TABLE 5.2

California Postoperative In-Hospital Mortality with Lung Cancer Surgery, 1983-1986

Hospital Volume (no. per year)

Lesser Resections

Pneumonectomy

 

Patients

Adjusted Mortality (%)

Adjusted Odds Ratio

Patients

Adjusted Mortality (%)

Adjusted Odds Ratio

<9

2,588

5.2

1.0

365

13.6

1.0

9-16

2,945

4.1

0.7

374

11.4

0.8

17-24

2,553

3.5

0.6

377

11.7

0.8

>24

2,822

3.4

0.6

413

9.7

0.6

 

SOURCE: Romano and Mark, 1992.

A study of 30-day mortality examined a broader range of conditions. Begg and colleagues (1998) chose five procedures that involve preoperative judgment, diagnostic accuracy, meticulous surgical technique, and demanding postoperative care:

  1. pneumonectomy (removal of part or all of the lung),
  2. pancreatectomy (removal of part or all of the pancreas),
  3. esophagectomy (removal of part or all of the esophagus),
  4. hepatic resection (removal of part or all of the liver), and
  5. pelvic exenteration (removal of two or more pelvic organs in one operation).

Medicare claims files were linked to Surveillance, Epidemiology, and End Results program (SEER) data for care provided to the elderly from 1984 to 1993. "Curative" surgery is rarely performed for these cancers in the elderly. Of all incident cases of these cancers over the 10-year period, the number of procedures within two months of diagnosis ranged from about 1 to 7 percent of all patients diagnosed (Table 5.3).

TABLE 5.3

Medicare-SEER Patient Selection Statistics, 1984-1993

Procedure

Primary Cancer Diagnosis

Incident Cases

Procedures

Percentage

Pancreatectomy

Pancreas

19,205

742

3.9

Esophagectomy

Esophagus

6,782

503

7.4

Pneumonectomy

Lung-bronchus

103,425

1,375

1.3

Hepatic resection

Colon-rectum

126,395

801

0.6

Pelvic exenteration

Various

185,305

1,592

0.9

 

SOURCE: Begg et al., 1998.

Within the small set of patients undergoing surgery, a trend of decreasing 30-day mortality with increasing volume was seen for all conditions except pneumonectomy. When the volume-mortality relationship was observed, the risk of death was at least double in low-, compared



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