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Editorial
Do We Have Enough Information to Act Accordingly? The Relation Between Case Volume and Results Revisited Again
¿Sabemos lo suficiente para actuar en consecuencia? La relación volumen de casos y resultados clínicos examinada una vez más
Josep M. Borrasa,b
a Pla director d’Oncologia, Departament de Salut, Barcelona, Spain
b Departament de Ciències Clíniques, IDIBELL, Universitat de Barcelona, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Surgery is a key element in the multidisciplinary strategy of oncologic treatment&#46; In fact&#44; 80&#37; of patients diagnosed with cancer will be treated surgically&#44; totalling more than 12 million candidates for surgery worldwide in 2015&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given this central role in oncologic therapy&#44; it is no surprise that two very relevant objectives of research are quality assessment and how surgical care services should be organised&#46; The debate about the correlation between surgical volume and results has been the subject of many studies since the 1980s&#46; In general&#44; they have demonstrated an association between volume and results&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> although it is not always clear for all procedures&#44; and certain elements have been debated &#40;whether to analyse results per hospital vs per surgeon&#44; 30-day mortality vs survival&#44; adjustment techniques for risk factors&#44; etc&#46;&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The use of clinical&#8211;administrative databases is a classic strategy&#44; and a good example is the article by P&#233;rez-L&#243;pez et al&#46;&#44; which accompanies this editorial&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> The use of this data source has relevant limitations derived from its purpose&#46; An example of these can be observed when we see that the authors did not separate colon from rectal cancer surgery&#44; which are 2 different surgical treatments both in technique as well as in complexity&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> In this article&#44; they were analysed jointly to avoid inappropriate classifications given the imprecision in the assignation&#44; leading to a mix of surgeries of differing complexities&#44; which makes it difficult to correctly interpret the results&#46; Although these limitations of the minimum basic data set &#40;MBDS&#41; should be taken into consideration&#44; it is undoubtedly the best database available and it covers the entire Spanish National Healthcare System &#40;NHS&#41;&#44; making its conclusions especially relevant&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The result is consistent with the international literature<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> and with previous studies done in Catalonia using the same approach&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Together&#44; they emphasise the need to consider reorganising the complex surgical oncology treatments offered by hospitals in our country and in accordance with the cancer strategy recommendations of the Spanish NHS &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://www.msssi.es/">http&#58;&#47;&#47;www&#46;msssi&#46;es</a>&#41;&#46; The data by P&#233;rez-L&#243;pez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> demonstrate that there are numerous hospitals in Spain that operate with very low case volumes &#40;see Table 2 of the article&#41;&#59; their association with worse clinical results should motivate critical reflection and intervention&#46; Along these lines&#44; several reorganisation initiatives in our country are trying to improve the clinical results and quality of gastrointestinal oncology surgery &#40;and neurosurgery&#44; thoracic surgery and sarcomas as well&#41;&#44; in keeping with the experience of other countries such as the Netherlands&#44; Denmark&#44; France and England&#46; These initiatives have been promoted by the healthcare administration of Spanish <span class="elsevierStyleItalic">autonomous communities</span>&#46; For their application&#44; it is assumed that a minimum volume of cases should be defined after which surgeons have sufficient experience to perform complex surgeries&#46; This minimum volume&#44; which is a useful tool for planning&#44; is very controversial amongst professionals&#46; The evidence for any cut point could be arguable as often times this sort of studies opt for dividing the case volumes by tertiles or quartiles&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> which is analytically useful but leads to different cut off criteria depending on the database used&#46; The practical application is always difficult and tends to be conservative&#46; This has been demonstrated by the criteria for minimal volumes used in Catalonia&#44; which are low compared to those from other countries &#40;for example&#44; 6 cases per year in oesophageal cancer surgery vs 20 in the Netherlands&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Nonetheless&#44; the debate cannot be exclusively centred on volume&#46; It should also be complemented with the continuous evaluation of clinical results&#44; while adjusting for known prognostic factors and using clinical databases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Furthermore&#44; what also must be considered are all the healthcare aspects necessary to achieve good therapeutic results&#44; such as the quality of pathology studies&#44; imaging tests&#44; medical oncology and radiotherapy&#46; All this is viable&#44; as demonstrated by initiatives such as the Viking<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> project or clinical audits of all the cases treated in a region&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">7&#44;8</span></a> Such initiatives evaluate care results in all their complexity and should be the pathway towards the necessary and continued improvement of quality oncological care&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The reorganisation of oncologic surgery should be based on administrative and clinical data&#46; The study by P&#233;rez-L&#243;pez et al&#46;&#44; together with other available evidence and healthcare policies applied in several European countries&#44; demonstrate the need for and the viability of these initiatives&#46;</p></span>"
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Article information
ISSN: 21735077
Original language: English
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