Here’s another study highlighting the importance of having esophagectomies (esophageal surgery) at high volume centers. It’s a topic we’ve talked about before, and as it’s something I feel very strongly about – something readers will probably see mentioned again. It also helps answer the question – “Do I need to travel to X for surgery or can I have it at the local hospital?” This was the main questions the researchers were looking at for this study in terms of costs, logistics and burdens on patient and family.
This article by Bilimoria et. al (2010), published in the Annals of Surgery, was actually comparing outcomes for multiple surgery types at small community hospital versus large specialty center, not just thoracic surgeries but the research findings are similar to what we have reported previously. The irony of this study is that the researchers were expressly trying to prove the opposite, that small hospitals are safe for high complexity, high morbidity/ mortality operations – as a way to cut costs, and save money by preventing additional patient shifting to larger institutions that may be at a considerable distance for patients. They demonstrated limited success in their results for other surgeries – but the need for high volume esophagectomy programs for successful surgical outcomes remains unchanged. (Some of this may be due to the fact that many of these esophagectomies at smaller hospitals are performed by general, not thoracic surgeons.)
The answer for patients with esophageal cancer is: Yes – you do need to go to the esophageal cancer center (not your local community hospital). This is regardless of classification of low or high risk (which is based on age, and a Charlson score – which is a score used to add up other risk factors). This is something I have had to address with patients in my own personal practice as both a referring provider (at a smaller facility) and as a receiving provider (when I was at a larger esophageal surgery center.)
I’ve reposted the abstract below, so you can read for yourself. (The article itself is several pages long). [Italics are mine..]
Bilimoria, et. al. (2010). Risk-based Selective Referral for Cancer Surgery: A Potential Strategy to Improve Perioperative Outcomes Annals of Surgery. 2010;251(4):708-716.
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.