Cancer care provided by anesthesiologists who perform six or more complex gastrointestinal (GI) procedures a year was independently associated with a lower risk of adverse postoperative outcomes compared to anesthesiologists with low procedural volume, a population-based cohort study found.
In a study cohort of 8,096 patients who had undergone esophagectomy, pancreatectomy, or hepatectomy for GI cancer, the primary outcome of 90-day major morbidity and hospital readmission occurred in 36.3% of patients treated by high-volume (six procedures a year or more) anesthesiologists compared with 45.7% of patients treated with their low-volume counterparts, Julie Hallet, MD, University of Toronto, Toronto, Ontario, and colleagues reported in JAMA Surgery.
After adjusting for potential confounders including surgery and institutional volume, care by a high-volume anesthesiologist was independently associated with a 15% lower risk of achieving the primary composite outcome at an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.76-0.94) compared with a low-volume anesthesiologist, investigators added.
“The current study is important because it presents a real-world assessment of the association between anesthesiologist volume and perioperative outcomes,” Hallet and colleagues observed. “…Implications of our results [include] organizing perioperative care to increase anesthesiologist volume.”
In an accompanying editorial, Karl Bilimoria, MD, Feinberg School of Medicine, Northwestern University, Chicago, Illinois and colleagues pointed out that many people overlook the fact that surgery is a “team sport” requiring a coordinated effort to provide optimal care to patients with complex surgical needs.
“This team coordination applies to what occurs both inside and outside the operating room,” the editorialists noted.
On the other hand, they acknowledged that an individual anesthesiologist’s expertise in a specific surgical procedure has not been well established; as such, they applauded Hallet et al’s efforts to shed light on this topic.
For their analysis, Hallet and colleagues used administrative healthcare data sets from various data sources in Ontario, Canada, to identify adult patients who underwent esophagectomy, pancreatectomy, or hepatectomy for GI cancer from Jan. 1, 2007 through Dec. 31, 2018. of the 8,096 patients recruited for the study, 66.3% were men and the median age was 65 years (interquartile range [IQR], 57-72 years).
A total of 842 anesthesiologists and 186 surgeons treated all patients involved in the study during the study period. The median anesthesiologist volume was three (IQR, 1.5-6) procedures a year and the median surgeon volume was 27 (IQR, 15-45) procedures per year.
As the authors noted, the 75th percentile was chosen as the cutoff point to distinguish high volume, namely six or more procedure per year. Slightly over one-quarter (26.7%) of patients received care from a high-volume anesthesiologist.
For secondary outcomes, care by a high-volume anesthesiologist was associated with a 17% lower risk of 90-day major morbidity (aOR: 0.83; 95% CI, 0.75-0.91) and a similar, 16% lower risk of patients requiring an unplanned intensive care unit admission (aOR: 0.84; 95% CI, 0.76-0.64), investigators noted.
Major morbidity was defined as Clavien-Dindo classification grade 3 to 5 postoperative complications, which included mortality as a grade 5 complication, the study authors explained —and, they added, the 90-day time frame was chosen because it better represents the morbidity burden of surgery, they added.
Looking at each of the three complex GI procedures provided, investigators found that care by a high-volume anesthesiologist was associated with a significantly decreased risk of a primary composite outcome for hepatectomy patients (aOR: 0.84; 95% CI, 0.72-0.97) and a non-significant decreased risk for pancreatectomy patients (aOR: 0.77; 95% CI, 0.55-1.07).
The same protective effect from high-volume anesthesiologist care was not, however, seen for esophagectomy patients, where the aOR for a primary composite outcome was 1.07 (95% CI, 0.91-1.24).
The duration of each operative procedure did not alter the final results.
As the authors noted, complex GI cancer surgery represents a “unique opportunity” to analyze volume-associated outcomes for anesthesiologist because all 3 procedures carry a substantial risk of postoperative morbidity and mortality. “In addition, these surgical procedures require unique intraoperative management that differs from other procedures with specific fluid and blood management strategies and longer operating times,” they added. As such, these types of procedures may be more susceptible to variation that is associated with experience and expertise.
“The median anesthesiologist volume was very low despite policy-mandated regionalization of esophagectomy, pancreatectomy, and hepatectomy, which contrasted with high surgeon and institutional volumes,” Hallet and colleagues observed. “…This finding suggests that redistribution of volume within institutions, such as creating specialized anesthesiology teams, could increase the number of high-volume anesthesiologists.”
However, as Bilimoria and colleagues pointed out in their editorial, it should be recognized that underlying processes and mechanisms driving improved outcomes are what lie at the heart of the matter.
“As the authors [themselves] correctly pointed out, volume likely serves as a proxy for factors such as experience, processes of care, multidisciplinary team organization, and technical skills, to name a few,” Bilimoria and colleagues wrote. Procedure-specific intraoperative resuscitation and transfusion, for example, have both been shown to affect postoperative outcomes.
Thus, the merits of policies that regulate patient care only on the basis of volume need to be critically examined, as the editorialists emphasized. And while these policies may be useful to gauge quality metrics, “such policies may have unintended consequences, including limiting access to care and altering the training of successive high-performing clinicians,” they added.
The study also demonstrated that despite regionalizing cancer surgery and standardizing both surgeon and institutional volumes in the province, “wide variation in outcomes remained,” they pointed out.
“[M]uch work still needs to be done to uncover the true underlying factors associated with improved outcomes,” the editorialists concluded.
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Cancer care provided by anesthesiologists who performed six or more complex GI procedures a year was associated with a lower risk of adverse postoperative outcomes compared with care provided by low-volume anesthesiologists.
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Volume of care likely serves as a proxy for factors such as experience and technical skills, and regulating patient care on the basis of volume alone could have unintended consequences, the editorialists noted.
Pam Harrison, Contributing Writer, BreakingMED™
Hallet reported receiving personal fees from Ipsen Biopharmaceuticals Canada as well as speaking honoraria and personal fees from Advanced Accelerator Applications and Novartis Oncology.
Bilimoria had no conflicts of interest to declare.
Cat ID: 935
Topic ID: 78,935,730,188,935,192,925
