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Volume–Outcome Associations after Major Hepatectomy for Hepatocellular Carcinoma: a Nationwide Taiwan Study

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Objective

The objective of this study was to explore volume–outcome associations after major hepatectomy for hepatocellular carcinoma (HCC).

Methods

This population-based cohort study retrospectively analyzed 23,107 major hepatectomies for HCC patients from 1998 to 2009. Relationships between hospital/surgeon volume and patient outcome were analyzed by propensity score matching (PSM). Five-year overall survival (OS) was estimated by Kaplan–Meier method, and differences were compared by log-rank test.

Results

The mean length of stay (LOS) after major hepatectomy was 18.1 days, and the mean hospital cost was US$5,088.2. After PSM, the mean OS in high- and low-volume hospitals was 71.1 months (standard deviation (SD) 0.7 months) and 68.6 months (SD 0.6 months), respectively; the mean OS in high- and low-volume surgeons was 78.5 months (SD 0.7 months) and 66.9 months (SD 0.7 months), respectively. The PSM analysis showed that treatment by high-volume hospitals and treatment by high-volume surgeons were both associated with significantly shorter LOS, lower hospital cost, and longer survival compared to their low-volume counterparts (P < 0.001).

Conclusions

The results of this nationwide study support the regionalization of HCC treatment by hospital volume and by surgeon volume. High surgeon volume revealed both short- and long-term benefits. The applicability of PSM in volume–outcome analysis may also be confirmed.

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References

  1. Richardson AJ, Pang TC, Johnston E, Hollands MJ, Lam VW, Pleass HC. The volume effect in liver surgery—a systematic review and meta-analysis. J Gastrointest Surg 2013;17(11):1984-1996.

    Article  PubMed  Google Scholar 

  2. Hyder O, Sachs T, Ejaz A, Spolverato G, Pawlik TM. Impact of hospital teaching status on length of stay and mortality among patients undergoing complex hepatopancreaticobiliary surgery in the USA. J Gastrointest Surg 2013;17(12):2114-2122.

    Article  PubMed  Google Scholar 

  3. Shi HY, Lee KT, Wang JJ, Sun DP, Lee HH, Chiu CC. Artificial neural network model for predicting 5-year mortality after surgery for hepatocellular carcinoma: a nationwide study. J Gastrointest Surg 2012;16:2126-2131.

    Article  PubMed  Google Scholar 

  4. Shi HY, Lee KT, Lee HH, Ho WH, Sun DP, Wang JJ, Chiu CC. Comparison of artificial neural network and logistic regression models for predicting in-hospital mortality after primary liver cancer surgery. PLoS One 2012;7:e35781.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  5. Farges O, Goutte N, Bendersky N, Falissard B; ACHBT-French Hepatectomy Study Group. Incidence and risks of liver resection: an all-inclusive French nationwide study. Ann Surg 2012;256(5):697-704.

    Article  PubMed  Google Scholar 

  6. Shetty GS, You YK, Choi HJ, Na GH, Hong TH, Kim DG. Extending the limitations of liver surgery: outcomes of initial human experience in a high-volume center performing single-port laparoscopic liver resection for hepatocellular carcinoma. Surg Endosc 2012;26:1602-1608.

    Article  PubMed  Google Scholar 

  7. Tschuor Ch, Croome KP, Sergeant G, Cano V, Schadde E, Ardiles V, Slankamenac K, Clariá RS, de Santibaňes E, Hernandez-Alejandro R, Clavien PA. Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion – an extension of the ALPPS approach. Eur J Surg Oncol 2013;39(11):1230-1235.

    Article  PubMed  Google Scholar 

  8. McKay A, You I, Bigam D, Lafreniere R, Sutherland F, Ghali W, Dixon E. Impact of surgeon training on outcomes after resective hepatic surgery. Ann Surg Oncol 2008;15:1348-1355.

    Article  PubMed  Google Scholar 

  9. Ramacciato G, D'Angelo F, Baldini R, Petrucciani N, Antolino L, Aurello P, Nigri G, Bellagamba R, Pezzoli F, Balesh A, Cucchetti A, Cescon M, Del Gaudio M,Ravaioli M, Pinna AD. Hepatocellular carcinomas and primary liver tumors as predictive factors for postoperative mortality after liver resection: a meta-analysis of more than 35,000 hepatic resections. Am Surg 2012;78:456-467.

