pneumonectomy. The likelihood of an in-hospital death was 40 percent lower for high-volume hospitals (more than 24 procedures per year) than for low-volume hospitals (fewer than 9 procedures per year) for both lesser resections and pneumonectomy after controlling for patient demographic characteristics and clinical comorbidity (chronic obstructive pulmonary disease, coronary artery disease, and diabetes). The distribution of procedures by volume was as follows: 24 percent in low-; 50 percent in medium-; and 26 percent in high-volume hospitals (Table 5.2).

Although volume had a significant effect, there was no difference in the risk of in-hospital death associated with teaching status. Hospitals were stratified into high, low, and non-teaching according to the number of residency programs at a facility. The effect of individual surgeon volume was not addressed. A limitation of this study is its reliance on hospital discharge data, which do not capture postdischarge events. The outcome is limited to in-hospital mortality, but this could be affected by hospital policies regarding length of stay (e.g., hospitals could have low in-hospital mortality but very high mortality following premature discharges).

TABLE 5.1

Initial NSCLC Care in Virginia, 1989-1991 (percent)

 

Total

Local

Regional

Distant

Initial Treatment Category

Age < 64

Age > 65

Age < 64

Age > 65

Age < 64

Age > 65

Age < 64

Age > 65

 

(n = 336)

(n = 1.132)

(n = 71)

(n = 331)

(n = 105)

(n = 331)

(n = 160)

(n = 468)

Surgery only

23.6

21.2

74.6a

50.4a

23.1

18.8

1.3

3.1

Surgery plusb

13.1

7.8

5.6

4.1

28.8a

13.8a

5.6

6.1

Radiation

40.0

39.4

7.0

25.8

31.7

41.9

60.0

47.0

Radiation + chemotherapy

6.9

1.2

1.4

0.6

3.8

0.6

11.3

2.0

Chemotherapy

4.2

1.6

0.0

0.0

2.9

1.1

6.9

2.9

None

12.2

28.9

11.3

19.1

8.7

23.9

15.0a

38.9a

Any surgery

36.7a

28.0a

80.2a

54.8a

51.9a

32.0a

6.9

9.1

Any radiation

59.1a

47.9a

14.0

30.5

65.4

56.0

76.2a

54.9a

Any chemotherapy

11.9a

3.3a

1.4

0.8

8.6

2.0

18.8a

5.1a

NOTE: Patients under age 65 were privately insured through Virginia Blue Cross/Blue Shield. Individuals age 65 and older were Medicare enrollees. Unstaged patients were excluded.

a Differences between cohorts were statistically different at p < .00005.

b "Surgery plus" is defined as surgery plus radiation, chemotherapy, or radiation and

SOURCE: Hillner et al., 1998a.



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