Hospital Volume Predicts Guideline-Concordant Care in Stage III Esophageal Cancer

Background: Esophageal cancer is a deadly disease requiring multidisciplinary coordination of care and surgical proficiency for adequate treatment. We hypothesize that quality of care is varied nationally. Methods: From published guidelines, we developed quality measures for management of stage III esophageal cancer: utilization of neoadjuvant therapy, surgical sampling of at least 15 lymph nodes, resection within 60 days of chemotherapy or radiation, and completeness of resection. Measure adherence was examined across 1345 hospitals participating in the National Cancer Database from 2004 to 2016. We examined the association of volume, program accreditation, safety net status, geographic region, and patient travel distance on adequate adherence (≥85% of patients are adherent) using logistic regression modeling. Results: The rate of adequate adherence was worst in nodal staging (12.6%) and highest for utilization of neoadjuvant therapy (84.8%). Academic programs had the highest rate of adequate adherence for induction therapy (77.2%; P < .001), timing of surgery (56.6%; P < .001), and completeness of resection (78.5%; P < .001) but the lowest for nodal staging (4.4%; P = .018). For every additional esophagectomy performed per year, the odds of adequate adherence increased for induction therapy (odds ratio [OR]. 1.16; 95% confidence interval [CI], 1.06-1.27) and completeness of resection (OR, 1.15; 95% CI, 1.06-1.25) but decreased for nodal staging (OR, 0.76; 95% CI, 0.65-0.89). Conclusions: Care provided at higher volume and academic facilities was more likely to be guideline concordant in some areas but not in others. Understanding the processes that support the delivery of guideline concordant care may provide valuable opportunities for improvement.