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ESOPHAGECTOMY IN THE UNITED STATES: A DECADE OF OUTCOMES
Paul T. Kroner*, Dawn L. Francis, Mathew Thomas, Kenneth R. DeVault
Gastroenterology, Mayo Clinic Florida, Jacksonville, FL
Background
Esophagectomy is the surgical procedure of choice for some stages of esophageal cancer. Prior studies show improved outcomes at urban, teaching, high-volume centers. To date, no national study has examined the trend in esophagectomy procedure volumes or outcomes relating to teaching status, urban location or number of hospital beds. The aim of this study was to explore the trend in esophagectomy volume, mortality and other outcomes relating to hospital teaching status, location, size and economic impact in the past decade in the US using a national database.
Methods
Retrospective cohort study using the National Inpatient Sample from 2005 to 2014, an inpatient database including over 350 million US hospital admissions. All patients with an ICD-9CM code for Esophagectomy were included. None were excluded. The primary outcome was the trend in mean esophagectomy volumes. Secondary outcomes were trends in inpatient mortality, resource utilization measured by length of hospital stay (LOS), total hospitalization charges and costs (adjusted for inflation with the Consumer-Price Index). Odds ratios and means were adjusted for age, sex, race, median income in the patient's zip code, Charlson Comorbidity Index, hospital region, rural location, size and teaching status using multivariate logistic regression.
Results
45,488 esophagectomies were performed in the US in the past decade. Trends are shown on Figure 1. The total number of procedures increased from 4,442 in 2005 to 4,585 in 2014. Though crude mortality decreased from 6.1% in 2005 to 3.4% in 2014 (p=0.01), after adjusting for confounders on multivariate analysis this was not seen (aOR:0.96,p=0.08). Teaching centers displayed decreased mortality (aOR:0.47,p<0.01) and LOS (Adj. Mean:-1.7days,p=0.03) when compared to non-teaching centers (aOR:0.47,p<0.01). Total hospital costs did not vary for patients with esophagectomy in the studied time frame. After adjusting for inflation, total charges increased from $176,502 in 2005 to $208,699 in 2014. These increases were seen irrespective of teaching status, urban location or hospital size, which was corroborated on multivariate analysis (Adj.Mean:$7,995,p<0.01). All outcomes are shown in Table 1.
Conclusion
The total number of esophagectomies has been stable over the past decade. The in-hospital mortality is improving but remains at 3.4% in 2014. The outcomes in teaching hospitals are statistically better including lower mortality and shorter length of hospital stay. Urban and large hospitals also had lower mortality and shorter stays, but this may have been cofounded by the location and size of teaching hospitals in those areas. Although costs remained essentially unchanged, total hospitalization charges have increased significantly, a trend that is observed across most medical conditions and is attributed to changing insurance models and policies.
Table 1
| Adjusted Values | Adjusted OR/Mean (95%CI)
| p-value | Inpatient Mortality
Teaching Hospital
Urban Location
Large Hospital Size | 0.96 (0.91-1.01)
0.47 (0.36-0.62)
0.75 (0.40-1.40)
1.04 (0.70-1.54) | 0.08
<0.01
0.37
0.84 | Length of Stay
Teaching Hospital
Urban Location
Large Hospital Size | 1.03 (0.86 - 1.24)
-1.5 (-2.8 - -0.2)
0.9 (-2.4 - 4.2)
0.5 (-1.0 - 2.1) | 0.75
0.03
0.60
0.51 | Total Hosp. Charges
Teaching Hospital
Urban Location
Large Bedsize | $7,995 ($4,134 - $11,856)
$10,285 (-$22,169 - $42,739)
$40,412 (-$7,346 - $88,171)
$8,730 (-$66,527 - $83,986) | <0.01
0.53
0.10
0.23 | Total Costs
Teaching Hospital
Urban Location
Large Hospital Size | $422 (-$375 - $1,221)
$3,134 (-$3,936 - $10,204)
$967 (-$13,179 - $15,112)
$3,617 (-$7,237 - $14,471) | 0.30
0.39
0.89
0.51 | | Crude Values | 2005 | 2014 | p-value | Overall Inpatient Mortality
Teaching Hospital
Non-Teaching Hospital
Urban Location
Rural Location
Large Hospital Size
Small Hospital Size | 6.1%
4.6%
10.7%
5.8%
13.5%
5.6%
2.9% | 3.4%
3.4%
4.0%
3.3%
7.1%
3.1%
4.0% | <0.01
0.10
0.07
<0.01
0.27
0.01
0.63 | Length of Stay (days)
Teaching Hospital
Non-Teaching Hospital
Urban Location
Rural Location
Large Hospital Size
Small Hospital Size
| 18.5
18.3
18.9
18.6
15.9
18.3
15.5 | 15.5
15.3
19.1
15.4
26.9
15.1
14.7 | <0.01
<0.01
0.51
<0.01
0.96
<0.01
0.34 | Total Hosp. Charges
Teaching Hospital
Non-Teaching Hospital
Urban Location
Rural Location
Large Hospital Size
Small Hospital Size | $176,502
$181,107
$165,136
$179,836
$96,773
$151,386
$121,520 | $208,699
$204,567
$277,943
$207,920
$257,338
$204,036
$201,468 | <0.01
0.03
<0.01
<0.01
<0.01
<0.01
<0.01 | Hospital Costs
Teaching Hospital
Non-Teaching Hospital
Urban Location
Rural Location
Large Hospital Size
Small Hospital Size | $60,801
$60,991
$60,200
$61,402
$46,429
$55,994
$46,028 | $58,620
$57,973
$69,475
$57,053
$94,062
$57,504
$61,997 | 0.22
0.16
0.85
0.12
0.04
0.68
0.08 |
Table 1 - Crude and adjusted (yearly incremental) values for Mortality, Length of Stay, Total Hospitalization Charges and Hospital costs in patients who underwent Esophagectomy in the past decade, stratified by hospital teaching status, urban location and hospital size.
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