What provider volumes and characteristics are appropriate for gastric cancer resection? Results of an international RAND/UCLA expert panel.

Background. A relationship between higher volume providers and improved outcomes has been suggested by some studies and has been used to construct guidelines for many diseases. For gastric cancer (GC), however, optimal volume cutoffs are not clear. Methods. A multidisciplinary expert panel of 16 physicians from 6 countries scored 120 scenarios regarding provider characteristics for gastric resections for GC. Appropriateness of scenarios was scored from I (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores from 1 to 3 were considered inappropriate, 4 to 6 uncertain, and 7 to 9 appropriate. Agreement was reached when 12 of 16 panelists scored the statement similarly. Appropriate scenarios agreed on were scored subsequently for necessity. Results. Surgeon and hospital practice volume scenarios were evaluated. The panel felt it was inappropriate for surgeons doing <= 2 GC cases per year to perform a multivisceral resection (MVR), D2 lymphadenectomy (D2-LND), or laparoseopic total gastrectomy, and <= 6 GC cases per year for an MVR involving a pancreatoduodenectomy (MVR-PD), or endoscapic mucosalresections (EMR). It was considered appropriate for surgeons doing <= 11 GC cases per year to perform open gastrectomy or D2-LND, and <= 20 GC cases per year for any MVR, lap aroscopic gastrectomy, or EMR. For hospitals, it was considered inappropriate for hospitals managing <= 4 GC cases per year to perform D2-LND or lap aroscopic total gastrectomy, and <= 10 GC cases per year for MVR-PD or EMR. Hospital volumes >= 21 cases per year was considered appropriate for any GC procedure. It was inappropriate for an MVR to be performed in a hospital without interventional radiology services and for a MVR-PD in a hospital with no level I intensive care unit. Conclusion. Appropriate and inappropriate provider volumes for a variety of gastric procedures have been defined by an international expert panel.