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Open Access 09-01-2024 | Pneumonectomy | Global Health Services Research

Variation in Hospital Mortality After Complex Cancer Surgery: Patient, Volume, Hospital or Social Determinants?

Authors: Muhammad Musaab Munir, MD, Selamawit Woldesenbet, MS, MPH, PhD, Yutaka Endo, MD, PhD, Mary Dillhoff, MD, Jordan Cloyd, MD, Aslam Ejaz, MD, Timothy M. Pawlik, MD, PhD, MPH, MTS, MBA, FACS, FRACS (Hon.)

Published in: Annals of Surgical Oncology | Issue 5/2024

Abstract

Introduction

We sought to define the individual contributions of patient characteristics (PCs), hospital characteristics (HCs), case volume (CV), and social determinants of health (SDoH) on in-hospital mortality (IHM) after complex cancer surgery.

Methods

The California Department of Health Care Access and Information database identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PD), or proctectomy (PR) for a malignant diagnosis between 2010 and 2020. Multi-level multivariable regression was performed to assess the proportion of variance explained by PCs, HCs, CV and SDoH on IHM.

Results

A total of 52,838 patients underwent cancer surgery (ES: n = 2,700, 5.1%; PN: n = 30,822, 58.3%; PD: n = 7530, 14.3%; PR: n = 11,786, 22.3%) across 294 hospitals. The IHM for the overall cohort was 1.7% and varied from 4.4% for ES to 0.8% for PR. On multivariable regression, PCs contributed the most to the variance in IHM (overall: 32.0%; ES: 21.6%; PN: 28.0%; PD: 20.3%; PR: 39.9%). Among the overall cohort, CV contributed 2.4%, HCs contributed 1.3%, and SDoH contributed 1.2% to the variation in IHM. CV was the second highest contributor to IHM among ES (5.3%), PN (5.3%), and PD (5.9%); however, HCs were a more important contributor among patients who underwent PR (8.0%). The unexplained variance in IHM was highest among ES (72.4%), followed by the PD (67.5%) and PN (64.6%) patient groups.

Conclusions

PCs are the greatest underlying contributor to variations in IHM following cancer surgery. These data highlight the need to focus on optimizing patients and exploring unexplained sources of IHM to improve quality of surgical care.

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Mosadeghrad AM. Factors affecting medical service quality. Iran J Public Health. 2014;43(2):210–20.PubMedPubMedCentral

Burke LG, Frakt AB, Khullar D, Orav EJ, Jha AK. Association between teaching status and mortality in US hospitals. JAMA. 2017;317(20):2105–13.PubMedPubMedCentralCrossRef

Friese CR, Lake ET, Aiken LH, Silber JH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Serv Res. 2008;43(4):1145–63.PubMedPubMedCentralCrossRef

Munir MM, Endo Y, Alaimo L, Moazzam Z, Lima HA, Woldesenbet S, et al. Impact of community privilege on access to care among patients following complex cancer surgery. Ann Surg. 2023;278(6):e1250–8.PubMedCrossRef

Ellis L, Canchola AJ, Spiegel D, Ladabaum U, Haile R, Gomez SL. Racial and ethnic disparities in cancer survival: the contribution of tumor, sociodemographic, institutional, and neighborhood characteristics. J Clin Oncol. 2018;36(1):25–33.PubMedCrossRef

Stitzenberg KB, Sigurdson ER, Egleston BL, Starkey RB, Meropol NJ. Centralization of cancer surgery: Implications for patient access to optimal care. J Clin Oncol. 2009;27(28):4671–8.PubMedPubMedCentralCrossRef

Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011;364(22):2128–37.PubMedPubMedCentralCrossRef

Birkmeyer JD, Sun Y, Wong SL, Stukel TA. Hospital volume and late survival after cancer surgery. Ann Surg. 2007;245(5):777.PubMedPubMedCentralCrossRef

Birkmeyer JD, Siewers AE, Finlayson EVA, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128–37.PubMedCrossRef

10.

