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Qualitätsindikatoren für die onkologische Kolonchirurgie

Evidenzbasierte Entwicklung eines Indikatorensets für die Ergebnisqualität

Quality indicators for colon cancer surgery

Evidence-based development of a set of indicators for the outcome quality

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Zusammenfassung

Hintergrund

Die Bewertung der chirurgischen Qualität gewinnt zunehmend an Bedeutung. Auch wenn sich in der Literatur vereinzelt Empfehlungen zu Qualitätsindikatoren (QI) für die onkologische Kolonchirurgie finden, so sind diese meist nicht evidenzbasiert hergeleitet. Zudem fehlen Referenzbereiche.

Fragestellung

Ziel dieser Arbeit war es, im von der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) beauftragten Expertenkreis QI für die onkologische Kolonchirurgie zu entwickeln, die auf dem aktuellsten wissenschaftlichen Stand basieren. Die QI-Referenzbereiche aus der Literatur wurden den Referenzwerten aus dem StuDoQ(Studien‑, Dokumentations- und Qualitätszentrum)|Kolonkarzinom-Register gegenübergestellt, um hieraus eine an die hiesige Versorgung angepasste Empfehlung abzuleiten.

Ergebnisse

Auf Basis der aktuellen wissenschaftlichen Evidenz wurden im Expertenkonsens fünf QI für die Kolonchirurgie definiert und anhand des QUALIFY-Instruments bewertet. Mortalität, MTL30 (Mortalität, Transfer in ein anderes Akutkrankenhaus oder Liegedauer ≥30 Tage), Anastomoseninsuffizienz mit Reinterventionsbedarf, Wundinfekt mit Notwendigkeit der Wunderöffnung sowie Anzahl resezierter Lymphknoten ≥12 qualifizierten sich aufgrund ihrer Relevanz, Wissenschaftlichkeit und Praktikabilität. Basierend auf der systematischen Literaturrecherche sowie der Auswertung des StuDoQ|Kolonkarzinom-Registers werden präliminäre QI-Referenzwerte vorgeschlagen.

Schlussfolgerungen

Das vorgestellte QI-Set scheint geeignet für die Qualitätsbewertung der onkologischen Kolonchirurgie im hiesigen Versorgungssystem. Die Validität der QI und die Referenzbereiche müssen im Rahmen der Implementierung überprüft werden. Das StuDoQ|Kolonkarzinom-Register bietet sowohl zur Erfassung der QI als auch zur Ermittlung der Risikoadjustoren die geeignete Struktur.

Abstract

Background

Quality assessment in surgery is gaining in importance. Although sporadic recommendations for quality indicators (QI) in oncological colon surgery can be found in the literature, these are usually not systematically derived from a solid evidence base. Moreover, reference ranges for QI are unknown.

Objective

The aim of this initiative was the development of evidence-based QI for oncological colon resections by an expert panel invited by the German Society of General and Visceral Surgery (DGAV). Reference ranges from the literature and reference values from the Study, Documentation, and Quality Center (StuDoQ)|Colon Cancer Register were compared in order to deduce recommendations which are tailored to the German healthcare system.

Results

Based on the most recent scientific evidence and agreed by expert consensus, five QI for oncological colon surgery were defined and evaluated according to the QUALIFY tool. Mortality, MTL30 (mortality, transfer to another acute care hospital, or length of stay ≥30 days), anastomotic leakage requiring reintervention, surgical site infections necessitating reopening of the wound and ≥12 lymph nodes in the specimen qualified as QI owing to their relevance, scientific nature, and practicability. Based on the results of the systematic literature search and the statistical analysis of the StuDoQ|Colon Cancer Register, preliminary reference values are proposed for each QI.

Conclusion

The presented set of QI seems appropriate for quality assessment of oncological colon surgery in the context of the German healthcare system. The validity of the QI and the reference values must be reviewed within the framework of their implementation. The StuDoQ|Colon Cancer Register provides a suitable infrastructure for collecting clinical data for quality assessment and risk adjustment.

