Variation in outcomes across surgeons meeting the Leapfrog volume standard for complex oncologic surgery

Abstract

BACKGROUND A large body of evidence supports regionalization of complex oncologic surgery to high‐volume surgeons at high‐volume hospitals. However, whether there is heterogeneity of outcomes among high‐volume surgeons at high‐volume hospitals remains unknown. METHODS Patients who underwent esophagectomy, lung resection, pancreatectomy, or proctectomy for primary cancer were identified within the Medicare 100% Standard Analytic File (2013‐2017). Mixed‐effects analyses assessed the association between Leapfrog annual volume standards for surgeons (esophagectomy ≥7, lung resection ≥15, pancreatectomy ≥10, proctectomy ≥6) and hospitals (esophagectomy ≥20, lung resection ≥40, pancreatectomy ≥20, proctectomy ≥16) relative to postoperative complications and 90‐day mortality. Additional analyses using New York's all‐payer Statewide Planning and Research Cooperative System (2004‐2015) were performed. RESULTS Among 112,154 Medicare beneficiaries, high‐volume surgeons at high‐volume hospitals were associated with lower adjusted odds of complications (esophagectomy: odds ratio [OR], 0.73 [95% CI, 0.61‐0.86]; lung resection: OR, 0.88 [95% CI, 0.82‐0.94]; pancreatectomy: OR, 0.73 [95% CI, 0.66‐0.80]; proctectomy: OR, 0.92 [95% CI, 0.85‐0.99]) and 90‐day mortality (esophagectomy: OR, 0.60 [95% CI, 0.44‐0.76]; lung resection: OR, 0.82 [95% CI, 0.73‐0.93]; pancreatectomy: OR, 0.66 [95% CI, 0.56‐0.76]; proctectomy: OR, 0.74 [95% CI, 0.65‐0.85]). For the average patient at the average high‐volume hospital, there was a 2‐fold difference in the adjusted complication rate between the best‐performing and worst‐performing high‐volume surgeon for all operations (esophagectomy, 28%‐55%; lung resection, 7%‐21%; pancreatectomy, 16%‐35%; proctectomy, 16%‐28%). Wide variation was also present in adjusted 90‐day mortality for esophagectomy (3.5%‐9.3%). Results from New York's all‐payer database were similar. CONCLUSIONS Even among high‐volume surgeons meeting the Leapfrog volume standards, wide variation in postoperative outcomes exists. These findings suggest that volume alone should not be used as a quality indicator, and quality metrics should be continuously evaluated across all surgeons and hospital systems. LAY SUMMARY Previous studies have demonstrated a surgical volume‐outcome relationship for high‐risk operations—that is high‐volume surgeons and hospitals that perform a specific surgical procedure more frequently have better outcomes for that operation. Although most high‐volume surgeons had better outcomes, this study demonstrated that some high‐volume surgeons did not have better outcomes. Therefore, volume is an important factor but should not be the only factor considered when assessing the quality of a surgeon and a hospital for cancer surgery.

Disparities in access to care among patients with appendiceal or colorectal cancer and peritoneal metastases: A medicare insurance-based study in the United States

“…A PSM surgeon was defined as a surgeon who performed at least one CRS/HIPEC case for a Medicare beneficiary during the study period and had a specialty taxonomy in the CMS National Plan and Provider Enumeration System (NPPES) of general surgery, surgical oncology, or colon & rectal surgery. Surgeons were matched to the NPPES using the National Provider Identifier number of the primary surgeon within the Medicare claim for the CRS/HIPEC procedure ( 17 , 18 ). Three-year OS was defined as death from any cause within 3 years of the initial diagnosis date of PM.…”

“…For the binomial outcomes of CRS/HIPEC and outpatient evaluation by a PSM surgeon, Bayesian mixed-effects multivariable analyses were performed. Weakly informative independent normal priors were specified for the log odds ratio, variance parameters were set to 1, co-variances to 0, and the degree of belief to 0.002, and the Gibbs sampler was utilized to run Bayesian models for 13,000 Monte Carlo Markov chain iterations with a burn-in of 3,000 iterations ( 18 , 25 ).…”

Disparities in Care Access to Liver-Directed Therapy Among Medicare Beneficiaries with Colorectal Cancer Liver Metastasis

“…20 This methodology, using the NIS to estimate total volume for hospitals within Medicare claims, has been previously utilized and described. 21 , 22 Using the estimated total annual hospital volume, hospitals were dichotomized into low- and high-volume liver surgery centers. Utilizing the lowest tertile of annual volume as the cutoff a priori, low-volume liver surgery centers were defined as hospitals that performed an average of < 20 liver resections for cancer per year, and high-volume liver surgery centers were defined as hospitals that performed an average of ≥ 20 liver resections for cancer per year.…”

“… 27 , 28 Weakly informative independent normal priors were specified for the log odds ratio, variance parameters were set to 1, covariances to 0, and the degree of belief to 0.002, and the Gibbs sampler was utilized to run Bayesian models for 13,000 Monte Carlo Markov chain iterations with a burn-in of 3000 iterations. 22 , 29…”

Impact of Care Coordination on the Content of Communication Between Surgeons and Patients With Rectal Cancer

“…There is significant variation in outcomes for the ~45,000 patients diagnosed with rectal cancer nationwide each year. 1 , 2 Evidence-based guidelines representing substantial advances in rectal cancer care are associated with decreased rates of recurrence and improved survival. 3 , 4 However, studies reveal that close to half of patients with rectal cancer do not receive guideline-recommended staging and treatment, leading to significant disparities in outcomes such as cancer recurrence and permanent ostomy.…”