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Original Investigation
Pacific Coast Surgical Association
August 21, 2019

Defining Value for Pancreatic Surgery in Early-Stage Pancreatic Cancer

Author Affiliations
  • 1Divison of Surgical Oncology, Department of Surgery, University of California, Davis, Medical Center, Sacramento
  • 2Center for Healthcare Policy and Research, University of California, Davis, Sacramento
  • 3Divison of Health Policy and Management, Department of Public Health Sciences, University of California, Davis, Medical Center, Sacramento
JAMA Surg. 2019;154(10):e193019. doi:10.1001/jamasurg.2019.3019
Key Points

Question  Is the regionalization of surgical care for resectable pancreatic cancer at high-volume surgical centers and National Cancer Institute–designated cancer centers associated with improved survival, health care costs, and/or value (ie, survival relative to costs)?

Findings  In this retrospective analysis of 2786 patients with stages I to II pancreatic adenocarcinoma who underwent pancreatic resection, although high-volume centers were associated with greater overall survival, high-volume and National Cancer Institute–designated centers were not associated with improved health care costs or value.

Meaning  Targeted measures are needed at high-volume and National Cancer Institute–designated centers to enhance pancreatic surgery value, especially considering they treat a significant fraction of patients with pancreatic cancer.


Importance  Value-based care is increasingly important, with rising health care costs and advances in cancer treatment leading to greater survival for patients with cancer. Regionalization of surgical care for pancreatic cancer has been extensively studied as a strategy to improve perioperative outcomes, but investigation of long-term outcomes relative to health care costs (ie, value) is lacking.

Objective  To identify patient and hospital characteristics associated with improved overall survival, decreased costs, and greater value among patients with pancreatic cancer undergoing curative resection.

Design, Setting, and Participants  This retrospective cohort study identified 2786 patients with stages I to II pancreatic cancer who underwent pancreatic resection at 157 hospitals from January 1, 2004, through December 31, 2012. The study used the California Cancer Registry, which collects data from all California residents newly diagnosed with cancer, linked to the Office of Statewide Health Planning and Development database, which collects administrative data from all California licensed hospitals. Data were analyzed from November 11, 2017, through September 4, 2018.

Exposures  Pancreatic resection at high-volume and/or National Cancer Institute (NCI)–designated cancer centers.

Main Outcomes and Measures  The primary outcomes were overall survival, surgical hospitalization costs, and value. High value was defined as the fourth quintile or higher for survival and the second quintile or less for costs. Costs were calculated from charges using cost-charge ratios and adjusted for geographic variation and inflation. Multivariable regression models were used to determine factors associated with overall survival, costs, and high value.

Results  Among the 2786 patients included (1394 [50.0%] male; mean [SD] age, 67.0 [10.7] years), postoperative chemotherapy (adjusted hazard ratio [aHR], 0.71; 95% CI, 0.64-0.79; P < .001) and high-volume centers (aHR, 0.78; 95% CI, 0.61-0.99; P = .04) were associated with greater overall survival. Higher Elixhauser comorbidity index scores (estimate, 0.006; 95% CI, 0.003-0.008), complications (estimate, 0.22; 95% CI, 0.17-0.27), readmissions (estimate, 0.34; 95% CI, 0.29-0.39), and longer lengths of stay (estimate, 0.03; 95% CI, 0.03-0.04) were associated with higher costs (P < .001), whereas postoperative chemotherapy was associated with lower costs (estimate, −0.06; 95% CI, −0.11 to −0.02; P = .006). National Cancer Institute–designated and high-volume centers were not associated with costs. Although grades III and IV tumors (odds ratio [OR], 0.65; 95% CI, 0.39-0.91; P = .001), T3 category disease (OR, 0.71; 95% CI, 0.46-0.95; P = .005), complications (OR, 0.68; 95% CI, 0.49-0.86; P < .001), readmissions (OR, 0.64; 95% CI, 0.44-0.84; P < .001), and length of stay (OR, 0.82; 95% CI, 0.78-0.85; P < .001) were inversely associated with high-value care, NCI designation (OR, 1.07; 95% CI, 0.66-1.49; P = .74) and high-volume centers (OR, 1.08; 95% CI, 0.54-1.61; P = .07) were not.

Conclusions and Relevance  In this study, high-value care was associated with important patient characteristics and postoperative outcomes. However, NCI-designated and high-volume centers were not associated with greater value. These data suggest that targeted measures to enhance value may be needed in these centers.

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