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Literatur

  1. http://www.leitlinien.de/mdb/edocs/pdf/schriftenreihe/schriftenreihe36.pdf. Zugegriffen: 23.10.2015

  2. Reiter A, Fischer B, Kotting J et al (2007) QUALIFY–a tool for assessing quality indicators. Z Arztl Fortbild Qualitatssich 101:683–688

    PubMed  Google Scholar 

  3. http://www.cochrane.de/sites/cochrane.de/files/public/uploads/20130517_Manual_Literaturrecherche_Final-1.pdf. Zugegriffen: 22.10.2015

  4. Team RC (2017) R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna

    Google Scholar 

  5. Viechtbauer W (2010) Conducting meta-analyses in R with the metafor package. J Stat Softw 36:1–48

    Article  Google Scholar 

  6. Stijnen T, Hamza TH, Ozdemir P (2010) Random effects meta-analysis of event outcome in the framework of the generalized linear mixed model with applications in sparse data. Stat Med 29:3046–3067

    Article  PubMed  Google Scholar 

  7. Wiegering A, Wellner U, Seyfried F et al (2017) MTL30 as surrogate parameter for quality of surgically treated diseases : establishment based on the StuDoQ register of the German Society for General and Visceral Surgery. Chirurg. https://doi.org/10.1007/s00104-017-0479-z

    Google Scholar 

  8. Gouvas N, Agalianos C, Papaparaskeva K et al (2016) Surgery along the embryological planes for colon cancer: a systematic review of complete mesocolic excision. Int J Colorectal Dis 31:1577–1594

    Article  PubMed  Google Scholar 

  9. Kontovounisios C, Kinross J, Tan E et al (2015) Complete mesocolic excision in colorectal cancer: a systematic review. Colorectal Dis 17:7–16

    Article  CAS  PubMed  Google Scholar 

  10. Munkedal DL, Laurberg S, Hagemann-Madsen R et al (2016) Significant individual variation between pathologists in the evaluation of colon cancer specimens after complete mesocolic excision. Dis Colon Rectum 59:953–961

    Article  PubMed  Google Scholar 

  11. Benz SR, Tannapfel A, Tam Y et al (2015) Complete mesocolic excision for right-sided colon cancer - the role of central lymph nodes. Zentralbl Chir 140:449–452

    CAS  PubMed  Google Scholar 

  12. Panis Y, Maggiori L, Caranhac G et al (2011) Mortality after colorectal cancer surgery: a French survey of more than 84,000 patients. Ann Surg 254:738–743

    Article  PubMed  Google Scholar 

  13. Mamidanna R, Burns EM, Bottle A et al (2012) Reduced risk of medical morbidity and mortality in patients selected for laparoscopic colorectal resection in England: a population-based study. Arch Surg 147:219–227

    Article  PubMed  Google Scholar 

  14. de Vries S, Jeffe DB, Davidson NO et al (2014) Postoperative 30-day mortality in patients undergoing surgery for colorectal cancer: development of a prognostic model using administrative claims data. Cancer Causes Control 25:1503–1512

    Article  PubMed  PubMed Central  Google Scholar 

  15. Benz S, Barlag H, Gerken M et al (2016) Laparoscopic surgery in patients with colon cancer: a population-based analysis. Surg Endosc 31(6):2586–2595. https://doi.org/10.1007/s00464-016-5266-2

    Article  PubMed  Google Scholar 

  16. Dimick JB, Staiger DO, Hall BL et al (2013) Composite measures for profiling hospitals on surgical morbidity. Ann Surg 257:67–72

    Article  PubMed  Google Scholar 

  17. Merkow RP, Hall BL, Cohen ME et al (2013) Validity and feasibility of the american college of surgeons colectomy composite outcome quality measure. Ann Surg 257:483–489

    Article  PubMed  Google Scholar 

  18. Jung SH, Yu CS, Choi PW et al (2008) Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery. Dis Colon Rectum 51:902–908

    Article  PubMed  Google Scholar 

  19. Law WL, Choi HK, Lee YM et al (2007) Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy. J Gastrointest Surg 11:8–15

    Article  PubMed  Google Scholar 

  20. McArdle CS, McMillan DC, Hole DJ (2005) Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer. Br J Surg 92:1150–1154

    Article  CAS  PubMed  Google Scholar 

  21. Walker KG, Bell SW, Rickard MJ et al (2004) Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer. Ann Surg 240:255–259

    Article  PubMed  PubMed Central  Google Scholar 

  22. Buchs NC, Gervaz P, Secic M et al (2008) Incidence, consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study. Int J Colorectal Dis 23:265–270

