1
|
Mu H, Yang X, Li Y, Zhou B, Liu L, Zhang M, Wang Q, Chen Q, Yan L, Sun W, Pan G. Three-year follow-up study reveals improved survival rate in NSCLC patients underwent guideline-concordant diagnosis and treatment. Front Oncol 2024; 14:1382197. [PMID: 38863625 PMCID: PMC11165022 DOI: 10.3389/fonc.2024.1382197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/15/2024] [Indexed: 06/13/2024] Open
Abstract
Background No studies in China have assessed the guideline-concordance level of the first-course of non-small cell lung cancer (NSCLC) diagnosis and treatment and its relationship with survival. This study comprehensively assesses the current status of guideline-concordant diagnosis (GCD) and guideline-concordant treatment (GCT) of NSCLC in China and explores its impact on survival. Methods First course diagnosis and treatment data for NSCLC patients in Liaoning, China in 2017 and 2018 (n=1828) were used and classified by whether they underwent GCD and GCT according to Chinese Society of Clinical Oncology (CSCO) guidelines. Pearson's chi-squared test was used to determine unadjusted associations between categorical variables of interest. Logistic models were constructed to identify variables associated with GCD and GCT. Kaplan-Meier analysis and log-rank tests were used to estimate and compare 3-year survival rates. Multivariate Cox proportional risk models were constructed to assess the risk of cancer mortality associated with guideline-concordant diagnosis and treatment. Results Of the 1828 patients we studied, 48.1% underwent GCD, and 70.1% underwent GCT. The proportions of patients who underwent both GCD and GCT, GCD alone, GCT alone and neither GCD nor GCT were 36.7%, 11.4%, 33.5% and 18.4%, respectively. Patients in advanced stage and non-oncology hospitals were significantly less likely to undergo GCD and GCT. Compared with those who underwent neither GCD nor GCT, patients who underwent both GCD and GCT, GCD alone and GCT alone had 35.2%, 26.7% and 35.7% higher 3-year survival rates; the adjusted lung cancer mortality risk significantly decreased by 29% (adjusted hazard ratio[aHR], 0.71; 95% CI, 0.53-0.95), 29% (aHR, 0.71; 95% CI, 0.50-1.00) and 32% (aHR, 0.68; 95% CI, 0.51-0.90). Conclusion The 3-year risk of death is expected to be reduced by 29% if patients with NSCLC undergo both GCD and GCT. There is a need to establish an oncology diagnosis and treatment data management platform in China to monitor, evaluate, and promote the use of clinical practice guidelines in healthcare settings.
Collapse
Affiliation(s)
- Huijuan Mu
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Institute of Chronic Diseases, Liaoning Provincial Center for Disease Control and Prevention, Shenyang, China
| | - Xing Yang
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Yanxia Li
- Institute of Chronic Diseases, Liaoning Provincial Center for Disease Control and Prevention, Shenyang, China
| | - Bingzheng Zhou
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
- Department of Orthopaedic Surgery and Sports Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Li Liu
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Institute of Chronic Diseases, Liaoning Provincial Center for Disease Control and Prevention, Shenyang, China
| | - Minmin Zhang
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Qihao Wang
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Qian Chen
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Lingjun Yan
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Wei Sun
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| | - Guowei Pan
- Institute of Preventive Medicine, China Medical University, Shenyang, China
- Research Center for Universal Health, School of Public Health, China Medical University, Shenyang, China
| |
Collapse
|
2
|
Jain S, Rosenbaum PR, Reiter JG, Ramadan OI, Hill AS, Hashemi S, Brown RT, Kelz RR, Fleisher LA, Silber JH. Mortality Among Older Medical Patients at Flagship Hospitals and Their Affiliates. J Gen Intern Med 2024; 39:902-911. [PMID: 38087179 DOI: 10.1007/s11606-023-08415-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/05/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND We define a "flagship hospital" as the largest academic hospital within a hospital referral region and a "flagship system" as a system that contains a flagship hospital and its affiliates. It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region. OBJECTIVE To compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region. DESIGN A matched cohort study PARTICIPANTS: The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals. MAIN MEASURES 30-day (primary) and 90-day (secondary) all-cause mortality. KEY RESULTS 30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI [-0.88%, -0.37%], P<0.001). This difference was smaller in affiliates versus controls (-0.43%, [-0.75%, -0.11%], P=0.008) than in flagship hospitals versus controls (-1.02%, [-1.46%, -0.58%], P<0.001; difference-in-difference -0.59%, [-1.13%, -0.05%], P=0.033). Similar results were found for 90-day mortality. LIMITATIONS The study used claims-based data. CONCLUSIONS In aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.
