1. Complexity of Case Mix is an Independent Predictor of Mortality After Esophagectomy A Nationwide Inpatient Sample Data Analysis ML Inra MD, EB Habermann PhD MPH, KM Thomsen BA, MS Allen MD, SD Cassivi MD MSc, FC Nichols MD, KR Shen MD, DA Wigle MD PhD, SH Blackmon MD MPH

2. ©2014 MFMER | slide-2 No Disclosures

3. ©2014 MFMER | slide-3 Background Favors vol >20/yr 0.10.20.512510 Favors vol <20/yr Odds ratio CitationYear Effect odds-ratioP Total (no.) Begg19980.230.12 503 van Lanschot20010.430.00 1,892 Kuo20010.250.00 1,193 Dimick20010.160.00 1,136 Gillison20020.990.95 1,076 Birkmeyer20020.420.00 6,337 Urbach20030.660.14 613 Finlayson20030.410.00 5,282 Random combined (8)0.420.0018,032 Adapted from: Metzger R, Bollschweiler E, Vallböhmer D, Maish M, DeMeester TR, Hölscher AH. High Vol centers for esophagectomy: what is the number needed to achieve low postoperative mortality? Dis Esophagus. 2004;17(4):310-4. Studies suggest regionalization of esophagectomy to high volume centers

4. ©2014 MFMER | slide-4 Background Esophagectomy outcome variation still exists Metzger R, Bollschweiler E, Vallböhmer D, Maish M, DeMeester TR, Hölscher AH. High Vol centers for esophagectomy: what is the number needed to achieve low postoperative mortality? Dis Esophagus. 2004;17(4):310-4. Case load Mortality rate (%) 20 30 40 50 100 5 0 15 20 25 30

5. ©2014 MFMER | slide-5 Objective Accurately describe surgical centers best able to perform esophagectomy Centers performing complex esophageal reconstruction have improved outcomes following esophagectomy, independent of volume Hypothesis

6. ©2014 MFMER | slide-6 Methods Retrospective review of the Nationwide Inpatient Sample (NIS) database (2000- 2011) Selected hospitals performing esophagectomy on adults (Age ≥18)

7. ©2014 MFMER | slide-7 Methods Hospitals were separated into two categories Hospitals NOT performing complex reconstruction Hospitals performing complex reconstruction Complex reconstruction = jejunal or colonic interposition to reconstruct the esophagus

8. ©2014 MFMER | slide-8 Methods Hospitals were also subdivided by esophagectomy volume: Low volume <13 per year Mid volume 13-24 per year High volume ≥ 25 per year

9. ©2014 MFMER | slide-9 Methods Primary endpoints included: Prolonged length of stay (PLOS) PLOS was defined as ≥20 days, which was the 75 th percentile In-hospital mortality

10. ©2014 MFMER | slide-10 Methods Hospital and patient characteristics were assessed in relation to outcomes: Hospital capacity, location, teaching status and region Patient age, gender, income, admission status and cancer diagnosis

11. ©2014 MFMER | slide-11 Statistics Hospital and patient characteristics were compared using t-tests and chi-square tests Multivariable logistic regression analysis determined the effect of case complexity on: Prolonged LOS In-hospital mortality

12. ©2014 MFMER | slide-12 ResultsHospitalsperforming complex recon n = 444 (18%)Hospitals NOT performing complex recon n = 2,032 (82%) NIS-Sampled Hospitals performing esophagectomy (2000-2011) n = 2,476 Esophagectomiesperformed n = 5,312 Esophagectomies performed n = 5,899

13. ©2014 MFMER | slide-13 Hospital Characteristics p<0.001 % High capacity

14. ©2014 MFMER | slide-14 Patient Demographics p=0.012 p<0.001 %

15. ©2014 MFMER | slide-15 PLOS Outcomes for Esophagectomy Patients p<0.001 21% 28% 24% % of patients with PLOS

16. ©2014 MFMER | slide-16 Independent Predictors of PLOS Variable Odds ratioP Non-complex vs. complex hospital <0.001 Age ≥70 vs. 50-59 <0.001 Esophageal cancer vs. non-cancer 0.012 Emergency vs. elective admission <0.001 Urgent vs. elective admission <0.001 Black vs. white <0.001 Hispanic vs. white 0.004 Increased PLOS 0.80.60.40.2

17. ©2014 MFMER | slide-17 In-Hospital Mortality Outcomes for Esophagectomy Patients p<0.001 5% 9% 7% % Mortality

18. ©2014 MFMER | slide-18 Variable Odds ratioP Non-complex vs. complex hospital <0.001 Age ≥70 vs. 50-59 <0.001 Esophageal cancer vs. non-cancer <0.001 Emergency vs. elective admission <0.001 Urgent vs. elective admission <0.001 Black vs. white 0.008 Independent Predictors of In-Hospital Mortality Increased in-hospital mortality 0.80.60.40.2

19. ©2014 MFMER | slide-19 Hospital Distribution by Volume Grouping % of Hospitals 93%

20. ©2014 MFMER | slide-20 % of Esophagectomies Hospital & Esophagectomy Distribution by Volume Grouping 55% 17%

21. ©2014 MFMER | slide-21 In-hospital Mortality by Volume p<0.001 % Mortality

22. ©2014 MFMER | slide-22 Results Low volume hospital mortality by complexity Hospital typeMortalityp Low Volume, Non-complex 477/4638 (10.3%) p<0.001 Low volume, Complex 96/1360 (7.1%) Low volume = <13 esophagectomies per year

23. ©2014 MFMER | slide-23 Summary of Findings Hospital experience with complex esophageal cases predicted post- esophagectomy outcomes independent of volume Hospitals that perform complex esophageal reconstruction have lower incidences of PLOS and in-hospital mortality Case complexity independently predicted mortality in low volume hospitals, reducing it by nearly 30%

24. ©2014 MFMER | slide-24 Conclusions Volume remains a strong driver of esophagectomy outcome Complexity is a novel independent predictor of in-hospital mortality and PLOS Esophagectomies in hospitals that perform complex esophageal reconstruction have nearly half the mortality compared to non-complex hospitals

25. ©2014 MFMER | slide-25 Thank you