    PubMed  Google Scholar 

  10. Mishra A, Otgonsuren M, Venkatesan C, Afendy M, Erario M, Younossi ZM. The inpatient economic and mortality impact of hepatocellular carcinoma from 2005 to 2009: analysis of the US nationwide inpatient sample. Liver Int 2013;33:1281-1286.

    Article  PubMed  Google Scholar 

  11. Saxena A, Chua TC, Perera M, Chu F, Morris DL. Surgical resection of hepatic metastases from neuroendocrine neoplasms: a systematic review. Surg Oncol 2012;21(3):e131-141.

    Article  PubMed  Google Scholar 

  12. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613-619.

    Article  CAS  PubMed  Google Scholar 

  13. Sudan R, Bennett KM, Jacobs DO, Sudan DL. Multifactorial analysis of the learning curve for robot-assisted laparoscopic biliopancreatic diversion with duodenal switch. Ann Surg 2012;255(5):940-945.

    Article  PubMed  Google Scholar 

  14. Joffe MM, Rosenbaum PR. Invited commentary: propensity scores. Am J Epidemiol 1999;150:327-333.

    Article  CAS  PubMed  Google Scholar 

  15. Shaheen NJ, Kim HP, Bulsiewicz WJ, Lyday WD, Triadafilopoulos G, Wolfsen HC, Komanduri S, Chmielewski GW, Ertan A, Corbett FS, Camara DS, Rothstein RI, Overholt BF. Prior fundoplication does not improve safety or efficacy outcomes of radiofrequency ablation: results from the U.S. RFA Registry. J Gastrointest Surg 2013;17(1):21-28.

    Article  PubMed  Google Scholar 

  16. Lorenzo CS, Limm WM, Lurie F, Wong LL. Factors affecting outcome in liver resection. HPB 2005;7:226-230.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Lutjens LR. Determinants of hospital length of stay. J Nurs Adm 1993;23:14-18.

    Article  CAS  PubMed  Google Scholar 

  18. Rosenthal GE, Harper DL, Quinn LM, Cooper GS. Severity-adjusted mortality and length of stay in teaching and nonteaching hospitals. Results of a regional study. JAMA 1997;278:485-490.

    Article  CAS  PubMed  Google Scholar 

  19. Fortney JC, Booth BM, Smith GR. Variation among VA hospitals in length of stay for treatment of depression. Psychiatr Serv 1996;47:608-613.

    CAS  PubMed  Google Scholar 

  20. Hsia CY, Chau GY, King KL, Loong CC, Lui WY, Wu CW. Factors for prolonged length of stay after elective hepatectomy for hepatocellular carcinoma. The surgeon's role in the managed care era. Hepatogastroenterology 2003;50:798-804.

    PubMed  Google Scholar 

  21. Kim WR, Gores GJ, Benson JT, Therneau TM, Melton LJ 3rd. Mortality and hospital utilization for hepatocellular carcinoma in the United States. Gastroenterology 2005;129:486-493.

    Article  PubMed  Google Scholar 

  22. Lin HC, Tung YC, Chen CC, Tang CH. Relationships between length of stay and hospital characteristics under the case-payment system in Taiwan: using data for vaginal delivery patients. Chang Gung Med J 2003;26:259-268.

    PubMed  Google Scholar 

  23. Chiu HC, Lee LJ, Hsieh HM, Mau LW. Inappropriate hospital utilization for long-stay patients in southern Taiwan. Kaohsiung J Med Sci 2003;19:225-232.

    Article  PubMed  Google Scholar 

  24. Chuang KY, Wu SC, Dai YT, Ma AH. Post-hospital care of stroke patients in Taipei: use of services and policy implications. Health Policy 2007;82:28-36.

