The quality of cancer care initiative in the Netherlands

doi:10.1016/j.ejso.2010.06.004

European Journal of Surgical Oncology (EJSO)

Volume 36, Supplement 1, September 2010, Pages S3-S13

https://doi.org/10.1016/j.ejso.2010.06.004 Get rights and content

Abstract

Background

In 2007 the Dutch Cancer Society formed a ‘Quality of Cancer Care’ taskforce comprising medical specialists, from all disciplines involved in the care for cancer patients. This taskforce was charged with the evaluation of quality of cancer care in the Netherlands and the development of strategies for improvement.

Objective

The experts first focused on the relation between procedural volume and patient outcome and later aimed to identify other factors associated with high and low quality of the care provided in different regions and (types of) hospitals in the Netherlands. The question if cancer care in the Netherlands could be organized differently to assure high quality of care for all patients, was the main subject of investigation.

Methods

An extensive review of the literature on infrastructure, volume and specialization on the one hand and outcome on the other was performed. In addition, a meta-analysis of the volume–outcome relationship for pancreatectomies, bladder, lung, colorectal and breast cancer resections was performed. Finally, variation in quality of cancer care between regions, groups of hospitals and individual hospitals in our country was investigated on data from the Netherlands Cancer Registry.

Results

In the Netherlands quality of care varies by hospital and region. These differences are not limited to surgical procedures and postoperative mortality, but are also demonstrated in other parts of the care process. Differences are only partly explained by differences in infrastructure, procedural volume and specialization between hospitals. Essential information on differences in case mix between these hospitals are lacking from the Netherlands Cancer Registry. More detailed clinical data are needed to reveal the mechanisms behind the differences in quality of care between Dutch hospitals.

Conclusion

On a population level, there is potential for improvement of outcome for cancer patients in the Netherlands by reducing variation in optimal treatment rates between hospitals. Not only treatment of tumours with a low incidence but also other complex or high risk cancer procedures should be provided in a specialized setting, with the right infrastructure, sufficient volume and adequate expertise. In addition, outcomes should be monitored continuously and fed back to individual caregivers.

Introduction

In most European countries quality of care is high on the political agenda. Especially in cancer care future developments force us to re-evaluate the way care is provided for our patients. First the number of cancer patients is rising and will continue to do so. Second, the relative part of elderly cancer patients, with an increased risk of treatment related morbidity and mortality will rise. Moreover, care processes, including diagnostic procedures, multidisciplinary decision making and combined modality treatments, are becoming more and more complex, demanding more specific knowledge, expertise and infrastructure in institutions providing cancer care.

Simultaneously, there is a growing concern about the quality and safety of health care: it harms too frequently and routinely fails to deliver the desired benefits.¹ A plethora of articles on variation in quality of care delivered by different types of hospitals, has contributed to the concern that the care delivered is not always, the care that should be received.2, 3, 4 Authorities as well as the public demand more accountability and transparency in the quality of the care provided. In many countries quality indicators are developed to gain insight in differences in quality of care between institutions. Unfortunately, few quality indicators are validated; have proven their capacity to discriminate between high and low quality of care.

In the Netherlands, under the supervision of the Signaling Committee of the Dutch Cancer Society a ‘Quality of Cancer Care’ taskforce was formed in 2007, comprising medical specialists, from all disciplines involved in the care for cancer patients, who had expertise in quality of care improvement projects. This taskforce was charged with the evaluation of quality of cancer care in the Netherlands and the development of strategies for improvement. The experts first focused on the relation between procedural volume and patient outcome and later aimed to identify other factors associated with high and low quality of the care provided in different regions and (types of) hospitals in the Netherlands. The question if cancer care in the Netherlands could be organized differently to assure high quality of care for all patients, was the main subject of investigation.

