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Invited Commentary
November 16, 2018

Regionalization of Complex Cancer Surgery: How, When, and Why?

Author Affiliations
  • 1Colon and Rectal Surgery, Mayo College of Medicine, Phoenix, Arizona
JAMA Netw Open. 2018;1(7):e184586. doi:10.1001/jamanetworkopen.2018.4586

Some hospitals are better and some are worse—this we know is true. But, how do we know? The goal of accurately discerning which hospitals are high performers is undertaken by a growing array of agencies in the public and private sectors. Each of these agencies is seeking to provide patients and payers with an evaluation of quality that is clear enough to guide informed decision-making.

If this goal could be met, patients diagnosed with cancer would be empowered to seek the highest-quality care based on objective assessments of hospital and surgeon quality. Real-world experience, however, shows that quality of care and complication rates are not the only factor influencing where patients choose to receive their care. In a seminal study by Finlayson et al,1 patients with pancreatic cancer were given the choice of undergoing an operation locally or traveling to a regional facility with better mortality outcomes. Even with a mortality risk of 12% at a local hospital compared with 3% for the regional facility, 23 out of 100 patients preferred to stay local.

The relatively sluggish movement toward regionalization of complex cancer surgery within the United States is a real-world reflection of the importance of considerations other than complication rates. Luft et al2 published the first major research study documenting a significantly lower rate of mortality with major surgery in 1979. Decades after this initial characterization of the volume-outcome association for complex surgery, the majority of such operations in the United States continue to occur at low-volume hospitals. Despite a wealth of research showing better outcomes at high-volume hospitals and efforts by organizations such as the Leapfrog group to implement regionalization, our health care system remains remarkably intractable to significant change.

The study by Resio et al3 takes an important step beyond existing research and asks why patients often make the counterintuitive choice to not travel for higher-quality care. Their findings are different from the earlier findings of Finlayson et al,1 and this may reflect temporal differences or differences in the surveyed population. Superior outcomes were a powerful but incomplete incentive for patients to travel for their care. The most important point made by this study is that a significant portion of patients were willing to travel for higher-quality care if some of the challenges of travel could be addressed. This point raises a host of questions regarding policy pertaining to the regionalization of complex cancer surgery.

How good are the data available to patients in making decisions regarding where to obtain treatment? Public reports of hospital-based surgical outcomes are variable, opaque, conflicting, and occasionally misleading. The respondents in this survey were given 6 measures of surgical quality: complication rate, infection rate, mortality rate, cure rate, complete resection rate, and surgeon volume. This degree of detail regarding outcomes is ideal, but impossible to obtain for an average patient and likely not even known to the treating hospital. Furthermore, each one of these metrics could be challenged as an adequate reflection of high-quality care. And, what do we say to a patient who can look up a particular hospital’s quality on Hospital Compare, ProPublica, and US News & World Report and come up with 3 different answers?

How well are patients able to interpret outcomes of these reports? For informed decision a certain degree of health literacy is required on the part of the patients in correctly interpreting these data.4 However, quantification of risk is difficult even for trained professionals. Findings from the study by Resio et al3 reflect this truth, noting that 45% of respondents who were in the most easily motivated quartile for at least 1 indicator were also in the most resistant quartile for 1 or more of the other quality indicators.

Does regionalized care always mean better care? Which operations should prompt a patient to seek out a regional center of excellence? And, which is more important, the surgeon or the hospital? The relationship between volume and outcome is different for different operations and also evolving over time. Global improvements in surgical mortality have attenuated this association over time, primarily owing to gains made in low- and medium-volume hospitals.5 Paradoxically, regionalization may actually negatively affect outcomes by fragmenting the provision of care.6

Perhaps the most important barrier to regionalization is outside the control of patients or clinicians. The most commonly identified barrier to regionalization in the study by Resio et al3 was insurance coverage. As the authors mentioned, even passage of the Affordable Care Act would have precluded many patients access to the highest-quality cancer centers. The uncertain future of the Affordable Care Act coupled with current political resistance to universal health care means that access will remain a major impediment to receiving specialty care at a regional center. Countries with single-payer health care policy initiatives to encourage regionalization have shown a greater movement toward regionalization than the United States.7

