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Gastrectomy case volume and textbook outcome: an analysis of the Population Registry of Esophageal and Stomach Tumours of Ontario (PRESTO)

Levy J, Gupta V, Amirazodi E, Allen-Ayodabo C, Jivraj N, Jeong Y, Davis LE, Mahar AL, de Mestral C, Saarela O, Coburn N; the PRESTO Group. Gastric Cancer. 2020; 23(3):391-402. Epub 2019 Nov 4. DOI:

Objective — To determine the association between gastric cancer surgery case-volume and Textbook Outcome, a new composite quality measurement.

Background — Textbook Outcome included (a) negative resection margin, (b) greater than 15 lymph nodes sampled, (c) no severe complication, (d) no re-intervention, (e) no unplanned ICU admission, (f) length of stay of 21 days or less, (g) no 30-day readmission and (h) no 30-day mortality following surgery.

Methods — All patients undergoing gastrectomy for non-metastatic gastric adenocarcinoma registered in the Population Registry of Esophageal and Stomach Tumours of Ontario between 2004 and 2015 were included. We used multivariable generalized estimating equation (GEE) logistic regression modelling to estimate the association between gastrectomy volume (surgeon and hospital annual volumes) and Textbook Outcome. Volumes were considered as continuous variables and quintiles.

Results — Textbook Outcome was achieved in 378 of 1660 patients (22.8%). The quality metrics least often achieved were inadequate lymph node sampling and presence of severe complications, which occurred in 46.1% and 31.7% of patients, respectively. Accounting for covariates and clustering, neither surgeon volume nor hospital volume were significantly associated with Textbook Outcome. However, hospital volume was associated with adequate lymphadenectomy and fewer unplanned ICU admissions.

Conclusions — Higher case volume can impact certain measures of quality of care but may not address all care structures necessary for ideal Textbook recovery. Future quality improvement strategies should consider using case-mix adjusted Textbook Outcome rates as a surgical quality metric.

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