Nov 10, 2019
This podcast discusses the work of Sheetz and colleagues describing the impact of centralization of high-risk cancer surgery within health care systems and networks in the United States.
This JCO Podcast provides observations and commentary on the JCO article “Centralization of High-Risk Cancer Surgery Within Existing Hospital Systems” by Sheetz et al. My name is Stephen Edge, and I am Vice President of Healthcare Outcomes and Policy and Professor of Surgery and Oncology at the Roswell Park Comprehensive Cancer Center and the University at Buffalo in Buffalo, NY. My oncologic specialty is surgical oncology.
Recent years have seen substantial consolidation of hospitals and practices into networked care systems. The benefits of health networks may include efficiencies of scale, better ability to thrive in the shifting health care economy, and enhanced quality.
In the article that accompanies this podcast, Dr. Sheetz and colleagues at the University of Michigan studied the impact of health care networks on the outcome of high-risk cancer surgeries for pancreas, esophagus, lung, colon and rectal cancer. They examined the distribution of these surgeries in health care networks, and the relationship between outcomes and the degree of centralization of surgeries to a high-volume network hospital.
There is a well-established relationship between hospital case volume and operative mortality for complex cancer surgery, most pronounced for pancreas and esophagus cancer. Some countries now mandate regionalization of these procedures to high volume centers. Most, but not all, studies show that regionalization improves outcomes for these procedures. Organized regionalization of cancer surgery in the United States has been limited though market forces have led to some consolidation of high-risk surgeries. This has been encouraged through recommendations of the Leapfrog Group that for the last 25 years has set minimum hospital volume standards for high risk surgeries.
Sheetz and colleagues used the Medicare Provider Analysis and Review (MedPAR) files that include all beneficiaries of Medicare Part A to identify persons age 65 and older undergoing pancreatectomy, esophagectomy, lung resection, colectomy and proctectomy for the years 2005 – 2014. They used American Hospital Association data to identify hospital characteristics such as size, teaching status and which hospitals are in the same health system if any. They combined these data with information from the National Inpatient Sample to derive estimates of the total number of cases of each type beyond Medicare beneficiaries.
They defined a “high volume hospital” and “high volume system” as one that met the Leapfrog Group volume criteria; and centralization of surgery as the proportion of surgeries of each type performed at the highest volume hospital in a given health network. Outcomes assessed were 30-day mortality after surgery, major complications, and hospital readmission.
The procedures most centralized in networks were pancreatectomy and esophagectomy with a mean of 71% and 51%, respectively. However, for pancreas surgery 74% and for esophagus surgery 84% of systems did not meet or have a hospital that met the Leapfrog Group volume recommendations for pancreatectomy.
Complications were about 20% lower for pancreas and esophagus surgery at health systems with the highest surgery centralization. The impact on complications of lung and colorectal surgery was less. More important was the reduction in risk-adjusted 30-day mortality. For pancreas and esophagus surgery the mortality at the most centralized systems mortality was 60% and 53% lower, respectively, then the least centralized systems. The absolute rates dropped from 8.9% to 3.7% for pancreas and 10.3% to 4.8% for esophagus surgery. The reduction for lung resection was less and there was no significant mortality difference for colorectal surgery. Importantly, the team observed the same level of reduction associated with system surgery centralization for low volume and high-volume systems, and those with and without a high-volume hospital.
Certainly, this study is not without its limitations. Because the MedPAR files include primarily fee-for-service Medicare, they had to estimate the total number of cases. They did not have specific information on the health systems or the distance of patients from a high-volume center. They did not know the systems’ governance relationships or the degree of coordination between system hospitals, services and providers.
However, the study reinforces the well-established volume-outcome relationships in the context of hospitals with common governance. While individual surgeons may be excellent at low volume hospitals the finding of a greater relative impact on mortality than complications suggest that it not just the surgeon, but that high-volume hospitals with their larger teams and resources are less likely to “fail to rescue” a patient with a major complication. This was realized within these health systems.
Networks with a common governance and shared financial and reputation risk should be motivated to assure best outcomes and limit inefficiency. Networks have central program oversight and should pay more heed to factors that impact quality and have the ability to foster providing the right care at the right place. They also should be more attuned to the needs of their customers and their unique geographic and economic situations and can meet the needs of people in dense metropolitan areas and the vast expanses of rural America.
However, referral to the network flagship cannot be a one-way street. Health systems should establish programs that address these cancers across the continuum of the disease. Evidence shows that some of those who might benefit from these high-risk surgeries never see a team to help determine this. Conversely, many or people with pancreas, esophageal and lung cancer present with disease not amenable to surgery. It makes sense for a health system to assure that all patients with these cancers get a full, multidisciplinary evaluation and that those who cannot have resection receive appropriate referral or return to providers close to home who can provide the necessary care, clinical trials, and supportive services.
When the volume/outcome associations were first described, organized medicine was slow to address the issue and instead tried to fathom what factors led to better outcome with volume. In the absence of policy and professional leadership, market forces slowly changed practices so that now many or most of the very high-risk procedures are done at high volume centers. But this has taken 30 – 40 years and likely impacted many lives. Conversely, surgeons and policy makers have led the charge to regionalize other high-risk services such as trauma care, cardiac surgery, and pediatric surgery. The findings of Sheetz et al. support renewal of efforts in policy and practice to assure cancer patients receive the best options.
Sheetz and colleagues are to be congratulated for their insightful work. Despite its inherent limitations, they have shed light on a key area needing attention of health systems, professional societies and policy makers.
This concludes this JCO Podcast. Thank you for listening.