K. H. Sheetz1, J. B. Dimick1, H. Nathan1 1University of Michigan,Surgery,Ann Arbor, MI, USA
Background:
Hospital consolidation has the potential to improve the quality of care within regional delivery networks. We evaluated the extent to which hospital networks centralize high-risk cancer surgery and whether centralization is associated with changes in short-term clinical outcomes.
Methods:
We merged results from the American Hospital Association’s annual survey on network participation with Medicare claims to identify patients undergoing surgery for pancreatic, esophageal, colon, lung, or rectal cancer between 2005 and 2014. We calculated the degree to which networks centralized each procedure by calculating the annual proportion of surgeries performed at the highest volume hospital within each network. We then estimated the independent effect of centralization on the incidence of postoperative complications, death, and failure to rescue after accounting for patient complexity, hospital volume, and overall hospital quality.
Results:
The average degree of centralization varied from 25.2% (Range 6.6–100%) for colectomy to 71.2% (Range 8.3–100%) for pancreatectomy. Greater centralization was associated with lower rates of postoperative complications and death for lung resection, esophagectomy, and pancreatectomy. For example, there was a 1.6% (95% CI -2.3 to -0.9) absolute reduction in 30-day mortality following pancreatectomy for each 20% increase in the degree of centralization within networks. Independent of volume and hospital quality, postoperative mortality for pancreatectomy was 58% lower in the most centralized networks compared to the least centralized networks (8.9% vs. 3.7%, p<0.01). Centralization was not associated with better outcomes for colectomy or proctectomy.
Conclusions:
Greater centralization of complex cancer surgery within existing hospital networks was associated with better outcomes. As hospitals affiliate in response to broader financial and organization pressures, these networks may also present unique opportunities to improve the quality of high-risk cancer care.