How do we navigate our way through these obstacles in search of optimal outcomes for all patients? A potential model is direct employer-to-provider contracting that sidesteps insurers altogether. Currently only 6% of employers contract directly with providers but 22% are considering it for 2019.8 For example, Walmart, the largest private employer in the United States, has a Center of Excellence Network for spine surgery and cancer surgery.9 The company contracts with 12 high-quality centers across the country to provide bundled payments in a value-based payment program. Walmart covers 100% of procedural costs, as well as travel and lodging for the patient and caregiver. Another example is the contract between Boeing and the MemorialCare Health Alliance Accountable Care Organization to provide health care for all of its 15 000 employees and 22 000 dependents in California.10 These efforts represent attempts to align the interests of the payer with the patient and address some of the concerns raised in this article by patients as barriers to regional care.

If one considers the measurably better outcomes achieved by regional centers as a dose and regionalization as a response, then one has to wonder as to what the shape of the dose-response curve should be. Complex cancer surgery is clearly an appropriate target for regionalization, and Resio et al3 are right to have focused on this domain of care. There is no end in sight, however, to discussions regarding which patients and operations should be steered to regional centers or what policy levers can be used as a steering wheel. For now, at least, we know that traffic can be directed.

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Article Information

Published: November 16, 2018. doi:10.1001/jamanetworkopen.2018.4586

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Wasif N et al. JAMA Network Open.

Corresponding Author: David A. Etzioni, MD, MSHS, Colon and Rectal Surgery, Mayo College of Medicine, 5777 E Mayo Blvd, Phoenix, AZ 85054 (etzioni.david@mayo.edu).

Conflict of Interest Disclosures: None reported.

Finlayson  SR, Birkmeyer  JD, Tosteson  AN, Nease  RF  Jr.  Patient preferences for location of care: implications for regionalization.  Med Care. 1999;37(2):204-209. doi:10.1097/00005650-199902000-00010PubMedGoogle ScholarCrossref
Luft  HS, Bunker  JP, Enthoven  AC.  Should operations be regionalized? the empirical relation between surgical volume and mortality.  N Engl J Med. 1979;301(25):1364-1369. doi:10.1056/NEJM197912203012503PubMedGoogle ScholarCrossref
Resio  BJ, Chiu  AS, Hoag  JR,  et al.  Motivators, barriers, and facilitators to traveling to the safest hospitals in the United States for complex cancer surgery.  JAMA Netw Open. 2018;1(7): e184595. doi:10.1001/jamanetworkopen.2018.4595Google Scholar
Jewett  JJ, Hibbard  JH.  Comprehension of quality care indicators: differences among privately insured, publicly insured, and uninsured.  Health Care Financ Rev. 1996;18(1):75-94.PubMedGoogle Scholar
Wasif  N, Etzioni  DA, Habermann  EB,  et al.  Does improved mortality at low- and medium-volume hospitals lead to attenuation of the volume to outcomes relationship for major visceral surgery?  J Am Coll Surg. 2018;227(1):85-93.e9. doi:10.1016/j.jamcollsurg.2018.02.011PubMedGoogle ScholarCrossref
Justiniano  CF, Xu  Z, Becerra  AZ,  et al.  Long-term deleterious impact of surgeon care fragmentation after colorectal surgery on survival: continuity of care continues to count.  Dis Colon Rectum. 2017;60(11):1147-1154. doi:10.1097/DCR.0000000000000919PubMedGoogle ScholarCrossref
Simunovic  M, Urbach  D, Major  D,  et al.  Assessing the volume-outcome hypothesis and region-level quality improvement interventions: pancreas cancer surgery in two Canadian Provinces.  Ann Surg Oncol. 2010;17(10):2537-2544. doi:10.1245/s10434-010-1114-0PubMedGoogle ScholarCrossref
Masterson  L.  More employers go direct to providers, sidestepping payers. https://www.healthcaredive.com/news/more-employers-go-direct-to-providers-sidestepping-payers/518269/. Accessed September 26, 2018.
Welborn  S.  The right care at the right time: expanding our centers of excellence network. https://news.walmart.com/2016/10/10/the-right-care-at-the-right-time-expanding-our-centers-of-excellence-network. Accessed September 26, 2018.
Burns  J.  With direct contracting boeing cuts out the middleman.  Manag Care. 2017;26(11):32-34.PubMedGoogle Scholar
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