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Volume-Based Referral for Cancer Surgery: Informing the Debate

Brent K. Hollenbeck, Rodney L. Dunn, David C. Miller, Stephanie Daignault, David A. Taub, John T. Wei

From the Department of Urology, University of Michigan; and Michigan Surgical Collaborative for Outcomes Research and Evaluation, Ann Arbor, MI

Address reprint requests to Brent K. Hollenbeck, MD, MS, 1500 E Medical Center Dr, TC3875-0330, Ann Arbor, MI 48109-0330; e-mail: bhollen{at}umich.edu

Purpose Mounting evidence suggests a relationship between hospital volume and outcomes after major cancer surgery; however, the absolute benefits of volume-based referral on a national basis are unclear.

Patients and Methods Data from the Nationwide Inpatient Sample were used to measure the likelihood of operative mortality and a prolonged length of stay (LOS) after six cancer surgeries (prostatectomy, cystectomy, esophagectomy, pancreatectomy, pneumonectomy, and liver resection) between 1993 and 2003. Using sampling weights, the adjusted likelihood of the outcomes was used to calculate the number of lives saved (or prolonged LOS avoided) in the United States.

Results The magnitude of the volume–operative mortality effect varied from an adjusted odds ratio (OR) of 1.3 (95% CI, 0.8 to 2.3) for cystectomy to 4.9 (95% CI, 2.4 to 10.1) for pancreatectomy. After accounting for varying rates of procedure utilization, the lives saved per 100 surgeries regionalized ranged from 0.2 (95% CI, 0.12 to 0.24 lives saved) for prostatectomy to 9.2 (95% CI, 6.7 to 10.4 lives saved) for pancreatectomy. The volume–prolonged LOS effect varied from an adjusted OR of 0.9 (95% CI, 0.5 to 1.6) for liver resection to 4.8 (95% CI, 3.5 to 6.7) for prostatectomy. After accounting for procedure use, the number of prolonged hospitalizations avoided ranged from –1.7 (95% CI, –11.3 to 3.6 hospitalizations) to 14.3 (95% CI, 12.9 to 15.4 hospitalizations) per 100 surgeries regionalized for liver resection and prostatectomy, respectively.

Conclusion For patients undergoing major cancer surgery, the benefits of volume-based referral depend on the interplay between procedure utilization, the magnitude of effect, and the outcome chosen.

Supported in part by a grant from the John and Suzanne Munn Endowed Research Fund of the University of Michigan Comprehensive Cancer Center.

Presented at the 100th Annual Meeting of the American Urological Association, May 21-26, 2005, San Antonio, TX.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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