Section snippets

Survival of cancer patients in the Netherlands

In a European perspective the survival of cancer patients in the Netherlands is favourable for the majority of tumours.5, 6 Especially, in head and neck tumours survival is highest in Europe, though in other cancer types, like esophageal, gastrointestinal, liver, pancreatic and ovarian tumours, outcome is less favourable. In addition, recent Dutch studies show marked variation in outcome between different providers. Surgery for ovarian carcinoma by gynaeco-oncologists in the Netherlands proved

Volume and outcome

Since, Birkmeyer et al. published their article on the inverse relationship between hospital volume and mortality after high risk surgical procedures in the New England Journal of Medicine in 2002,² there has been a debate about volume and outcome of many cancer procedures in the Netherlands. Despite several publications on excess mortality of patients in who high risk cancer procedures, like esophagectomies and pancreatectomies, were performed in low volume hospitals,9, 12 no change in

Variation in quality of care

To be able to answer the question to what extent variation in quality of cancer care exists between regions, groups of hospitals or individual hospitals in our country, data from the Netherlands Cancer Registry were investigated. In the Netherlands all newly diagnosed malignancies are registered in this nationwide population-based registry. Data are collected from the medical records by specially trained registrars and are coded according to a national manual. Information on patient

Current strategies for quality improvement

In the Dutch health care system, the choice (and responsibility) to refer a patient needing specialized care to a colleague or hospital with adequate expertise is entirely in the hands of individual medical professionals. During the past 30 years the comprehensive cancer centres (CCCs), non-hospital organizations that serve as platforms for regional and national consultation between professionals, have played an important role in the coherence of cancer care in the Netherlands. Aim of the

Quality assurance, indicators and audits

Knowledge, experience and skills of individual medical specialists (or their teams) providing care for cancer patients might vary in such a way that it leads to variation in outcome. An overwhelming number of evidence-based guidelines were developed in our country to transfer the best available knowledge on cancer care to all physicians treating these patients. Unfortunately, little is known about the adherence to these guidelines in daily practice and more interestingly: the reasons for

International perspective

The first population-based colorectal audits were set up in the mid nineties in the Scandinavian countries. More recently, similar colorectal audit initiatives were introduced in the UK, Belgium, the Netherlands, Spain, Germany and Poland. Other European countries started regional initiatives.

Despite all these quality efforts, still considerable differences in survival rates between European countries exist. For instance, 5 year relative survival after colorectal cancer varies between 32% and

Conclusions

In the opinion of the medical professionals participating in the quality of cancer care taskforce of the Dutch Cancer Society, overall quality of care for cancer patients treated in the Netherlands is high. Nevertheless, there is potential for further improvement of outcome on a population level by reducing variation in optimal treatment rates between hospitals. This opinion is based on an extensive review of the literature and evaluation of the best available data on the performance of

Conflict of interest statement

The authors hereby declare that there are no conflicts of interest that could inappropriately influence this manuscript with the title.

Funding

This article is published in a supplement sponsored by a grant from the Dutch Cancer Society. The Dutch Cancer Society did not influence the article in any way.

Acknowledgements

The authors would like to thank Ilfet Songun, Gea Gooiker and Willem van Gijn for performing the review and meta-analyses of the literature, the working group Output of the NCR for providing and analyzing data from the cancer registry, and all the members of the Quality of Cancer Care taskforce of the Dutch Cancer Society for their contribution to the Quality of Cancer Care report.

References (122)

V.E. Lemmens et al.
Mixed adherence to clinical practice guidelines for colorectal cancer in the Southern Netherlands in 2002
Eur J Surg Oncol
(2006)
W.W. Li et al.
The influence of provider characteristics on resection rates and survival in patients with localized non-small cell lung cancer
Lung Cancer
(2008)
M.P. Coleman et al.
EUROCARE-3 summary: cancer survival in Europe at the end of the 20th century
Ann Oncol
(2003)
S.H. Lee et al.
An adequate level of training for technical competence in screening and diagnostic colonoscopy: a prospective multicenter evaluation of the learning curve
Gastrointest Endosc
(2008)
V.E. Lemmens et al.
Pathology practice patterns affect lymph node evaluation and outcome of colon cancer: a population-based study
Ann Oncol
(2006)
E.P. van Vliet et al.
Staging of esophageal carcinoma in a low-volume EUS center compared with reported results from high-volume centers
Gastrointest Endosc
(2006)
K.C. Peeters et al.
Surgical quality assurance in rectal cancer treatment: the key to improved outcome
Eur J Surg Oncol
(2005)
J.B. Dimick et al.
Variation in postoperative complication rates after high-risk surgery in the United States
Surgery
(2003)
J.B. Dimick et al.
National trends in outcomes for esophageal resection
Ann Thorac Surg
(2005)
E.Y. Kuo et al.
Impact of hospital volume on clinical and economic outcomes for esophagectomy
Ann Thorac Surg
(2001)

M.G. Patti et al.