    Article  PubMed  Google Scholar 

  23. Kanellos I, Blouhos K, Demetriades H et al (2004) The failed intraperitoneal colon anastomosis after colon resection. Tech Coloproctol 8(Suppl 1):s53–s55

    Article  PubMed  Google Scholar 

  24. Khan AA, Wheeler JM, Cunningham C et al (2008) The management and outcome of anastomotic leaks in colorectal surgery. Colorectal Dis 10:587–592

    Article  CAS  PubMed  Google Scholar 

  25. Bakker IS, Grossmann I, Henneman D et al (2014) Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 101:424–432

    Article  CAS  PubMed  Google Scholar 

  26. Krarup PM, Nordholm-Carstensen A, Jorgensen LN et al (2015) Association of comorbidity with anastomotic leak, 30-day mortality, and length of stay in elective surgery for colonic cancer: a nationwide cohort study. Dis Colon Rectum 58:668–676

    Article  PubMed  Google Scholar 

  27. Marinello FG, Baguena G, Lucas E et al (2016) Anastomotic leakage after colon cancer resection: does the individual surgeon matter? Colorectal Dis 18:562–569

    Article  CAS  PubMed  Google Scholar 

  28. Kube R, Mroczkowski P, Steinert R et al (2009) Anastomotic leakage following bowel resections for colon cancer: multivariate analysis of risk factors. Chirurg 80:1153–1159

    Article  CAS  PubMed  Google Scholar 

  29. Frasson M, Flor-Lorente B, Rodriguez JL et al (2015) Risk factors for anastomotic leak after colon resection for cancer: multivariate analysis and nomogram from a multicentric, prospective, national study with 3193 patients. Ann Surg 262:321–330

    Article  PubMed  Google Scholar 

  30. Tan WP, Talbott VA, Leong QQ et al (2013) American Society of Anesthesiologists class and Charlson’s comorbidity index as predictors of postoperative colorectal anastomotic leak: a single-institution experience. J Surg Res 184:115–119

    Article  PubMed  Google Scholar 

  31. Adegboyega TO, Borgert AJ, Lambert PJ et al (2016) Applying the national surgical quality improvement program risk calculator to patients undergoing colorectal surgery: theory vs reality. Am J Surg 213(1):30–35. https://doi.org/10.1016/j.amjsurg.2016.04.011

    Article  PubMed  Google Scholar 

  32. Guillou PJ, Quirke P, Thorpe H et al (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718–1726

    Article  PubMed  Google Scholar 

  33. Veldkamp R, Kuhry E, Hop WC et al (2005) Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 6:477–484

    Article  PubMed  Google Scholar 

  34. Papageorge CM, Zhao Q, Foley EF et al (2016) Short-term outcomes of minimally invasive versus open colectomy for colon cancer. J Surg Res 204:83–93

    Article  PubMed  Google Scholar 

  35. Chang GJ, Rodriguez-Bigas MA, Skibber JM et al (2007) Lymph node evaluation and survival after curative resection of colon cancer: systematic review. J Natl Cancer Inst 99:433–441

    Article  PubMed  Google Scholar 

  36. Dillman RO, Aaron K, Heinemann FS et al (2009) Identification of 12 or more lymph nodes in resected colon cancer specimens as an indicator of quality performance. Cancer 115:1840–1848

    Article  PubMed  Google Scholar 

  37. Vather R, Sammour T, Kahokehr A et al (2009) Lymph node evaluation and long-term survival in Stage II and Stage III colon cancer: a national study. Ann Surg Oncol 16:585–593

    Article  PubMed  Google Scholar 

  38. Mathis KL, Green EM, Sargent DJ et al (2013) Surgical quality surrogates do not predict colon cancer survival in the setting of technical credentialing: a report from the prospective COST trial. Ann Surg 257:102–107

    Article  PubMed  Google Scholar 

  39. Tsikitis VL, Larson DL, Wolff BG et al (2009) Survival in stage III colon cancer is independent of the total number of lymph nodes retrieved. J Am Coll Surg 208:42–47

    Article  PubMed  Google Scholar 

  40. Wang J, Kulaylat M, Rockette H et al (2009) Should total number of lymph nodes be used as a quality of care measure for stage III colon cancer? Ann Surg 249:559–563

