Variation in Hospital Mortality After Complex Cancer Surgery: Patient, Volume, Hospital or Social Determinants?

Defining the role and impact of specialty surgeons in ensuring high-quality, accessible abdominal surgery: a report from the 2024 GI Surgery Summit

BACKGROUND

The 2024 GI Surgery Summit brought together Society for Surgery of the Alimentary Tract (SSAT), Society of Surgical Oncology (SSO), and Society of University Surgeons (SUS) members to assess the current state of gastrointestinal (GI) surgery. This report reviews the key discussions and recommendations after the dedicated plenary session that addressed challenges in providing high-quality, accessible GI surgery for all patients.

METHODS

The Summit took place from January 14 to 16. During the plenary session "Defining the role and impact of specialty surgeons in ensuring high-quality, accessible abdominal surgery," leaders, rising leaders, and members of SSAT, SSO, and SUS met and discussed challenges in providing high-quality, accessible GI surgery.

RESULTS

Actionable recommendations to address the challenges in providing high-quality, accessible GI surgical care were made, including engaging communities and patients, building alliances across hospitals and surgeons, and establishing standards of GI surgical care.

CONCLUSION

Surgeons, hospital systems, and surgical societies can improve healthcare access and outcomes for all GI surgical patients.

Upper gastrointestinal cancers: Trends and determinants of location of death

BACKGROUND

Patients diagnosed with upper gastrointestinal cancers often require extensive end-of-life care. We sought to investigate social determinants of health associated with disparities in the location of death among patients who died of upper gastrointestinal cancers.

METHODS

Patients who died between 2003 and 2020 from esophageal cancer, gastric cancer, hepatobiliary cancer, and pancreatic cancer were identified using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Social determinants of health were assessed using the Social Vulnerability Index. Patients were categorized on the basis of location of death: inpatient hospital, home, nursing home, hospice, and outpatient medical facility/emergency department. Multivariable regression and mediation analyses defined the association of patient race as well as social determinants of health with location of death.

RESULTS

Among 815,780 decedents (esophageal cancer: 15.3%; gastric cancer: 3.6%; hepatobiliary cancer: 36.6%; pancreatic cancer: 54.5%), most were male (60.8%), aged 55-74 years (52.3%), and White (89.1%). Most decedents died at home (55.7%), followed by inpatient hospital (24.8%), hospice (9.0%), nursing home (8.1%), and outpatient medical facility/emergency department (2.5%). During the study period, location of death shifted notably from inpatient hospital (36.8% to 21.3%) to home (45.8% to 56.3%). Residents of high Social Vulnerability Index areas were more likely to die at inpatient hospital compared with home (31.8% vs 24.3%) (P < .001). Black race (reference: White; odds ratio; 0.41, 95% confidence interval, 0.40-0.42) and social vulnerability (reference: low Social Vulnerability Index; odds ratio, 0.64, 95% confidence interval, 0.63-0.65) remained independently associated with lower odds of dying at home compared with an inpatient hospital. Notably, 65% of the overall race-based association with death at inpatient hospital was driven indirectly through social determinants of health.

CONCLUSION

Social determinants are important drivers of end-of-life care and impact the potential ability of patients with cancer to die at home.

Impact of hospital volume and facility characteristics on postoperative outcomes after hepatectomy: A mediation analysis

BACKGROUND

The impact of hospital procedural volume on outcomes after hepatectomy relative to other facility-related factors remains unclear. We sought to define the comparative impact of hospital volume compared with other facility-related factors on postoperative outcomes among Medicare beneficiaries undergoing hepatectomy.

METHODS

Data on patients who underwent hepatectomy between 2013 and 2021 were collected from the Medicare Standard Analytic Files and linked with facility-level data from the American Hospital Association Survey databases. Hospital volume was stratified into high- (top 10%) and low-volume centers. Propensity score matching was used to account for variable imbalances in patient characteristics among high-compared with low-volume centers. Mediation analysis was employed to delineate facility-related factors responsible for the impact of hospital volume on outcomes with a specific focus on incidence of complications, in-hospital mortality, and failure to rescue.

RESULTS

The analytic cohort included 22,969 patients from 340 institutions. After propensity score matching, receipt of surgery at a high-volume center was associated with a lower likelihood of postoperative complications (39.9% vs 41.7%, P = .01), in-hospital mortality (2.2% vs 2.8%, P = .02), and failure to rescue (5.4% vs 6.5%, P = .04) versus low-volume centers. Mediation analysis revealed that hospital capacity (bed capacity and nurse-to-bed ratio) contributed the most to the variations in risk of complications and in-hospital mortality, whereas liver transplant program status had the largest impact on failure to rescue.

CONCLUSIONS

Hospital volume is a significant determinant of postoperative outcomes after hepatectomy, with hospital capacity and liver transplant program status being important mediators of this effect. Centralization and optimal resource distribution are important to achieve favorable outcomes following liver resection.