Collapse
Affiliation(s)
- Siddharth Jain
- Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA.
| | - Paul R Rosenbaum
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Statistics and Data Science, The Wharton School of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA
| | - Omar I Ramadan
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander S Hill
- Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA
| | - Sean Hashemi
- Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA
| | - Rebecca T Brown
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Division of Geriatric Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Rachel R Kelz
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lee A Fleisher
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Perioperative Outcomes Research and Transformation, The University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia, 2716 South Street, Suite 5140, Philadelphia, PA, 19146-2305, USA
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
- The Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Health Care Management, The Wharton School of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
3
|
Ramadan OI, Rosenbaum PR, Reiter JG, Jain S, Hill AS, Hashemi S, Kelz RR, Fleisher LA, Silber JH. Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes. Ann Surg 2024; 279:631-639. [PMID: 38456279 PMCID: PMC10926994 DOI: 10.1097/sla.0000000000006132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls. SUMMARY BACKGROUND DATA It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients. METHODS Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality. RESULTS We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001]. CONCLUSIONS Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.
Collapse
Affiliation(s)
- Omar I. Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Paul R. Rosenbaum
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Siddharth Jain
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sean Hashemi
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Rachel R. Kelz
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Lee A. Fleisher
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jeffrey H. Silber
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
4
|
Dykes EM, Montgomery KB, Kennedy GD, Krontiras H, Broman KK. Quality of breast surgery care at a comprehensive cancer center and its rural affiliate hospital. Am J Surg 2024; 227:52-56. [PMID: 37805304 PMCID: PMC10842465 DOI: 10.1016/j.amjsurg.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/06/2023] [Accepted: 09/22/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Cancer centers are increasingly affiliating with rural hospitals to perform surgery. Perioperative and oncologic outcomes for cancer center surgeons operating at rural hospitals are understudied. METHODS For patients with non-metastatic breast cancer from a rural catchment area who had oncologic surgery at an NCI-designated comprehensive cancer center (CC) or its rural affiliate (RA) from 2017 to 2022, we compared perioperative outcomes (composite of surgical site infection, seroma requiring drainage, and reoperation for margins) and receipt of guideline-concordant care (if patient received all applicable treatments) using descriptive statistics and chi-squared tests. RESULTS Among 168 patients, 99 had surgery at RA, 60 CC. RA patients were older, higher stage, and more often had lumpectomy. There were no differences in perioperative outcomes (CC 10%, RA 14%, p = 0.445) or guideline concordant care (RA 76%, CC 78%, p = 0.846). CONCLUSIONS Cancer center surgeons operating at a rural affiliate had comparable perioperative outcomes and guideline-concordant care.
Collapse
Affiliation(s)
- Elissa M Dykes
- University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA.
| | - Kelsey B Montgomery
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gregory D Kennedy
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Helen Krontiras
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristy K Broman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
5
|
Broman K, Richman J, Ross E, Zengul F, Weech-Maldonado R, Bhatia S. Hub and spoke framework for study of surgical centralization within United States health systems. Am J Surg 2023; 226:524-530. [PMID: 37156679 PMCID: PMC10524175 DOI: 10.1016/j.amjsurg.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/12/2023] [Accepted: 05/03/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Hospital consolidation into health systems has mixed effects on surgical quality, potentially related to degree of surgical centralization at high-volume (hub) sites. We developed a novel measure of centralization and evaluated a hub and spoke framework. METHODS Surgical centralization within health systems was measured using hospital surgical volumes (American Hospital Association) and health system data (Agency for Healthcare Research and Quality). Hub and spoke hospitals were compared using mixed effects logistic regression and system characteristics associated with surgical centralization were identified using a linear model. RESULTS Within 382 health systems containing 3022 hospitals, system hubs perform 63% of cases (IQR 40-84%). Hubs are larger, in metropolitan and urban areas, and more often academically affiliated. Degree of surgical centralization varies ten-fold. Larger, multistate, and investor-owned systems are less centralized. Adjusting for these factors, there is less centralization among teaching systems (p < 0.001). CONCLUSIONS A hub-spoke framework applies to most health systems but centralization varies significantly. Future studies of health system surgical care should assess the contributions of surgical centralization and teaching status on differential quality.