A Hospital’s annual rate of esophagectomy influences the operative mortality rate

J Gastrointest Surg

(1998)

J.B. Dimick et al.

Specialty training and mortality after esophageal cancer resection

Ann Thorac Surg

(2005)

R.A. Damhuis et al.

Hospital volume and post-operative mortality after resection for gastric cancer

Eur J Surg Oncol

(2002)

E.L. Hannan et al.

The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer

Surgery

(2002)

R.M. Wainess et al.

Epidemiology of surgically treated gastric cancer in the United States, 1988–2000

J Gastrointest Surg

(2003)

J.D. Birkmeyer et al.

Relationship between hospital volume and late survival after pancreaticoduodenectomy

Surgery

(1999)

M.A. Choti et al.

Should hepatic resections be performed at high-volume referral centers?

J Gastrointest Surg

(1998)

J.B. Dimick et al.

National trends in the use and outcomes of hepatic resection

J Am Coll Surg

(2004)

T.A. Gordon et al.

Complex gastrointestinal surgery: impact of provider experience on clinical and economic outcomes

J Am Coll Surg

(1999)

J. Engel et al.

Influence of hospital volume on local recurrence and survival in a population Sample of rectal cancer patients

Eur J Surg Oncol

(2005)

P. Renzulli et al.

The influence of the surgeon’s and the hospital’s caseload on survival and local recurrence after colorectal cancer surgery

Surgery

(2006)

B.R. Konety et al.

Impact of hospital and surgeon volume on in-hospital mortality from radical cystectomy: data from the health care utilization project

J Urol

(2005)

Institute of Medicine committee on Quality of Health Care in America

Crossing the quality Chasm: a new health system for the 21st Century

(2001)

J.D. Birkmeyer et al.

Hospital volume and surgical mortality in the United States

N Engl J Med

(2002)

H. Moller et al.

A visual summary of the EUROCARE-4 results: a UK perspective

Br J Cancer

(2009)

M.J. Engelen et al.

Surgery by consultant gynecologic oncologists improves survival in patients with ovarian carcinoma

Cancer

(2006)

D.J. Gouma et al.

Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume

Ann Surg

(2000)

J.J. van Lanschot et al.

Hospital volume and hospital mortality for esophagectomy

Cancer

(2001)

M.W. Wouters et al.

High-volume versus low-volume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data

Ann Surg Oncol

(2007)

M.W. Wouters et al.

Centralization of esophageal cancer surgery: does it improve clinical outcome?

Ann Surg Oncol

(2009)

D.J. Gouma et al.

Hospital experience and hospital mortality following partial pancreaticoduodenectomy in the Netherlands

Ned Tijdschr Geneeskd

(1997)

N.T. van Heek et al.

Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands

Ann Surg

(2005)

M.W. Wouters et al.

Volume- or outcome-based referral to improve quality of care for esophageal cancer surgery in the Netherlands

J Surg Oncol

(2009)

K. Hiotis et al.

Predictors of breast conservation therapy: size is not all that matters

Cancer

(2005)

M. Rutegard et al.

No influence of surgical volume on patients’ health-related quality of life after esophageal cancer resection

Ann Surg Oncol

(2008)

C. Verhoef et al.

Better survival in patients with esophageal cancer after surgical treatment in University hospitals: a plea for performance by surgical oncologists

Ann Surg Oncol

(2007)

S.C. Chen et al.

A comparison of dermatologists’ and primary care physicians’ accuracy in diagnosing melanoma: a systematic review

Arch Dermatol

(2001)

J. Khan et al.

Accuracy of choroidal melanoma diagnosis by general ophthalmologists: a prospective study

Eye (Lond)

(2007)

E.P. van Vliet et al.

Radiologist experience and CT examination quality determine metastasis detection in patients with esophageal or gastric cardia cancer

Eur Radiol

(2008)

S.L. Wong et al.

Hospital lymph node examination rates and survival after resection for colon cancer

J Am Med Assoc

(2007)

L.J. Schouten et al.

Quality of cancer registry data: a comparison of data provided by clinicians with those of registration personnel

Br J Cancer

(1993)

L.J. Schouten et al.

Completeness of cancer registration in Limburg, the Netherlands

Int J Epidemiol

(1993)

D.M. den et al.