Munir MM, Endo Y, Woldesenbet S, Beane J, Dillhoff M, Ejaz A, et al. Variations in travel patterns affect regionalization of complex cancer surgery in California. Ann Surg Oncol. 2023;30(13):8044–53.PubMedCrossRef

11.

Hospitals Move to Limit Low-Volume Surgeries [cited 2023 May 3]. Available at: https://www.usnews.com/news/articles/2015/05/19/hospitals-move-to-limit-low-volume-surgeries

12.

Schwartz DM, Fong ZV, Warshaw AL, Zinner MJ, Chang DC. The hidden consequences of the volume pledge: “no patient left behind”? Ann Surg. 2017;265(2):273–4.PubMedCrossRef

13.

Farjah F, Grau-Sepulveda MV, Gaissert H, Block M, Grogan E, Brown LM, et al. Volume pledge is not associated with better short-term outcomes after lung cancer resection. J Clin Oncol. 2020;38(30):3518–27.PubMedCrossRef

14.

Jacobs RC, Groth S, Farjah F, Wilson MA, Petersen LA, Massarweh NN. Potential impact of “take the volume pledge” on access and outcomes for gastrointestinal cancer surgery. Ann Surg. 2019;270(6):1079.PubMedCrossRef

15.

Wasif N, Etzioni DA, Habermann E, Mathur A, Chang YH. Correlation of proposed surgical volume standards for complex cancer surgery with hospital mortality. J Am Coll Surg. 2020;231(1):45-52.e4.PubMedCrossRef

16.

Morche J, Mathes T, Pieper D. Relationship between surgeon volume and outcomes: a systematic review of systematic reviews. Syst Rev. 2016;5(1):204.PubMedPubMedCentralCrossRef

17.

Wasif N, Etzioni DA, Habermann EB, Mathur A, Pockaj BA, Gray RJ, 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.PubMedCrossRef

18.

Jogerst KM, Chang YHH, Etzioni DA, Mathur AK, Habermann EB, Wasif N. Identifying the optimal case-volume threshold for pancreatectomy in contemporary practice. Am J Surg. 2022;223(2):318–24.PubMedCrossRef

19.

Singh GK, Daus GP, Allender M, Ramey CT, Martin EK, Perry C, et al. Social determinants of health in the United States: addressing major health inequality trends for the nation. Int J Matern Child Health AIDS. 2017;6(2):139–64.CrossRef

20.

Adler NE, Glymour MM, Fielding J. Addressing social determinants of health and health inequalities. JAMA. 2016;316(16):1641–2.PubMedCrossRef

21.

AHA Annual Survey Database^TM | AHA Data [cited 2023 Sep 19]. Available at: https://www.ahadata.com/aha-annual-survey-database

22.

CDC/ATSDR Social Vulnerability Index (SVI). 2023 [cited 2023 Sep 19]. Available at: https://www.atsdr.cdc.gov/placeandhealth/svi/index.html

23.

Leapfrog [cited 2022 Aug 12]. Available at: https://www.leapfroggroup.org/ratings-reports/leapfrog-hospital-survey-report-series-issued-2019

24.

Find Closest Facilities (Ready To Use)—ArcGIS Pro | Documentation [cited 2023 Jul 2]. Available at: https://pro.arcgis.com/en/pro-app/latest/tool-reference/ready-to-use/itemdesc-findclosestfacilities.htm

25.

Boscoe FP, Henry KA, Zdeb MS. A nationwide comparison of driving distance versus straight-line distance to hospitals. Prof Geogr. 2012;64(2):188.CrossRef

26.

Martins RS, Chang YH, Etzioni D, Stucky CC, Cronin P, Wasif N. Understanding variation in in-hospital mortality after major surgery in the United States. Ann Surg. 2023;278(6):865–72.PubMedCrossRef

27.

