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Evaluating the costs and benefits of using combination therapies
Author(s) -
Rodgers Anthony,
Laba TraceyLea,
Jan Stephen
Publication year - 2014
Publication title -
medical journal of australia
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.904
H-Index - 131
eISSN - 1326-5377
pISSN - 0025-729X
DOI - 10.5694/mja14.00675
Subject(s) - george (robot) , library science , health economics , citation , global health , operations research , medicine , health care , history , political science , art history , law , computer science , engineering
TO THE EDITOR: Following a retrospective review of New South Wales data, Smith and colleagues concluded that the better longterm survival outcomes following surgery for oesophagogastric cancer at higher-volume centres support surgery only being done at these centres.1 However, much missing data creates uncertainty about this conclusion. Survival outcomes directly relate to stage at diagnosis, so variable use of staging laparoscopy, endoscopic ultrasound and/or positron emission tomography, all of which can upstage a significant proportion of patients,2 and all more likely to be employed at higher-volume centres, could create considerable variation in recorded stage at diagnosis and in patient selection for surgery. Further, some patients considered surgical candidates at one hospital may be managed with definitive chemoradiation at another hospital.3 Most significantly, there are widely variable approaches to the use of adjuvant radiation and chemotherapy, including the timing and agents used,4 which have a significant impact on recurrence risk and survival. As 5-year survival is also confounded by deaths from other causes, this measure cannot be considered a reliable indicator of surgical quality. We note that more direct indicators — length of stay and 30-day mortality — did not differ for lower-volume versus higher-volume centres. Attempting to compare hospital surgical outcomes where there are no data on the variable approaches to initial staging or multidisciplinary management is likely to end with an “apples versus oranges” comparison. While surgery at higher-volume centres may produce better outcomes, procedures frequently enough in institutions able to provide the range of diagnostics, perioperative support services, multidisciplinary care and expertise that surgeons require and patients need for great outcomes.3,4 Can anyone defend institutions performing these procedures at a low volume?