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Complex top-ranking hospital-complexed cancer surgery



A larger study was observed in which higher mortality rates were observed in patients who received complex cancer surgeries in affiliated hospitals.

Those who underwent colectomy, esophagectomy, gastrectomy, pulmonary lobectomy and pancreaticododenectomy (Whipple) in network hospitals were more likely to die within 90 days compared to those who had surgery at the main hospital (OR 1.40, 95 % CI 1.23-1.59, P<0.001), Daniel J. Boffa, MD, from the Yale School of Medicine in New Haven, Connecticut, and colleagues reported.

"This is not surprising, since affiliated hospitals are generally smaller, less likely to teach hospitals and carry out complex surgical procedures less frequently (lower volume) when compared to the most popular hospitals," they wrote in Open Network JAMA. "To this extent, including the characteristics of the hospitals in the adjusted models has attenuated (but did not eliminate) the differences in mortality of 90 days."

The risk of death in the 90 days was highest for patients undergoing gastrectomy in an affiliated hospital (OR 2.04, 95% CI 1.41- 2.95, P<0.001), followed by:

  • Pancreaticoduodenectomy (OR 1.59, 95% CI 1.12-2.24, P<0.009)
  • Esophagectomy (OR 1.48, 95% CI 0.98-2.2, P<0.06)
  • Lobectomy (OR 1.34, 95% CI 1.03-1.74, P<0.03)
  • Colectomy (OR 1.32, 95% CI 1.12-1.56, P= 0.001)

For perioperative safety, 79.6% of emblematic hospitals exceeded the national average, while only 34.7% of their affiliated hospitals did.

Earlier studies suggest that patients are likely to be strongly influenced by the state of affiliation of a hospital, the authors explained. A study showed that respondents would prefer to opt for a complex cancer treatment in a United States hospital that has an affiliation with a front-line cancer center. Another study found that half believed that first line hospitals and their affiliates offered a similar quality of care and were equally safe.

"Almost a third of respondents who were willing to go an extra hour to have a complex cancer surgery in a high-ranking cancer hospital changed their preference to a smaller local hospital if they shared an affiliation with a cancer hospital with higher rating. "they wrote. "As a result, there is reason to worry that a part of the American public could misrepresent the distribution of brands as an indication of equivalent care."

To carry out its cross-sectional analysis, the Boffa group examined the results of 29,228 Medicare patients who underwent complex surgeries for colon cancer, esophagus, lungs, pancreas and stomach from the most important cancer hospitals, according to classified by United States news and world report, as well as hospitals on your network. The authors explained that in 2016 the 59 most popular cancer hospitals and their affiliates made almost a third of the complex cancer surgeries for Medicare beneficiaries.

In a comment that accompanied the investigation, MD, Lesh. Dossett, MD, MPH, from the University of Michigan at Ann Arbor, wrote that "in general, affiliation to the network did not fulfill its theoretical potential to improve quality in patients receiving surgery."

But he warned that the study only endorsed a narrow portion of cancer care and noted that the results do not apply to less complex operations for breast cancer, prostate, skin or thyroid in the initial stage. He also pointed out several important limitations of the study. The researchers did not adjust to other types of cancer treatment, such as chemotherapy and radiation, nor did they adjust to the treatment of "cancer not operable in the late stage, or care, surveillance and survival care," he said.

"In addition, it is likely that it is not possible or feasible for all patients in the geographical area of ​​capture of the flagship to be treated in that center," wrote Dossett. "Understanding that patients are treated optimally in the flagship and that they can receive high quality care in the small subsidiary is a first step."

Boffa reported non-financial support from Epic Sciences out of the current study. A co-author reported funding for Centers for Medicare and Medicaid Services related to the development of rankings and hospital performance measures. Another co-author revealed relations with Medtronic and Roche / Genentech.

Dossett has not reported competing interests.

2019-04-12T17: 45: 00-0400


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