Collapse
Affiliation(s)
- K Broman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - J Richman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - E Ross
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - F Zengul
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, USA
| | - R Weech-Maldonado
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, USA
| | - S Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
6
|
Gordon T. A surgical patient's perspective. Am J Surg 2023; 226:396-399. [PMID: 37147144 DOI: 10.1016/j.amjsurg.2023.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/13/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023]
Affiliation(s)
- Toby Gordon
- Johns Hopkins University, 100 International Drive, Baltimore, MD, 21202, USA.
| |
Collapse
|
7
|
Shalowitz DI, Magalhaes M, Miller FG. Ethical Outreach for Rural Cancer Care in the United States: Balancing Access With Optimal Clinical Outcomes. JCO Oncol Pract 2023; 19:225-229. [PMID: 36689691 DOI: 10.1200/op.22.00629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- David I Shalowitz
- Section on Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Monica Magalhaes
- Center for Population-Level Bioethics, Rutgers University, New Brunswick, NJ
| | | |
Collapse
|
8
|
Gao X, Schroeder MC, Lizarraga IM, Tolle CL, Mullett TW, Charlton ME. Improving cancer care locally: Study of a hospital affiliate network model. J Rural Health 2022; 38:827-837. [PMID: 34897807 PMCID: PMC9189248 DOI: 10.1111/jrh.12639] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE The University of Kentucky Markey Cancer Center Affiliate Network (MCCAN) increased access to high-quality cancer care for patients treated in community hospitals across the state by leveraging the American College of Surgeons Commission on Cancer (CoC) standards to improve quality among its member sites. This study describes the network activities and services identified as most helpful or effective to its members, as well as the perceived value of joining MCCAN or pursing accreditation. METHODS An independent research team conducted in-depth, semistructured interviews with 18 administrators and clinicians from 10 MCCAN hospitals in 2019. Interviews were transcribed and a thematic analysis was conducted. FINDINGS Network affiliation and CoC accreditation were perceived as helpful to improving quality of care. Having both clinician and administrative champions were key facilitators to achieving CoC standards and made mentoring of member sites a critical activity of the Network. Other components identified as valuable and/or key to the Network's success included providing access to specific CoC-required clinical services (eg, genetic counseling); offering regular performance monitoring and individualized feedback; establishing a culture of quality improvement; and fostering trust within the Network with patient referrals (ie, sending patients back to their local hospital for ongoing care). CONCLUSIONS Quality improvement in community cancer programs is challenging but several strategies were identified by members as valuable and effective. Efforts to disseminate the MCCAN model should focus on identifying the needs of community hospitals, implementing a quality monitoring system, and fostering site-level champions who can be influential drivers of change.