    Article  PubMed  Google Scholar 

  25. Lee SD. Exploring policy and financing options for long term care in Taiwan. J Aging Soc Policy 2001;13:203-216.

    Article  CAS  PubMed  Google Scholar 

  26. Lee HC, Chang KC, Lan CF, Hong CT, Huang YC, Chang ML. Factors associated with prolonged hospital stay for acute stroke in Taiwan. Acta Neurol Taiwan 2008;17:17-25.

    CAS  PubMed  Google Scholar 

  27. Hsieh CI, Chung KP, Yang MC, Li TC. Association of treatment and outcomes of doctor-shopping behavior in patients with hepatocellular carcinoma. Patient Prefer Adherence 2013;7:693-701.

    Article  PubMed Central  PubMed  Google Scholar 

  28. Wang MJ, Lin SP. Study on doctor shopping behavior: insight from patients with upper respiratory tract infection in Taiwan. Health Policy 2010;94:61-67.

    Article  PubMed  Google Scholar 

  29. Cheng SH, Song HY. Physician performance information and consumer choice: a survey of subjects with the freedom to choose between doctors. Qual Saf Health Care 2004;13:98-101.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Robinson JC, Luft HS, McPhee SJ, Hunt SS. Hospital competition and surgical length of stay. JAMA 1988;259:696-700.

    Article  CAS  PubMed  Google Scholar 

  31. Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg 2007;94:145-161.

    Article  CAS  PubMed  Google Scholar 

  32. Livingston EH, Cao J. Procedure volume as a predictor of surgical outcomes. JAMA 2010;304:95-97.

    Article  CAS  PubMed  Google Scholar 

  33. Tol JA, van Gulik TM, Busch OR, Gouma DJ. Centralization of highly complex low-volume procedures in upper gastrointestinal surgery. A summary of systematic reviews and meta-analyses. Dig Surg 2012;29:374-383.

    Article  PubMed  Google Scholar 

  34. Derogar M, Sadr-Azodi O, Johar A, Lagergren P, Lagergren J. Hospital and surgeon volume in relation to survival after esophageal cancer surgery in a population-based study. J Clin Oncol 2013;31:551-557.

    Article  PubMed  Google Scholar 

  35. Boudourakis LD, Wang TS, Roman SA, Desai R, Sosa JA. Evolution of the surgeon-volume, patient-outcome relationship. Ann Surg 2009;250:159-165.

    Article  PubMed  Google Scholar 

  36. Nathan H, Cameron JL, Choti MA, Schulick RD, Pawlik TM. The volume-outcomes effect in hepato-pancreato-biliary surgery: hospital versus surgeon contributions and specificity of the relationship. J Am Coll Surg 2009;208:528-538.

    Article  PubMed  Google Scholar 

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Acknowledgement

This work was supported in part by the Chi Mei Medical Center and Kaohsiung Medical University Cooperation Program, Taiwan, R.O.C., under Grant Numbers 102CM-KMU-01.

Conflict of interest

The authors have no conflicts of interest in the publication of this study.

Author information

Authors and Affiliations

  1. Department of Surgery, Chi Mei Medical Center, Liouying, Taiwan

    Chih-Cheng Lu & Chong-Chi Chiu

  2. Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan

    Chong-Chi Chiu

  3. Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan

    Chong-Chi Chiu

  4. Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan

    Jhi-Joung Wang

  5. Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, 100-Shih-Chun 1st Road, Kaohsiung, 80708, Taiwan

    Yu-Hsien Chiu & Hon-Yi Shi

Authors
  1. Chih-Cheng Lu
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  2. Chong-Chi Chiu
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  3. Jhi-Joung Wang
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  4. Yu-Hsien Chiu
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  5. Hon-Yi Shi
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Corresponding author

Correspondence to Hon-Yi Shi.

Additional information

Chih-Cheng Lu and Chong-Chi Chiu contributed equally to this work.

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Lu, CC., Chiu, CC., Wang, JJ. et al. Volume–Outcome Associations after Major Hepatectomy for Hepatocellular Carcinoma: a Nationwide Taiwan Study. J Gastrointest Surg 18, 1138–1145 (2014). https://doi.org/10.1007/s11605-014-2513-5

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  • DOI: https://doi.org/10.1007/s11605-014-2513-5

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