Risk-based selective referral for cancer surgery: A potential strategy to improve perioperative outcomes

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. Conclusion:S 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.