Collapse
Affiliation(s)
- Xiang Gao
- Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, Iowa
| | - Mary C. Schroeder
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, Iowa
- Division of Health Services Research, College of Pharmacy, University of Iowa, Iowa City, Iowa
| | - Ingrid M. Lizarraga
- Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, Iowa
| | - Cheri L. Tolle
- Markey Cancer Center, Cancer Prevention and Control Program, University of Kentucky, Lexington, Kentucky
| | - Timothy W. Mullett
- Markey Cancer Center, Cancer Prevention and Control Program, University of Kentucky, Lexington, Kentucky
- Department of Surgery, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Mary E. Charlton
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, Iowa
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| |
Collapse
|
9
|
Niforatos JD, Zheutlin AR, Sussman JB. Prevalence of Third-Party Data Tracking by US Hospital Websites. JAMA Netw Open 2021; 4:e2126121. [PMID: 34550385 PMCID: PMC8459186 DOI: 10.1001/jamanetworkopen.2021.26121] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/19/2021] [Indexed: 01/15/2023] Open
Affiliation(s)
- Joshua D. Niforatos
- Department of Emergency Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexander R. Zheutlin
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Jeremy B. Sussman
- Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| |
Collapse
|
10
|
Boffa DJ, Mallin K, Herrin J, Resio B, Salazar MC, Palis B, Facktor M, McCabe R, Nelson H, Shulman LN. Survival After Cancer Treatment at Top-Ranked US Cancer Hospitals vs Affiliates of Top-Ranked Cancer Hospitals. JAMA Netw Open 2020; 3:e203942. [PMID: 32453382 PMCID: PMC7251445 DOI: 10.1001/jamanetworkopen.2020.3942] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Hospital networks formed around top-ranked cancer hospitals represent an opportunity to optimize complex cancer care in the community. OBJECTIVE To compare the short- and long-term survival after complex cancer treatment at top-ranked cancer hospitals and the affiliates of top-ranked hospitals. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using data from the unabridged version of the National Cancer Database. Included patients were individuals 18 years or older who underwent surgical treatment for esophageal, gastric, lung, pancreatic, colorectal, or bladder cancer diagnosed between January 1, 2012, and December 31, 2016. Patient outcomes after complex surgical procedures for cancer at top-ranked cancer hospitals (as ranked in top 50 by US News and World Report) were compared with outcomes at affiliates of top-ranked cancer hospitals (affiliation listed in American Hospitals Association survey and confirmed by search of internet presence). Data were analyzed from July through December 2019. EXPOSURES Undergoing complex cancer treatment at a top-ranked cancer hospital or an affiliated hospital. MAIN OUTCOMES AND MEASURES The association of affiliate status with short-term survival (ie, 90-day mortality) was compared using logistic regression, and the association of affiliate status with long-term survival was compared using time-to-event models, adjusting for patient demographic, payer, clinical, and treatment factors. RESULTS Among 119 834 patients who underwent surgical treatment for cancer, 79 981 patients (66.7%) were treated at top-ranked cancer hospitals (median [interquartile range] age, 66 [58-74] years; 40 910 [54.9%] men) and 39 853 patients (33.3%) were treated at affiliate hospitals (median [interquartile range] age, 69 [60-77] years; 19 004 [50.0%] men). In a pooled analysis of all cancer types, adjusted perioperative mortality within 90 days of surgical treatment was higher at affiliate hospitals compared with top-ranked hospitals (odds ratio, 1.67 [95% CI, 1.49-1.89]; P < .001). Adjusted long-term survival following cancer treatment at affiliate hospitals was only 77% that of top-ranked hospitals (time ratio, 0.77 [95% CI, 0.72-0.83]; P < .001). The survival advantage was not fully explained by differences in annual surgical volume, with both long- and short-term survival remaining superior at top-ranked hospitals even after models were adjusted for volume. CONCLUSIONS AND RELEVANCE These findings suggest that short- and long-term survival after complex cancer treatment were superior at top-ranked hospitals compared with affiliates of top-ranked hospitals. Further study of cancer care within top-ranked cancer networks could reveal collaborative opportunities to improve survival across a broad contingent of the US population.
