April 21, 2006Open Access
View Full PaperVolume and process of care in high‐risk cancer surgery
Key Result
Compared to low-volume centers, patients at high-volume hospitals were more likely to undergo stress tests (OR 1.51; 95% CI 1.21-1.87) and receive perioperative invasive monitoring.
Study Design
Type
Observational (n=71,558)
Multicenter
Yes
Structured PICO
Does hospital volume affect process of care and operative mortality in patients undergoing high-risk cancer surgery?
P
Population
71,558 US Medicare patients undergoing major resections for lung, esophageal, gastric, liver, or pancreatic cancer.
E
Exposure
High-volume hospitals (highest 20th by volume)
C
Comparator
Low-volume hospitals (lowest 20th by volume)
O
Outcome
Specific processes of care (preoperative, intraoperative, and postoperative) and operative mortality
Although high-volume hospitals differ from low-volume hospitals in perioperative care processes for high-risk cancer surgery, these differences do not explain the observed volume-outcome relationship in operative mortality.
Main Result
Odds Ratio: 1.51 (95% CI 1.21–1.87)
Abstract
BACKGROUND: Although relations between procedure volume and operative mortality are well established for high-risk cancer operations, differences in clinical practice between high-volume and low-volume centers are not well understood. The current study was conducted to examine relations between hospital volume, process of care, and operative mortality in cancer surgery. METHODS: Using the Medicare claims database (2000-2002), we identified all patients undergoing major resections for lung, esophageal, gastric, liver, or pancreatic cancer (n=71,558). Preoperative, intraoperative, and postoperative processes of care potentially related to operative mortality were identified from inpatient, outpatient, and physician claims files using appropriate International Classification of Diseases--Clinical Modification (ICD-9) and Current Procedural Terminology (CPT) codes. We then assessed variation in the use of each process according to hospital volume, adjusting for patient characteristics and procedure type. Study Participants were US Medicare patients. The main outcome measure was specific processes of care. RESULTS: Relative to those at low-volume centers (lowest 20th by volume), patients at high-volume hospitals (highest 20th) were significantly more likely to undergo stress tests (odds ratio OR: 1.51, 95% confidence interval CI: 1.21-1.87), but not other preoperative imaging tests. They were more likely to see medical or radiation oncologists (OR: 1.37, 95% CI: 1.16-1.62), but not other specialists, preoperatively. Although blood transfusions and use of epidural pain management did not vary significantly by volume, patients at high-volume hospitals had significantly longer operations and were more likely to receive perioperative invasive monitoring (OR: 2.56, 95% CI: 1.82-3.60). Differences in measurable processes of care did not explain volume-related differences in operative mortality to any significant degree. CONCLUSIONS: Although high-volume and low-volume hospitals differ with regard to many aspects of perioperative care, mechanisms underlying volume-outcome relations in high-risk cancer surgery remain to be identified.