By Christina Frangou

Patients fared better in the three months after gastrointestinal cancer surgery if they received care from high-volume anesthesiologists, according to a Canadian study.

Published in JAMA Surgery, the analysis showed that care from high-volume anesthesiologists was independently associated with a 15% lower odds of combined 90-day major morbidity (including mortality) and hospital readmission, after adjusting for patient case mix, institutional volume and surgeon volume (2021 Mar 21. doi:10.1001/jamasurg.2021.0135).

All patients were treated at high-volume cancer centers.

“Anesthesiology care and perioperative care is becoming more complex, just like surgeries are becoming more complex and patients themselves more complex, and anesthesiology can have important impact on how well patients are going to do after surgery,” said study co-author Julie Hallet, MD, a staff surgical oncologist at Sunnybrook Health Sciences Centre and an assistant professor of surgery at the University of Toronto.

Dr. Hallet and her colleagues used administrative health care data sets to identify 8,096 adult patients in Ontario, Canada, who underwent esophagectomy, pancreatectomy or hepatectomy for cancer between Jan. 1, 2007 and Dec. 31, 2018.

In this study, anesthesiologists had lower volumes than surgeons, with a median of three procedures per year compared with 27 for surgeons. Anesthesiologists were classified as high-volume if they performed six or more of the particular procedure annually in the two years before the index surgery.

Ontario has a highly regionalized system for oncologic surgery. Since 2006, hepatopancreaticobiliary surgery in the province has been concentrated at 10 designated centers of excellence and esophageal cancer surgery at 15. These centers have requirements for institutional annual case volume, surgeon fellowship and perioperative care infrastructure, but not anesthesiology services.

“We may have a different anesthesiologist for every case that we do over a six-month period,” said Dr. Hallet.
The findings suggest patients may benefit if perioperative care were reorganized to increase anesthesiologist volume, Dr. Hallet noted. Large institutions could create specialized anesthesiology teams, while smaller ones could build clinical networks with high-volume anesthesiologists, she said.

In an accompanying commentary, researchers from the Surgical Outcomes and Quality Improvement Center at Northwestern University, in Chicago, said the study offers a rare look at the contribution of anesthesia volume to outcomes (JAMA Surg. Published online March 17, 2021. doi:10.1001/jamasurg.2021.0136). As with surgery, volume is a useful proxy for quality, but may reflect factors such as experience, processes of care and team organization, the authors said.

“We commend Hallet et al for their methodical and thought-provoking study, but much work still needs to be done to uncover the true underlying factors associated with improved outcomes,” Rachel Hae-Soo Joung, MD, and her colleagues wrote.