Collapse
Affiliation(s)
- Daniel J. Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Katherine Mallin
- American College of Surgeons Cancer Programs, National Cancer Database, Chicago, Illinois
| | - Jeph Herrin
- Cancer Outcomes Public Policy and Effectiveness Research Center, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michelle C. Salazar
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Bryan Palis
- American College of Surgeons Cancer Programs, National Cancer Database, Chicago, Illinois
| | - Matthew Facktor
- Department of Thoracic Surgery, Geisinger Heart Institute, Danville, Pennsylvania
| | - Ryan McCabe
- American College of Surgeons Cancer Programs, National Cancer Database, Chicago, Illinois
| | - Heidi Nelson
- American College of Surgeons Cancer Programs, Chicago, Illinois
| | | |
Collapse
|
11
|
Resio BJ, Hoag JR, Chiu AS, Monsalve A, Sathe T, Xu X, Boffa DJ. Variations in Surgical Safety According to Affiliation Status With a Top-Ranked Cancer Hospital. JAMA Oncol 2019; 5:1359-1362. [PMID: 31294746 DOI: 10.1001/jamaoncol.2019.1808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Benjamin J Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jessica R Hoag
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Andres Monsalve
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Tejas Sathe
- Yale School of Medicine, New Haven, Connecticut
| | - Xiao Xu
- Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
12
|
Do the 2018 Leapfrog Group Minimal Hospital and Surgeon Volume Thresholds for Esophagectomy Favor Specific Patient Demographics? Ann Surg 2019; 274:e220-e229. [PMID: 31425294 DOI: 10.1097/sla.0000000000003553] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics. SUMMARY BACKGROUND DATA Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively. METHODS Patients undergoing esophagectomy for cancer were identified from the 2007-2013 New York and Florida Healthcare Cost and Utilization Project's State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18-57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age ≥71, ECI >4). RESULTS Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58-71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively. CONCLUSIONS Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities.
Collapse
|
13
|
Clark JM, Boffa DJ, Meguid RA, Brown LM, Cooke DT. Regionalization of esophagectomy: where are we now? J Thorac Dis 2019; 11:S1633-S1642. [PMID: 31489231 DOI: 10.21037/jtd.2019.07.88] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The morbidity and mortality benefits of performing high-risk operations in high-volume centers by high-volume surgeons are evident. Regionalization is a proposed strategy to leverage high-volume centers for esophagectomy to improve quality outcomes. Internationally, regionalization occurs under national mandates. Those mandates do not exist in the United States and spontaneous regionalization of esophagectomy has only modestly occurred in the U.S. Regionalization must strike a careful balance and not limit access to optimal oncologic care to our most vulnerable cancer patient populations in rural and disadvantaged socioeconomic areas. We reviewed the recent literature highlighting: the justification of hospital and surgeon annual esophagectomy volumes for regionalization; how safety performance metrics could influence regionalization; whether regionalization is occurring in the US; what impact regionalization may have on esophagectomy costs; and barriers to patients traveling to receive oncologic treatment at regionalized centers of excellence.
Collapse
Affiliation(s)
- James M Clark
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale New Haven Hospital, New Haven, CT, USA
| | - Robert A Meguid
- Division of Thoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lisa M Brown
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
| | - David T Cooke
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, CA, USA
| |
Collapse
|
14
|
Hoag JR, Resio BJ, Monsalve AF, Chiu AS, Brown LB, Herrin J, Blasberg JD, Kim AW, Boffa DJ. Differential Safety Between Top-Ranked Cancer Hospitals and Their Affiliates for Complex Cancer Surgery. JAMA Netw Open 2019; 2:e191912. [PMID: 30977848 PMCID: PMC6481444 DOI: 10.1001/jamanetworkopen.2019.1912] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Leading cancer hospitals have increasingly shared their brands with other hospitals through growing networks of affiliations. However, the brand of top-ranked cancer hospitals may evoke distinct reputations for safety and quality that do not extend to all hospitals within these networks. OBJECTIVE To assess perioperative mortality of Medicare beneficiaries after complex cancer surgery across hospitals participating in networks with top-ranked cancer hospitals. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study was performed of the Centers for Medicare & Medicaid Services 100% Medicare Provider and Analysis Review file from January 1, 2013, to December 31, 2016, for top-ranked cancer hospitals (as assessed by U.S. News and World Report) and affiliated hospitals that share their brand. Participants were 29 228 Medicare beneficiaries older than 65 years who underwent complex cancer surgery (lobectomy, esophagectomy, gastrectomy, colectomy, and pancreaticoduodenectomy [Whipple procedure]) between January 1, 2013, and October 1, 2016. EXPOSURES Undergoing complex cancer surgery at a top-ranked cancer hospital vs an affiliated hospital. MAIN OUTCOMES AND MEASURES Risk-adjusted 90-day mortality estimated using hierarchical logistic regression and comparison of the relative safety of hospitals within each cancer network estimated using standardized mortality ratios. RESULTS A total of 17 300 patients (59.2%; 8612 women and 8688 men; mean [SD] age, 74.7 [6.2] years) underwent complex cancer surgery at 59 top-ranked hospitals and 11 928 patients (40.8%; 6287 women and 5641 men; mean [SD] age, 76.2 [6.9] years) underwent complex cancer surgery at 343 affiliated hospitals. Overall, surgery performed at affiliated hospitals was associated with higher 90-day mortality (odds ratio, 1.40; 95% CI, 1.23-1.59; P < .001), with odds ratios that ranged from 1.32 (95% CI, 1.12-1.56; P = .001) for colectomy to 2.04 (95% CI, 1.41-2.95; P < .001) for gastrectomy. When the relative safety of each top-ranked cancer hospital was compared with its collective affiliates, the top-ranked hospital was safer than the affiliates in 41 of 49 studied networks (83.7%; 95% CI, 73.1%-93.3%). CONCLUSIONS AND RELEVANCE The likelihood of surviving complex cancer surgery appears to be greater at top-ranked cancer hospitals compared with the affiliated hospitals that share their brand. Further investigation of performance across trusted cancer networks could enhance informed decision making for complex cancer care.
