Hospital Referral Guidelines

Michigan Health and Safety Coalition Hospital Referral Guideline for Esophagectomy for Cancer*

• All hospitals performing esophagectomies for cancer (see Appendix A for a list of codes) should possess the following structural and process characteristics:

1. a surgeon with appropriate training and qualifications (e.g., certification by the American Board of Thoracic Surgery) should perform esophagectomies,
2. an active multidisciplinary tumor board which meets on a regular basis,
3. appropriate staff and facilities to provide high quality post-operative monitoring and care, and
4. post-surgical care that involves a multi-disciplinary approach including, but not limited to, chemotherapy and radiation therapy consultations.

• In collaboration with the Michigan Society of Thoracic and Cardiovascular Surgeons, all Michigan hospitals and surgeons performing esophagectomies should collect risk-adjusted morbidity and mortality data for the Society of Thoracic Surgery database to be analyzed by the Duke Clinical Research Institute and should participate in audits of data quality and accuracy as required.

• By May 2002, all Michigan surgeons performing esophagectomies should convene a group of Michigan expert thoracic surgeons to work with the Michigan Society of Thoracic and Cardiovascular Surgeons, Quality Committee to actively participate in designing and implementing a process improvement strategy that uses data derived from the Michigan STS database. Active participation includes:

1. establish attending regularly scheduled meetings and developing processes by which data will be collected and data quality will be ensured;
2. reviewing, analyzing, using and refining the Michigan STS data;
3. identifying risk-adjusted morbidity and mortality indicators that reflect differences in quality of care (consider respiratory complications, anastomotic leak rates, dysphagia, post-operative dilatation, regurgitation, and dumping symptoms as well as patient satisfaction);
4. sharing information across surgical programs and learning from successful programs perhaps using the Northern NE Cardiovascular model of rounding by inter-hospital teams to identify best practices;
5. developing, implementing, evaluating, and periodically updating measurable evidence-based quality of care indicators, hospital and physician-specific standards and guidelines, best practices and clinical protocols;
6. evaluating hospital and physician-specific performance relative to agreed upon standards and guidelines;
7. educating physicians and hospitals about quality of care indicators, standards, guidelines, protocols and best practices as well as their hospital-specific patient outcomes;
8. sharing data and disseminating hospital and physician-specific performance information with physicians, hospitals, purchasers, consumers, and others in an appropriate manner that communicates the quality of Michigan thoracic surgery programs and reassures purchasers and payers; and
9. identifying innovative models to cover the costs of data collection, analysis and use.

• While existing limited data suggest improved operative mortality in hospitals performing at least seven esophagectomies annually, there is a need to verify this and to establish a better numeric guideline. The ECP emphasizes its position that risk-adjusted outcomes, not operative mortality alone, best define "quality" in this field.

• Hospitals should require that their medical staff implement appropriateness criteria and use the criteria to perform clinical case review of esophagectomies.

* This is meant to be a guideline and not a standard of care; this guideline represents the best of an evidence-based review at this time; the guideline is based on the principles of CQI and is not intended to be used in a punitive manner; this guideline needs to be taken as a whole, and not have selected parts be used without considering the entire content of the guideline.