after the intended or index operation.

STS General Thoracic Surgery Database (2010-2012)

 

UC Davis

National Average

All Procedures Discharge Survival

98.7%

97.8%

All Procedures 30-Day Survival

98.7%

96.6%

Where Discharge Survival is the rate of leaving the hospital alive after the operation, and 30-Day Survival is the rate of surviving 30 days after an operation, even after having gone home.

LeapFrog Group Ratings for Esophageal Resection (2013)

 4-Bar, Best Odds for Survival Ranking or Highest Quality of Care Rating: Top in the Sacramento region.

Where 4-Bars (Highest Quality of Care Rating) means the patient has the best chances of surviving an esophageal resection.  An esophageal resection or Esophagectomy is a surgery to remove the esophagus and replace it with the stomach or colon and is most commonly performed for cancer, though sometimes it needs to be performed for very extreme non-cancer disease.

The LeapFrog Group determines the Highest Quality of Care Rating by surveying participating hospitals and measuring their outcomes.  A hospital can achieve a Highest Quality of Care Rating by:

-       Participating in the Leapfrog Survey

-       Performing ≥ 13 esophagectomies during the survey year

-       All of the esophagectomies performed by high-volume surgeon (≥ 2 esophagectomies/year)

The LeapFrog Highest Quality of Care Rating determines quality or value based on the volume, or the number of procedures performed.  The thinking is that having experience with a procedure refines quality outcomes and promotes value.  This volume-outcome relationship has been demonstrated in the scientific literature (Birkmeyer et al, New Engl J of Med, 2002) for both esophageal cancer surgery (Esophagectomy) as well as lung cancer surgery otherwise called pulmonary resection, such as lobectomy and pneumonectomy.

Since 2008 our UC Davis General Thoracic Surgery Program has performed 100 esophagectomies and over 200 lobectomy and pneumonectomies.

Patient-centered value outcomes, as mentioned above, have a lot to do with the skill of the surgeon and the surgeon’s volume based experience.  However the central driver of quality outcomes is careful planning, attention to detail, and scientific evidence based best-practice treatment algorithms that are followed in consensus by the entire care team.  Care processes or pathways that are patient/family-focused, foster coordination and communication amongst all providers can promote efficiency and improve results that are important to patients (Vanhaecht et al, Health Serv Mange Res, 2007).

At UC Davis, we have developed novel evidence based post-operative care pathways for esophagectomy (Cooke et al, Society of Thoracic Surgeons 49th Annual Meeting, 2013) and lung resection as well as Respiratory Therapy pathways that are designed to prevent pneumonia, need for replacement of a breathing tube and pronged need for a breathing tube (Tanner-Corbett…Cooke et al, 14th World Conference on Lung Cancer, 2011), and in effect, “stack the deck” in the patients favor to achieve important top clinical outcomes.

With our evolving health care system, the definition of quality has matured from not only advanced technology that is available, but also the value in outcomes that the patient experiences, and maximization of the outcomes that are most important to patients and their families.  Transparency in provider outcomes helps patients make informed decisions on how their care should be directed.

The American College of Physicians (ACP) Best Practice Advice for Upper Endoscopy for GERD is Available

Posted on January 10th, 2013 in Benign Esophagus, Esophageal Cancer | No Comments »

Gastroesophageal reflux disease (GERD) or acid reflux from the stomach into the esophagus is a known risk factor for Barrett’s metaplasia and subsequently an esophageal cancer known as adenocarcinoma. According to the National Cancer Institute (Cancer.gov) in 2012 there were 17,460 new cases of esophageal cancer in the United States and 15,070 deaths from the disease. Surgery, with or without chemotherapy and radiation may be curative for esophageal cancer, especially for those patients with early stage disease.

Unlike breast and colorectal cancer, screening criteria for esophageal cancer is debatable. Many primary care providers don’t know 1) who is at risk for esophageal cancer, and 2) who needs to be screened.

The ACP helps clarify some of these questions with their Best Practice Advice for screening upper endoscopy criteria for those patients with GERD.

The key points from their guidelines are as follows:

• Everyone with Barrett’s metaplasia should be in an endoscopic surveillance program at least every three years, if there is dysplasia, then surveillance should be more frequent
• Everyone should get a screening endoscopy if they have heartburn [GERD] + additional symptoms (including dysphagia, anemia, vomiting, etc…)
• Everyone should get screening endoscopy if they have GERD symptoms that do not respond to 4-8 weeks of proton-pump inhibitor therapy
• Men over 50 with chronic GERD and additional risk factors (including elevated body mass index, smoking, etc…) should get screening endoscopy

From our perspective, although being male is an independent risk factor for adenocarcinoma of the esophagus (male to female ratio of incidence is 3:1), we would still recommend counseling a woman on screening endoscopy if she fit the above demographics.

For more information on the ACP Best Practice Advice see the below URL:

http://annals.org/article.aspx?articleid=1467417