Dimick JB, Ghaferi AA, Osborne NH, Ko CY, Hall BL. Reliability Adjustment for Reporting Hospital Outcomes With Surgery. Ann Surg. 2012;255(4):703.PubMedCrossRef

28.

Social Determinants of Health - Healthy People 2030 | health.gov [cited 2022 Nov 17]. Available at: https://health.gov/healthypeople/priority-areas/social-determinants-health

29.

Arcaya MC, Tucker-Seeley RD, Kim R, Schnake-Mahl A, So M, Subramanian SV. Research on neighborhood effects on health in the United States: a systematic review of study characteristics. Soc Sci Med. 2016;168:16–29.PubMedPubMedCentralCrossRef

30.

Azap RA, Paredes AZ, Diaz A, Hyer JM, Pawlik TM. The association of neighborhood social vulnerability with surgical textbook outcomes among patients undergoing hepatopancreatic surgery. Surgery. 2020;168(5):868–75.PubMedCrossRef

31.

Diaz A, Hyer JM, Tsilimigras D, Pawlik TM. The impact of social vulnerability subthemes on postoperative outcomes differs by racial/ethnic minority status. Am J Surg. 2022;223(2):353–9.PubMedCrossRef

32.

Santa Mina D, van Rooijen SJ, Minnella EM, Alibhai SMH, Brahmbhatt P, Dalton SO, et al. Multiphasic prehabilitation across the cancer continuum: a narrative review and conceptual framework. Front Oncol. 2020;10:598425.PubMedCrossRef

33.

The ACS Strong for Surgery program: Changing clinician and system behavior to optimize health before surgery. The Bulletin. 2019 [cited 2023 Sep 19]. Available at: https://bulletin.facs.org/2019/10/the-acs-strong-for-surgery-program-changing-clinician-and-system-behavior-to-optimize-health-before-surgery/

34.

Berkel AEM, Bongers BC, Kotte H, Weltevreden P, de Jongh FHC, Eijsvogel MMM, et al. Effects of community-based exercise prehabilitation for patients scheduled for colorectal surgery with high risk for postoperative complications: results of a randomized clinical trial. Ann Surg. 2022;275(2):e299-306.PubMedCrossRef

35.

Carli F, Bousquet-Dion G, Awasthi R, Elsherbini N, Liberman S, Boutros M, et al. Effect of multimodal prehabilitation vs postoperative rehabilitation on 30-day postoperative complications for frail patients undergoing resection of colorectal cancer: a randomized clinical trial. JAMA Surg. 2020;155(3):233–42.PubMedPubMedCentralCrossRef

36.

Gillis C, Ljungqvist O, Carli F. Prehabilitation, enhanced recovery after surgery, or both? A narrative review. Br J Anaesth. 2022;128(3):434–48.PubMedCrossRef

37.

Billingsley KG, Morris AM, Dominitz JA, Matthews B, Dobie S, Barlow W, et al. Surgeon and hospital characteristics as predictors of major adverse outcomes following colon cancer surgery: understanding the volume-outcome relationship. Arch Surg Chic Ill. 2007;142(1):23–31.CrossRef

38.

Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients. Ann Surg. 2009;250(6):1029–34.PubMedCrossRef

39.

Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368–75.PubMedCrossRef

40.

Ward ST, Dimick JB, Zhang W, Campbell D, Ghaferi AA. Association between hospital staffing models and failure to rescue. Ann Surg. 2019;270(1):91–4.PubMedCrossRef

41.

Sheetz KH, Dimick JB, Ghaferi AA. Impact of hospital characteristics on failure to rescue following major surgery. Ann Surg. 2016;263(4):692–7.PubMedCrossRef

42.

Friese CR, Earle CC, Silber JH, Aiken LH. Hospital characteristics, clinical severity, and outcomes for surgical oncology patients. Surgery. 2010;147(5):602–9.PubMedCrossRef

43.

Zhang W, Ayanian JZ, Zaslavsky AM. Patient characteristics and hospital quality for colorectal cancer surgery. Int J Qual Health Care J Int Soc Qual Health Care. 2007;19(1):11–20.CrossRef

44.

