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High-risk patients with certain cancers are the best candidates for referral to high-volume cancer surgery hospitals

Initiatives to regionalize cancer surgery—that is, refer cancer patients to hospitals that perform a high volume of cancer surgeries each year—are already underway. However, for patients in isolated rural areas, regionalizing surgery could create unreasonable travel burdens, delays in initial evaluation, and problems with continuity of care after surgery. Loss of surgical caseload at small rural hospitals could threaten their financial viability and their ability to recruit and retain surgeons. To avoid these potential harms, it is important that regionalization efforts target only those patients likely to benefit most, suggests John D. Birkmeyer, M.D., Chief of General Surgery at Dartmouth-Hitchcock Medical Center.

In a study supported in part by the Agency for Healthcare Research and Quality (HS10141), Dr. Birkmeyer and his colleagues found that older, high-risk individuals suffering from certain types of cancers benefit most from referral to high-volume cancer surgery hospitals. They used information from the Nationwide Inpatient Sample (1995-1997) to examine mortality for eight types of cancer surgery among 195,152 patients: colectomy, gastrectomy, esophagectomy, pancreatic resection, nephrectomy, cystectomy, and lung resection (either pulmonary lobectomy or pneumonectomy). They divided patients into low-, medium-, and high-volume hospital groups to analyze the relationship between hospital volume and in-hospital deaths, after adjusting for patient characteristics.

Higher volume hospitals achieved lower operative mortality rates for seven of the eight procedures. However, differences between low- and high-volume hospitals were significant for only three operations (esophagectomy, 15 vs. 6.5 percent; pancreatic resection 13.1 vs. 2.5 percent; and pulmonary lobectomy, 10.1 vs. 8.9 percent, respectively). Though not statistically significant, mortality differences greater than 1 percent were observed for gastrectomy, cystectomy, and pneumonectomy. Volume-related differences for colectomy and nephrectomy were small.

See "Hospital volume and operative mortality in cancer surgery: A national study," by Emily V. A. Finlayson, M.D., Philip P. Goodney, M.D., and Dr. Birkmeyer, in the July 2003 Archives of Surgery 128, pp. 721-725.

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