Quality assurance in surgical oncology: the tale of the Dutch rectal cancer TME trial

J Surg Oncol

(2008)

K.C. Peeters et al.

The TME trial after a Median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma

Ann Surg

(2007)

W. van Gijn et al.

Nationwide outcome registrations to improve quality of care in rectal surgery. An initiative of the European society of surgical oncology

J Surg Oncol

(2009)

J. Norstein et al.

Results of rectal cancer treatment: a national experience

C.M. Berenguer et al.

Improving surgical site Infections: using national surgical quality improvement program data to institute surgical care improvement project protocols in improving surgical outcomes

J Am Coll Surg

(2010)

S.F. Khuri et al.

Successful implementation of the department of veterans affairs’ national surgical quality improvement program in the private sector: the patient safety in surgery study

Ann Surg

(2008)

Cited by (46)

Association between surgical quality and long-term survival in lung cancer
2024, Lung Cancer
There are significant variations in both perioperative and long-term outcomes after lung cancer resection. While perioperative outcomes are often used as comparative measures of quality, they are unreliable, and their association with long-term outcomes remain unclear. In this context, we evaluated whether historical perioperative mortality after lung cancer resection is associated with 5-year survival.
The National Cancer Database (NCDB) was queried to identify patients diagnosed with non-small cell lung cancer (NSCLC) in 2010–2016 who underwent surgical resection (n = 234200). Hospital-level reliability-adjusted 90-day mortality rate quartiles for 2010–2013 was used as the independent variable to analyze 5-year survival for patients diagnosed in 2014–2016 (n = 85396).
There were 85,396 patients in the 2014–2016 cohort across 1,086 hospitals. Overall observed 90-day mortality rate was 3.2% (SD 17.6%) with 2.6% (SD 16.0%) for the historically best performing quartile vs. 3.9% (SD 19.4%) for the worst performing quartile (p < 0.0001). Patients who underwent resection at hospitals with the best historical mortality rate had significantly better 5-year survival across all stages compared to those treated at hospitals in the worst performing quartile in multivariate Cox regression analysis (all stages – HR 1.21 [95% CI 1.15–1.26]; stage I – HR 1.19 [95% CI 1.12–1.25]; stage II – HR 1.20 [95% CI 1.09–1.32]; stage III – HR 1.36 [95% CI 1.20–1.54]) and Kaplan-Meier survival estimates (all stages – p < 0.0001, stage I – p < 0.0001; stage II – p = 0.0004; stage III – p < 0.0001).
With expanded lung cancer screening criteria and likely increase in early-stage detection, profiling performance is paramount to ensuring mortality benefits. We found that episodes surrounding surgical resection may be used to profile long-term outcomes that likely reflect quality across a broader context of care. Evaluating lung cancer care quality using perioperative outcomes may be useful in profiling provider performance and guiding value-based payment policies.
Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide
2023, The Lancet Oncology
The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.
Preoperative risk factors for major postoperative complications after complex gastrointestinal cancer surgery: A systematic review
2021, European Journal of Surgical Oncology
Citation Excerpt :
These devices continuously transmit vital signs that alert healthcare personnel in case of deterioration. Reduction of postoperative complications can also be established by clinical auditing and benchmarking of surgical outcomes [80,81]. Auditing is used to measure quality of care using structure, process, and outcome indicators [82,83].
Patients undergoing complex gastrointestinal surgery are at high risk of major postoperative complications (e.g., anastomotic leakage, sepsis), classified as Clavien-Dindo (CD) ≥ IIIa. Identification of preoperative risk factors can lead to the identification of high-risk patients. These risk factors can also be used to design personalized perioperative care. This systematic review focuses on the identification of these factors. The Medline and Embase databases were searched for prospective, retrospective cohort studies and randomized controlled trials investigating the effect of risk factors on the occurrence of major postoperative complications and/or mortality after complex gastrointestinal cancer surgery. Risk of bias was assessed using the Quality in Prognostic Studies tool. The level of evidence was graded based on the number of studies reporting a significant association between risk factors and major complications. A total of 207 eligible studies were retrieved, identifying 33 risk factors for major postoperative complications and 13 preoperative laboratory results associated with postoperative complications. The present systematic review provides a comprehensive overview of preoperative risk factors associated with major postoperative complications. A wide range of risk factors are amenable to actions in perioperative care and prehabilitation programs, which may lead to improved outcomes for high-risk patients. Additionally, the knowledge of this study is important for benchmarking surgical outcomes.
Textbook outcome after rectal cancer surgery as a composite measure for quality of care: A population-based study
2021, European Journal of Surgical Oncology
Textbook outcome is a composite measure of combined outcome indicators, which has been suggested to be of additional value over single outcome parameters in clinical auditing of surgical treatment. This study aimed to assess textbook outcome after rectal cancer surgery as short-term marker for quality of care.
