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Risk-based Selective Referral for Cancer Surgery: A Potential Strategy to Improve Perioperative Outcomes

Bilimoria, Karl Y. MD, MS*†; Bentrem, David J. MD, MS; Talamonti, Mark S. MD; Stewart, Andrew K. MA*; Winchester, David P. MD*†‡; Ko, Clifford Y. MD, MS, MSHS

doi: 10.1097/SLA.0b013e3181c1bea2
Original Articles

Background: Studies have demonstrated volume-outcome relationships for numerous operations, providing an impetus for regionalization; however, volume-based regionalization may not be feasible or necessary. Our objective was to determine if low-risk patients undergoing surgery at Community Hospitals have perioperative mortality rates comparable with Specialized Centers.

Methods: From the National Cancer Data Base, 940,718 patients from ∼1430 hospitals were identified who underwent resection for 1 of 15 cancers (2003–2005). Patients were stratified by preoperative risk according to age and comorbidities. Separately for each cancer, regression modeling stratified by high- and low-risk groups was used to compare 60-day mortality at Specialized Centers (National Cancer Institute-designated and/or highest-volume quintile institutions), Other Academic Institutions (lower-volume, non-National Cancer Institute), and Community Hospitals.

Results: Low-risk patients had statistically similar perioperative mortality rates at Specialized Centers and Community Hospitals for 13 of 15 operations. High-risk patients had significantly lower perioperative mortality rates at Specialized Centers compared with Community Hospitals for 9 of 15 cancers. Regardless of risk group, perioperative mortality rates were significantly lower for pancreatectomy and esophagectomy at Specialized Centers. Risk-based referral compared with volume-based regionalization of most patients would require fewer patients to change to Specialized Centers.

Conclusions: Perioperative mortality for low-risk patients was comparable at Specialized Centers and Community Hospitals for all cancers except esophageal and pancreatic, thus questioning volume-based regionalization of all patients. Rather, only high-risk patients may need to change hospitals. Mortality rates could be reduced if factors at Specialized Centers resulting in better outcomes for high-risk patients can be identified and transferred to other hospitals.

Studies have demonstrated volume-outcome relationships for numerous operations, providing an impetus for regionalization; however, perioperative mortality for low-risk patients was comparable at specialized centers and Community Hospitals for most cancers, thus questioning volume-based regionalization. Rather, only high-risk patients may need to change hospitals.

From the *Cancer Programs, Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; †Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; ‡Department of Surgery, NorthShore University Health System, Evanston, IL; and §Department of Surgery, University of California, Los Angeles (UCLA) and VA Greater Los Angeles Healthcare System, Los Angeles, CA.

Supported by the American College of Surgeons Clinical Scholars in Residence Program and a Priority Grant from Northwestern University (KYB). The NCDB is supported by the American College of Surgeons, Commission on Cancer, and the American Cancer Society.

Reprints: Karl Y. Bilimoria, MD, MS, Division of Research and Optimal Patient Care, American College of Surgeons, 633 N. St. Clair St, 22nd Floor, Chicago, IL 60611. E-mail: kbilimoria@facs.org.

© 2010 Lippincott Williams & Wilkins, Inc.