Editor’s note: Due to the COVID-19 pandemic, the 2021 Triological Society Combined Sections Meeting was held virtually on Jan. 29-30. The physical distance didn’t stop otolaryngologists in every specialty area from discussing the latest treatments, techniques, and issues in otolaryngology research and clinical practice.
It has been increasingly recognized that hospitals performing a high volume of procedures tend to have better outcomes in those procedures, and now the role of market concentration is coming into better focus.
Christine Gourin, MD, MPH, a professor of otolaryngology–head and neck cancer at Johns Hopkins School of Medicine in Baltimore, has led research using national healthcare data to see how hospitals in highly concentrated markets with low competition compare on laryngectomy care with hospitals in unconcentrated markets with high competition. The research is part of Johns Hopkins’ participation in the “volume pledge,” in which Hopkins, Dartmouth College, and the University of Michigan have pledged to limit certain types of procedures at low-volume centers.
Examining laryngectomy procedures performed across the country from 2003 to 2011, researchers found that 69.2% were performed at hospitals in highly concentrated markets that are noncompetitive, while 26.2% were performed in unconcentrated, competitive markets. Most high-volume hospitals (68.0%) were located within highly concentrated markets. Researchers found that unconcentrated, less-competitive markets were associated with 28% higher costs, relative to markets with moderate and high concentration (JAMA Otolaryngol Head Neck Surg. 2019;145:939-947).
Other work by Dr. Gourin and her colleagues has found that the majority of extreme mark-up hospitals—those that charge the most compared to what it actually costs to provide the care—are not high-volume hospitals. “The more concentrated the market—in other words, the less competitive it is—the less likely it is to be a high-markup hospital,” she said. “And the less likely it is to have a for-profit hospital status.”
Within a large healthcare market, consolidation of larynx cancer care has favorable financial implications, and within these large markets, there’s a greater cost savings when the care within a particular hospital or healthcare system is provided at the high-volume hospital. —Christine Gourin, MD, MPH
For laryngectomy, then, consolidating the volume of surgeries into markets that are less competitive could be a way to improve quality and value, she suggested. “Within a large healthcare market, consolidation of larynx cancer care has favorable financial implications, and within these large markets, there’s a greater cost savings when the care within a particular hospital or healthcare system is provided at the high-volume hospital,” Dr. Gourin said.
There are potential hurdles to this strategy, she acknowledged, such as whether high-volume hospitals can increase their surgical load, especially with a backlog of cases due to COVID-19. Another challenge is that some patients, including many who live in the northeast part of the U.S., don’t want to travel very far for their care.
Robert Ferris, MD, PhD, director of the University of Pittsburgh Hillman Cancer Center, discussed the ways that surgeons were credentialed in the ECOG-ACRIN 3311 Trial that examined radiation dosing after surgical resection. For the trial, the “up-front-surgery had to be standardized into high quality, or else you couldn’t ask a question about adjuvant therapy,” Dr. Ferris said.
For initial credentialing, surgeons had to certify hospital credentialing for the modality they would be using and a minimum of 20 cases of surgical experience. They had to submit 10 cases with paired operative notes and pathology reports over a two-year period to an expert panel (Oral Oncol. 2020;110:104797). After approval, margin status and bleeding were monitored by the committee at every five cases. There were 120 surgeons who applied, and 87 were approved, with some not approved after they failed to respond to requests for more cases to be submitted, Dr. Ferris said.
The results of the surgeries in the trials showed that the credentialing process seems to have been a success, he said. Just under 4% of the cases had positive margins, and about 5% had grade 3 or 4 bleeding. “That, I think, gives a model for future surgical trials,” Dr. Ferris said. A similar process is now being used in a trial on surgical node biopsy, he added.
Looking back, Dr. Ferris said it would have been beneficial to also credential the clinical research staff, since some patients became ineligible during the trial, despite a quality surgery, because of untimely imaging or other wrinkles. “If it’s in the eligibility list … it doesn’t matter how good a surgery is or how great your radiation therapy is, they will be deemed ineligible later,” he said. “Some of the clinical research teams could have been a little bit more experienced.”
Carol Lewis, MD, MPH, associate professor of head and neck surgery at the University of Texas MD Anderson Cancer Center in Houston, described the quality outcomes associated with the department’s Enhanced Recovery After Surgery (ERAS) program for head and neck surgery with free flap reconstruction.
The program includes an extensive checklist of items performed before, during, and after surgery, and at follow-up, including providing preoperative patient education, limiting sedatives, using a set premedication regimen, using goal-directed fluid therapy, providing opioid-sparing anesthesia, encouraging early mobilization, removing catheters early, and offering coordinated follow-up and support.
Researchers found that, compared to those in a non-ERAS group, those participating in the program had a lower rate of ICU stays, a lower length of stay, a lower morphine equivalence, and a lower overall rate of complications (Ann Surg Oncol. 2021;28:867-876).
In addition, a meta-analysis and systematic review of 18 studies on ERAS programs for head and neck surgery with free flap reconstruction found that ERAS was linked with a reduced length of stay, a lower rate of readmission, and a lower rate of wound complications, but no difference in ICU length of stay, unplanned re-operation, or mortality (Oral Oncol. 2021;113:105117).
Dr. Lewis said that the balanced approach to using pain medication might have helped the most, helping patients through the post-analgesia care unit (JAMA Otolaryngol Head Neck Surg. 2020;146:708-713). She said one challenge is knowing to not reach too far with too many steps right away to get buy-in. “We’ve really had to stagger some things to make it a little more palatable and easier for people to wrap their brains around.”
Thomas R. Collins is a freelance medical writer based in Florida.