Patients who underwent elective rectal cancer surgery between 2012 and 2019 and registered in the Dutch ColoRectal Audit were included. Textbook outcome was achieved when the following criteria were met: 30-day and primary hospital admission survival, no reintervention, tumour-free margins, no postoperative complications, a hospital stay of less than 14 days and no readmission. Hospital variation was evaluated in case-mix corrected funnel-plots. A multilevel logistic regression analysis was performed to identify associated factors with textbook outcome.
The study population consisted of 20,521 patients who underwent primary rectal cancer surgery, of whom 56.3% achieved textbook outcome. Postoperative complications were the main contributor to not achieving textbook outcome. Case-mix corrected funnel plots demonstrated that underperforming hospitals in 2012–2015 were no underperformers in 2016–2019 anymore. Female sex, laparoscopic surgery, and rectal resection without defunctioning stoma creation were positively associated with textbook outcome.
Textbook outcome after rectal cancer resection is mainly driven by postoperative complications. Although textbook outcome showed some discriminating value for identifying underperforming hospitals, it does not fit the plan-do-check-act cycle of clinical auditing. In our opinion, textbook outcome has little added value to the current outcome indicators for rectal cancer surgery.
Postoperative intensive care unit stay after minimally invasive esophagectomy shows large hospital variation. Results from the Dutch Upper Gastrointestinal Cancer Audit
2021, European Journal of Surgical Oncology
Citation Excerpt :
Since 2011, the mandatory nationwide Dutch Upper Gastrointestinal Cancer Audit (DUCA) has registered all surgically treated esophageal or gastric cancer patients [3,8]. The audit aims to improve the quality of Dutch upper gastrointestinal cancer care by identifying and reducing hospital variation in treatment, outcomes and clinical care pathways [9]. Within the scope of value-based health care, this study aimed to 1) gain insight into different hospital policies towards direct postoperative ICU admission, 2) investigate Dutch hospital variation regarding length of direct postoperative ICU stay and 3) investigate the impact of this hospital variation on short-term surgical outcomes after MIE on a hospital level.
The value of routine intensive care unit (ICU) admission after minimally invasive esophagectomy (MIE) has been questioned. This study aimed to investigate Dutch hospital variation regarding length of direct postoperative ICU stay, and the impact of this hospital variation on short-term surgical outcomes.
Patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) undergoing curative MIE were included. Length of direct postoperative ICU stay was dichotomized around the national median into short ICU stay ( ≤ 1 day) and long ICU stay ( > 1 day). A case-mix corrected funnel plot based on multivariable logistic regression analyses investigated hospital variation. The impact of this hospital variation on short-term surgical outcomes was investigated using multilevel multivariable logistic regression analyses.
Between 2017 and 2019, 2110 patients from 16 hospitals were included. Median length of postoperative ICU stay was 1 day [hospital variation: 0–4]. The percentage of short ICU stay ranged from 0 to 91% among hospitals. Corrected for case-mix, 7 hospitals had statistically significantly higher short ICU stay rates and 6 hospitals had lower rates. ICU readmission, in-hospital/30-day mortality, failure to rescue, postoperative pneumonia, cardiac complications and anastomotic leakage were not associated with hospital variation in length of ICU stay. Total length of hospital stay was significantly shorter in hospitals with relatively short ICU stay.
This study showed significant hospital variation in postoperative length of ICU stay after MIE. Short ICU stay was associated with shorter overall hospital admission and did not negatively impact short-term surgical outcomes. More selected use of ICU resources could result in a national significant cost reduction.
Case-mix adjustment to compare nationwide hospital performances after resection of colorectal liver metastases
2021, European Journal of Surgical Oncology
Differences in patient demographics and disease burden can influence comparison of hospital performances. This study aimed to provide a case-mix model to compare short-term postoperative outcomes for patients undergoing liver resection for colorectal liver metastases (CRLM).
This retrospective, population-based study included all patients who underwent liver resection for CRLM between 2014 and 2018 in the Netherlands. Variation in case-mix variables between hospitals and influence on postoperative outcomes was assessed using multivariable logistic regression. Primary outcomes were 30-day major morbidity and 30-day mortality. Validation of results was performed on the data from 2019.
In total, 4639 patients were included in 28 hospitals. Major morbidity was 6.2% and mortality was 1.4%. Uncorrected major morbidity ranged from 3.3% to 13.7% and mortality ranged from 0.0% to 5.0%. between hospitals. Significant differences between hospitals were observed for age higher than 80 (0.0%–17.1%, p < 0.001), ASA 3 or higher (3.3%–36.3%, p < 0.001), histopathological parenchymal liver disease (0.0%–47.1%, p < 0.001), history of liver resection (8.1%–36.3%, p < 0.001), major liver resection (6.7%–38.0%, p < 0.001) and synchronous metastases (35.5%–62.1%, p < 0.001). Expected 30-day major morbidity between hospitals ranged from 6.4% to 11.9% and expected 30-day mortality ranged from 0.6% to 2.9%. After case-mix correction no significant outliers concerning major morbidity and mortality remained. Validation on patients who underwent liver resection for CRLM in 2019 affirmed these outcomes.
Case-mix adjustment is a prerequisite to allow for institutional comparison of short-term postoperative outcomes after liver resection for CRLM.