    Article  PubMed  Google Scholar 

  41. Wong SL, Ji H, Hollenbeck BK et al (2007) Hospital lymph node examination rates and survival after resection for colon cancer. JAMA 298:2149–2154

    Article  CAS  PubMed  Google Scholar 

  42. Rahbari NN, Weitz J, Hohenberger W et al (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery 147:339–351

    Article  PubMed  Google Scholar 

  43. Zhang C, Di J, Jiang B et al (2016) Prognostic factors for patients with stage II colon cancer: results of a prospective study. Int J Colorectal Dis 31:123–129

    Article  PubMed  Google Scholar 

  44. Won DD, Choi SB, Lee YS et al (2017) The positive impact of surgical quality control on adequate lymph node harvest by standardized laparoscopic surgery and national quality assessment program in colorectal cancer. Int J Colorectal Dis 32:975–982

    Article  PubMed  Google Scholar 

  45. Bertelsen CA, Neuenschwander AU, Jansen JE et al (2015) Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study. Lancet Oncol 16:161–168

    Article  PubMed  Google Scholar 

  46. Hogan AM, Winter DC (2009) Complete mesocolic excision (CME): a „novel“ concept? J Surg Oncol 100:182–183

    Article  CAS  PubMed  Google Scholar 

  47. Bertelsen CA, Neuenschwander AU, Jansen JE et al (2016) Short-term outcomes after complete mesocolic excision compared with ‚conventional‘ colonic cancer surgery. Br J Surg 103:581–589

    Article  CAS  PubMed  Google Scholar 

  48. Merkel S, Weber K, Matzel KE et al (2016) Prognosis of patients with colonic carcinoma before, during and after implementation of complete mesocolic excision. Br J Surg 103:1220–1229

    Article  CAS  PubMed  Google Scholar 

  49. Byrne BE, Mamidanna R, Vincent CA et al (2013) Population-based cohort study comparing 30- and 90-day institutional mortality rates after colorectal surgery. Br J Surg 100:1810–1817

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Swanson RS, Pezzi CM, Mallin K et al (2014) The 90-day mortality after pancreatectomy for cancer is double the 30-day mortality: more than 20,000 resections from the national cancer data base. Ann Surg Oncol 21:4059–4067

    Article  PubMed  Google Scholar 

  51. Talsma AK, Lingsma HF, Steyerberg EW et al (2014) The 30-day versus in-hospital and 90-day mortality after esophagectomy as indicators for quality of care. Ann Surg 260:267–273

    Article  PubMed  Google Scholar 

  52. Mamidanna R, Almoudaris AM, Faiz O (2012) Is 30-day mortality an appropriate measure of risk in elderly patients undergoing elective colorectal resection? Colorectal Dis 14:1175–1182

    Article  CAS  PubMed  Google Scholar 

  53. Kolfschoten NE, Kievit J, Gooiker GA et al (2013) Focusing on desired outcomes of care after colon cancer resections; hospital variations in ‚textbook outcome‘. Eur J Surg Oncol 39:156–163

    Article  CAS  PubMed  Google Scholar 

  54. Gooiker GA, Kolfschoten NE, Bastiaannet E et al (2013) Evaluating the validity of quality indicators for colorectal cancer care. J Surg Oncol 108:465–471

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Chirurgische Klinik, Universitätsmedizin Mannheim (UMM), Theodor-Kutzer-Ufer 1–3, 68167, Mannheim, Deutschland

    J. Hardt & S. Post

  2. Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland

    H.-J. Buhr & C. Klinger

  3. Chirurgische Klinik, Klinikum Sindelfingen-Böblingen, Böblingen, Deutschland

    S. Benz

  4. Chirurgische Klinik, Klinikum Südstadt Rostock, Rostock, Deutschland

    K. Ludwig

  5. Chirurgische Klinik, Universitätsklinikum Bonn (UKB), Bonn, Deutschland

    J. Kalff

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Correspondence to S. Post.

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J. Hardt, H.-J. Buhr, C. Klinger, S. Benz, K. Ludwig, J. Kalff und S. Post geben an, dass kein Interessenkonflikt besteht.

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Hardt, J., Buhr, HJ., Klinger, C. et al. Qualitätsindikatoren für die onkologische Kolonchirurgie. Chirurg 89, 17–25 (2018). https://doi.org/10.1007/s00104-017-0559-0

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