Collapse
Affiliation(s)
- Jessica R. Hoag
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin J. Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Andres F. Monsalve
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S. Chiu
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Lawrence B. Brown
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Jeph Herrin
- Department of Internal Medicine, Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Justin D. Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anthony W. Kim
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles
| | - Daniel J. Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
15
|
Mohammad Z, Mitchell KG, Nelson DB, Robb C, Jreissaty C, Tu J, Vaporciyan AA, Sepesi B, Antonoff MB. Lung Cancer Patient Perceptions of the Value of an Outreach Thoracic Surgical Clinic. Ann Thorac Surg 2019; 108:358-362. [PMID: 30928553 DOI: 10.1016/j.athoracsur.2019.02.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although specialty outreach clinics have been associated with improved outcomes and access to care, their role for patients with non-small cell lung cancer (NSCLC) has not been described. We sought to characterize perceptions of the utility of a specialty outreach clinic among patients with suspected NSCLC. METHODS Surveys were administered to patients who were suspected to have NSCLC and were seen at an outreach thoracic surgery clinic (2016 to 2017). The clinic was located approximately 20 miles from the academic cancer center. RESULTS Sixty-nine patients completed surveys. The median distance traveled to the clinic was 43.5 miles (interquartile range: 5.0 to 111.3 miles). Among patients traveling 50 miles or more, the overwhelming majority (27 of 32 patients, 84.4%) cited physician expertise as the primary benefit of treatment at the clinic. Moreover, compared with patients living in closer proximity, they were more willing to travel 100 miles or more to have surgery (71.0% versus 26.7%, p = 0.001) or to consult with a surgeon (71.0% versus 25.8%, p < 0.001). Patients for whom it was very important to receive care close to home (33 of 68 patients, 48.5%) were less willing to travel 100 miles or more for consultation (surgeon: 33.3% versus 65.6%, p = 0.011; medical oncologist: 33.3% versus 65.6%, p = 0.011; radiation oncologist: 33.3% versus 64.5%, p = 0.015) and for treatment (surgery: 33.3% versus 65.6%, p = 0.011; chemotherapy: 36.7% versus 60.7%, p = 0.067; radiotherapy: 33.3% versus 64.3%, p = 0.018). CONCLUSIONS Many patients value receiving oncologic care close to home and are sensitive to distance required to travel for care. Thoracic surgical outreach clinics may provide a benefit for patients with lung cancer in the settings of initial consultation, preoperative care, and postoperative care.
Collapse
Affiliation(s)
- Zoya Mohammad
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kyle G Mitchell
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David B Nelson
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Courtney Robb
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Claudine Jreissaty
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Janet Tu
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| |
Collapse
|
16
|
Reames BN, Anaya DA, Are C. Hospital Regional Network Formation and 'Brand Sharing': Appearances May Be Deceiving. Ann Surg Oncol 2019; 26:711-713. [PMID: 30607763 DOI: 10.1245/s10434-018-07129-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Bradley N Reames
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Daniel A Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Chandrakanth Are
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|