View all citing articles on Scopus

^☆: On behalf of the ’Quality of cancer care’ task force of the Signalling Committee Cancer of the Dutch Cancer Society (the committees full report is available on www.kwfkankerbestrijding.nl).

View full text

The quality of cancer care initiative in the Netherlands☆

Abstract

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Survival of cancer patients in the Netherlands

Volume and outcome

Variation in quality of care

Current strategies for quality improvement

Quality assurance, indicators and audits

International perspective

Conclusions

Conflict of interest statement

Funding

Acknowledgements

Eur J Surg Oncol

Lung Cancer

Ann Oncol

Gastrointest Endosc

Ann Oncol

Gastrointest Endosc

Eur J Surg Oncol

Surgery

Ann Thorac Surg

Ann Thorac Surg

J Gastrointest Surg

Ann Thorac Surg

Eur J Surg Oncol

Surgery

J Gastrointest Surg

Surgery

J Gastrointest Surg

J Am Coll Surg

J Am Coll Surg

Eur J Surg Oncol

Surgery

J Urol

Crossing the quality Chasm: a new health system for the 21st Century

Hospital volume and surgical mortality in the United States

N Engl J Med

A visual summary of the EUROCARE-4 results: a UK perspective

Br J Cancer

Surgery by consultant gynecologic oncologists improves survival in patients with ovarian carcinoma

Cancer

Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume

Ann Surg

Hospital volume and hospital mortality for esophagectomy

Cancer

High-volume versus low-volume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data

Ann Surg Oncol

Centralization of esophageal cancer surgery: does it improve clinical outcome?

Ann Surg Oncol

Hospital experience and hospital mortality following partial pancreaticoduodenectomy in the Netherlands

Ned Tijdschr Geneeskd

Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands

Ann Surg

Volume- or outcome-based referral to improve quality of care for esophageal cancer surgery in the Netherlands

J Surg Oncol

Predictors of breast conservation therapy: size is not all that matters

Cancer

No influence of surgical volume on patients’ health-related quality of life after esophageal cancer resection

Ann Surg Oncol

Better survival in patients with esophageal cancer after surgical treatment in University hospitals: a plea for performance by surgical oncologists

Ann Surg Oncol

A comparison of dermatologists’ and primary care physicians’ accuracy in diagnosing melanoma: a systematic review

Arch Dermatol

Accuracy of choroidal melanoma diagnosis by general ophthalmologists: a prospective study

Eye (Lond)

Radiologist experience and CT examination quality determine metastasis detection in patients with esophageal or gastric cardia cancer

Eur Radiol

Hospital lymph node examination rates and survival after resection for colon cancer

J Am Med Assoc

Quality of cancer registry data: a comparison of data provided by clinicians with those of registration personnel

Br J Cancer

Completeness of cancer registration in Limburg, the Netherlands

Int J Epidemiol