Simulation study on the regionalization of esophagectomy using data from 27,476 patients in Japan

Area of Science:

• Health Services Research
• Surgical Outcomes
• Health Policy

Background:

• A strong volume-outcome association for esophagectomy exists in Japan.
• No current national policy mandates regionalization of esophagectomy procedures.
• This study simulates the effects of regionalization on mortality, travel, and disparities.

Purpose of the Study:

• To simulate the impact of regionalization on esophagectomy outcomes in Japan.
• To assess changes in operative mortality and patient travel distances under different minimum volume standards (MVSs).
• To evaluate geographic disparities in access to care.

Main Methods:

• Utilized the Japanese National Clinical Database for patients undergoing esophagectomy for malignant tumors.
• Simulated four MVS scenarios (2, 5, 10, 15 annual cases per hospital).
• Estimated operative mortality and travel distance changes across metropolitan, provincial, and rural regions.

Main Results:

• 76% of hospitals performed fewer than 5 esophagectomies annually.
• Operative mortality decreased with increasing hospital volume (4.8% for <2 cases/year to 1.6% for ≥15 cases/year).
• Simulated MVSs reduced annual deaths by 8-29, but increased travel distances, especially in rural areas (up to 43 km).

Conclusions:

• Regionalization of esophagectomy in Japan can significantly reduce operative mortality.
• Increased travel burdens for rural patients are a key consideration.
• Policy implementation requires balancing improved outcomes with patient accessibility.