Regional Hepatopancreaticobiliary Surgical Program Improves Care in VA System
In a retrospective cohort study reported in JAMA Surgery, Lau et al found that implementation of a multidisciplinary hepatopancreaticobiliary surgical program in a Veterans Affairs (VA) health-care region resulted in improved care and outcomes.
The study involved analysis of practices and outcomes in a tertiary referral VA medical center within an eight-state designated VA health-care region from November 2005 through December 2013, before and after implementation of a hepatopancreaticobiliary surgical program in November 2008.
Increased Regional Referrals
A total of 516 patients with hepatopancreaticobiliary carcinoma referred to the surgical oncology service were included in the analysis. Establishment of the surgical program resulted in significant increases in regional referrals (17.3% vs 44.4%, P < .001), median monthly clinic visits (5 vs 20, P < .001), median number of hepatopancreaticobiliary surgical procedures per quarter (3 vs 9, P = .003), and multidisciplinary assessments (52.6% vs 70.0%, P < .001).
Improved Care Patterns
Among patients with hepatocellular carcinoma, there was increased use of any treatment (63.6% vs 83.2%, P = .004), liver resection (0% vs 15.3%, P = .002), percutaneous ablation (0% vs 11.5%, P = .009), and oncosurgical strategies (0% vs 12.2%, P = .007) after implementation. Among patients with colorectal liver metastases, use of ablation decreased (17.2% vs 3.9%, P = .02) and there was increased use of resection (20.7% vs 52.6%, P = .003) and perioperative chemotherapy (45.5% vs 76.7%, P = .01).
Improved Postoperative Outcomes
The rate of postoperative adverse events, defined as a composite of postoperative mortality, severe postoperative complications (Clavien-Dindo grades III–V), or reoperation within 60 days, was significantly reduced after program implementation (28.3% vs 13.9%, P = .01; odds ratio = 0.29, P = .005, on multivariate analysis). Trends were observed for reduced 90-day mortality after hepatobiliary operations (5.3% vs 2.5%, P = .39) and 30-day mortality after pancreatic operations (4.5% vs 0%, P = .10).
Significant reductions were observed for median length of stay (15 vs 10 days, P = .01) and for severe postoperative complications for pancreatic operations (45.5% vs 15.3%, P = .004). After the hepatopancreaticobiliary program implementation, margin-negative resections were achieved in 94.6% of liver and 90.0% of pancreatic operations.
The investigators concluded: “The development of [a hepatopancreaticobiliary surgical program] led to regionalization of care and improved quality of cancer care and surgical outcomes. Establishment of regional programs within the VA system can help improve the quality of care for patients presenting with complex cancers requiring subspecialized care.”
Daniel A. Anaya, MD, of the Michael E. DeBakey Veterans Affairs Medical Center, Houston, is the corresponding author for the JAMA Surgery article.
The study was supported the Office of Rural Health–South Central VA Veterans Integrated Service Network Clinical Systems Program Office. The authors reported no conflicts of interest.
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