Diaz A, Burns S, D’Souza D, Kneuertz P, Merritt R, Perry K, et al. Accessing surgical care for esophageal cancer: patient travel patterns to reach higher volume center. Dis Esophagus. 2020;33(7):doaa006.CrossRef

45.

Turrentine FE, Buckley PJ, Sohn MW, Williams MD. Travel time influences readmission risk: geospatial mapping of surgical readmissions. Am Surg. 2017;83(6):573–82.PubMedCrossRef

46.

Birkmeyer NJO, Goodney PP, Stukel TA, Hillner BE, Birkmeyer JD. Do cancer centers designated by the national cancer institute have better surgical outcomes? Cancer. 2005;103(3):435–41.PubMedCrossRef

47.

Mehta R, Tsilimigras DI, Paredes AZ, Sahara K, Dillhoff M, Cloyd JM, et al. Dedicated cancer centers are more likely to achieve a textbook outcome following hepatopancreatic surgery. Ann Surg Oncol. 2020;27(6):1889–97.PubMedCrossRef

48.

Paulson EC, Mitra N, Sonnad S, Armstrong K, Wirtalla C, Kelz RR, et al. National cancer institute designation predicts improved outcomes in colorectal cancer surgery. Ann Surg. 2008;248(4):675.PubMedCrossRef

49.

Wasif N, Chang YH, Pockaj BA, Gray RJ, Mathur A, Etzioni D. Association of distance traveled for surgery with short- and long-term cancer outcomes. Ann Surg Oncol. 2016;23(11):3444–52.PubMedCrossRef

50.

Finlayson SR, Birkmeyer JD, Tosteson AN, Nease RF. Patient preferences for location of care: implications for regionalization. Med Care. 1999;37(2):204–9.PubMedCrossRef

51.

Alvino DML, Chang DC, Adler JT, Noorbakhsh A, Jin G, Mullen JT. How far are patients willing to travel for gastrectomy? Ann Surg. 2017;265(6):1172.PubMedCrossRef

52.

Resio BJ, Chiu AS, Hoag JR, Brown LB, White M, Omar A, 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.PubMedPubMedCentralCrossRef

53.

Urbach DR. Pledging to eliminate low-volume surgery. N Engl J Med. 2015;373(15):1388–90.PubMedCrossRef

54.

Gani F, Azoulay D, Pawlik TM. Evaluating trends in the volume-outcomes relationship following liver surgery: does regionalization benefit all patients the same? J Gastrointest Surg. 2017;21(3):463–71.PubMedCrossRef

55.

Barber EL, Garg R, Persenaire C, Simon M. Natural language processing with machine learning to predict outcomes after ovarian cancer surgery. Gynecol Oncol. 2021;160(1):182–6.PubMedCrossRef

56.

Woldesenbet S, Munir MM, Pawlik TM. Invited commentary: mediation analysis and cancer screening, identifying areas to target to improve cancer disparities. J Surg Oncol. 2023;128(1):7–8.PubMedCrossRef

Title: Variation in Hospital Mortality After Complex Cancer Surgery: Patient, Volume, Hospital or Social Determinants?
Authors: Muhammad Musaab Munir, MD
Selamawit Woldesenbet, MS, MPH, PhD
Yutaka Endo, MD, PhD
Mary Dillhoff, MD
Jordan Cloyd, MD
Aslam Ejaz, MD
Timothy M. Pawlik, MD, PhD, MPH, MTS, MBA, FACS, FRACS (Hon.)
Publication date: 09-01-2024
Publisher: Springer International Publishing
Keywords: Pneumonectomy
Esophagus Resection
Esophagus Resection
Published in: Annals of Surgical Oncology / Issue 5/2024
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-023-14852-y

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Variation in Hospital Mortality After Complex Cancer Surgery: Patient, Volume, Hospital or Social Determinants?

Abstract

Introduction

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

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