Original Title: Avis: traitement chirurgical du cancer de l’œsophage: qualité et accessibilité au Québec

Authors' objectives: Esophageal cancer is uncommon in Quebec (500 new cases in 2017). Few patients with this disease are eligible for esophagectomy, a complex surgery which quality of care and clinical outcomes depend on many organizational conditions as well as on the volume of interventions and on the surgeon’s expertise. In this opinion, the Institut national d’excellence en santé et services sociaux (INESSS) proposes strategies to improve the quality of care and services with regard to treatment of patients suffering from esophageal cancer, more specifically of those who are undergoing esophageal surgery. The impact of centralizing care and services is considered from different perspectives. This report with recommendations presents: a) a review of quality standards related to esophageal surgery; b) a picture of the practice of esophagectomy in Quebec; and c) a review of the literature and the results of a consultation on the perspective of patients.

Authors' results and conclusions: RESULTS (QUALITY AND PERFORMANCE) Providing quality care and public access to local health care services are two major concerns of provincial level care management. Given the small number of cases, these concerns are all the more important in the case of esophagectomy. Quality depends on a set of organizational conditions, including the volume of interventions and the expertise of surgeons. The majority of the studies, including a meta-analysis, show a statistically significant and inversely proportional relationship between the volume of esophagectomies per centre and per surgeon on one side and postoperative mortality on the other side, including the hospitalization period, the 30 days and 90 days after surgery period and the long-term survival rate. The incidence of major postoperative complications, including anastomotic fistulas, pulmonary complications and cardiovascular complications would be higher in low volume hospitals. However, it is difficult to establish a minimum threshold that should be respected to ensure optimal care. According to standards published in other Canadian provinces and abroad, the volume threshold per centre is set around 20 interventions per year. As confirmed by a good quality meta-analysis, high volume facilities have a significant effect on long-term survival. Although few studies have examined the relation between the specialization of surgeons and the clinical outcomes, the relevant Canadian standards recommend specialty training in thoracic surgery. The decrease in postoperative mortality depends significantly on the number of esophageal surgeries performed on a one-year basis. According to a good quality meta-analysis, an impact on long-term survival can be expected when the annual volume of cases per surgeon stands at close to 10. Other factors are associated with quality of care, such as the presence of a multidisciplinary team, the access to human resources with relevant expertise and the availability of material means. Available international guidelines recommend a minimum of three thoracic surgeons per facility. Quality assurance procedures have been put in place in a few countries; they are essentially based on the monitoring of practices and clinical results as well as on the measurement of performance indicators. These procedures require the maintenance of records. Several European countries and some American states have embarked on a process of centralization. This process can lead to significant reductions in postoperative mortality when coupled with a quality management program. (PICTURE OF THE PRACTICE IN QUEBEC) A descriptive picture of the practice shows that over the past 3 years, an average of 172 esophagectomies have been performed annually and 146 of these surgeries were related to esophageal cancer treatment. A concentration effect is already present, since the majority of interventions (77%) were performed in 5 centres of the 2 major regions, namely Montreal and Quebec City. An intra-hospital mortality rate, estimated from 2010-2011 to 2012-2013 at about 4%, has since then increased to 6.6%. This recent increase, and the fact that the rate is higher than the Canadian average, which is evaluated from 2010 to 2012 at around of 4.7%, call for actions to be taken towards improvement of the quality of care provided to Quebec patients. The lack of completeness of the data on Quebec does not allow an analysis of the clinical results in accordance to the volume categories measured per facility and per surgeon, adequately adjusted for confounding factors. Several concerns are associated with the centralization of esophagectomy in Quebec, such as the loss of expertise of surgeons who should cease this practice and the difficulty of retaining qualified staff and attracting new surgeons, especially at the regional level. It would be possible to alleviate the effects of a centralization decision by granting, for example, to the specialized surgeons from non-designated facilities a privilege to continue their practice in a designated facility. The continuity of care and waitlist management must be ensured to provide all patients, regardless of their regional origin, with the equitable access to effective and timely care. (PATIENTS' PERSPECTIVES) For patients, especially for those who had the option of being operated in facilities located in their area, the main problem of possible centralization is the loss of esophageal surgery as a local service. The review of published studies and consultations has revealed that the patients attach importance to the quality care, even when it involves travel, sometimes over long distances. Coordination of care between local services and expert facilities as well as the quality of follow-up are also essential. The relocation raises concerns about the burden it puts on the family and the lack of support due to remoteness. The presence of loved ones helps to support patients throughout their hospital treatment. To reduce the burden of patients and their loved ones, the mitigation measures, whilst providing a quality care for patients, must include a better financial and logistical support for relocations or the telemedicine to reduce the need for relocations during follow-up.

Authors' recommendations: • The establishment of esophageal oncology centres of excellence in Quebec be done in such a way that esophagectomy is concentrated in a minimum of centres with recognized expertise. Those facilities should be provided with the necessary structure and resources and must respect a minimum volume of 20 cases yearly per facility, a minimum volume of 7 cases per surgeon and a critical mass of 3 surgeons with recognized expertise in esophageal surgery. In line with the above-described rules, every effort should be made to preserve the existing expertise in Quebec by facilitating, where possible, the integration of surgeons from facilities that lose their designation into the teams of designated centres. • The Direction générale de cancérologie (DGC) of ministère de la Santé et des Services Sociaux (MSSS): - establish a central registry of all patients who have undergone esophagectomy; - specify monitoring indicators and targets to be achieved; - monitor the provincial practice and results for the purpose of improving quality; - closely monitor the waiting time in order to ensure fairness and avoid waiting time differences between regions; - ensure the availability of the resources needed to adopt the quality approach. • The designated centres: - comply with the quality standards to be developed by the Direction générale de cancérologie (DGC); - set up a quality assurance program; - put in place procedures to feed the central registry; - produce an annual report to be submitted to the local and provincial authorities responsible for the quality of care. • From a network perspective, that partner centres in the regions be able to offer an adequate postoperative follow-up. In addition, INESSS recommends that: • Institutions set up means to minimize travel for pre- and post-operative care and services, in particular through the use of telemedicine. • Institutions coordinate between them to ensure continuity of pre- and postoperative care. • The relevant stakeholders improve access to accommodation and that designated centres facilitate the reception of patients and caregivers from remote areas. The most appropriate transportation be made available to patients and their families both ways - to designated centres and to return home

Authors' methods: A review of the literature was conducted to describe the quality standards that ensure the best clinical results, including a review of the publications from recognized organizations; emphasis was put on intervention volumes per centre and per surgeon as well as on their influence on the results. The picture of the practice was drawn from the information extracted from the medico-administrative databases and from the consultations with managers and professionals in the field. This report with recommendations also presents an analysis of the perspective of patients who have undergone esophagectomy, based on a comprehensive review of the literature and on a consultation with a group of patients and their relatives.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/traitement-chirurgical-du-cancer-de-loesophage-qualite-et-accessibilite-au-quebec.html

Year Published: 2018

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/traitement-chirurgical-du-cancer-de-loesophage-qualite-et-accessibilite-au-quebec.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec