Patients More Likely to Survive Complex Cancer Surgery at Top Hospitals than Affiliates

Comment: While head and neck surgeries were not included, this manuscript addresses one method by which hospitals seek to improve their branding and overall profile in the community: acquiring an affiliation (and thus, brand recognition) with a prominent institution or network. Fifty-nine hospitals achieved a top cancer hospital ranking and were affiliated with 343 additional hospitals. In prior survey studies, 31% of respondents thought that once a local hospital formed an affiliation with top-ranked cancer hospitals, it was no longer necessary to travel to top-ranked hospitals to undergo complex surgery and perceived the safety/outcomes to be identical (50% of respondents). This paper shows that the latter is not the case (eFigures 2–5 are striking).

I think this has interesting implications for: 1) criteria for establishing these affiliations (it’s not easy to access this information; do you just fork over money? Show adequate training and outcomes?) and ensuring high quality (or appropriate referrals for complex care); 2) larger institutions such as academic centers that acquire other hospitals or other affiliated facilities and need to protect their reputation in their home communities; and 3) how health systems may try to leverage affiliations and other branding to attract patients—and the ethical implications.—Jennifer A. Villwock, MD

Is there a difference in risk-adjusted perioperative mortality after complex cancer surgery between top-ranked cancer hospitals and affiliates that share their brand?

Bottom Line
The likelihood of surviving complex cancer surgery appears to be greater at top-ranked cancer hospitals compared with the affiliated hospitals that share their brand.

Background: Complex surgery can represent both the best chance of cure and the greatest potential for treatment-associated harm. Recently, leading cancer hospitals have increasingly shared their brands with smaller hospitals through affiliations. Previous studies have identified a wide variation in complex surgical procedure safety for cancer across hospitals, with lethal complications occurring up to four times more often at low-volume or underperforming hospitals.

Study design: Cross-sectional study of 29,228 Medicare beneficiaries older than 65 years of age who underwent complex cancer surgery (lobectomy, esophagectomy, gastrectomy, colectomy, and pancreaticoduodenectomy [Whipple procedure]) between Jan. 1, 2013, and Oct. 1, 2016, at top-ranked cancer hospitals (11,928 patients) and affiliated hospitals that share their brand (11,928 patients).

Setting: Centers for Medicare & Medicaid Services 100% Medicare Provider Analysis and Review file.

Synopsis: Ninety-day mortality was the primary outcome. Fifty-nine hospitals achieved a top cancer hospital ranking during the study period and were affiliated with 343 additional hospitals. The affiliate patient population was older than the top-ranked hospital population, but otherwise clinically similar. Observed 90-day mortality was significantly higher among affiliated hospital patients than top-ranked hospital patients for each procedure. Risk-adjusted 90-day mortality was significantly higher at affiliated hospitals than at top-ranked hospitals for all five procedures combined. The affiliated patients’ higher mortality risk of ranged in magnitude when stratified by procedure (colectomy odds ratio of 1.32 to gastrectomy odds ratio of 2.04). In an attempt to explain the differential 90-day mortality risk observed among the top-ranked cancer hospitals and affiliates, several hospital attributes were individually added to the adjusted hierarchical regression model. Although no single hospital attribute eliminated the differential, annual hospital volume and teaching status both attenuated the differential’s magnitude and significance. Limitations included observations that may not generalize to all scenarios in which hospitals share their brand, a focus on patients older than 65 years, and unavailable clinical and sociodemographic characteristics.

Citation: Hoag JR, Resio BJ, Monsalve AF, et al. Differential safety between top-ranked cancer hospitals and their affiliates for complex cancer surgery. JAMA Netw Open. 2019;2:e191912.