If you prefer to view this article in PDF form, click here.

Factors to consider before referring patients for major cancer surgery

Hospital and surgical volumes are correlated with better outcomes for patients undergoing complex surgical procedures. Staffing of ICUs and a high nurse-to-patient ratio also influence the quality of hospital care.

Eric D. Tetzlaff, MHS, PA-C

The author works in the Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston. He has indicated no relationships to disclose relating to the content of this article.

Cancer is the second leading cause of death in the United States, after heart disease.¹ The American Cancer Society (ACS) has estimated that in 2006 there were 1,399,790 new cancer cases diagnosed and 564,830 deaths attributable to cancer.² Primary care providers play an important role in educating patients about cancer prevention and early detection. By following the cancer screening recommendations of the ACS or the US Preventive Services Task Force, clinicians can help detect cancers at earlier stages, when treatments are most effective.

However, the role of the primary care provider cannot be limited to cancer prevention and early detection. These clinicians must be able to identify the best surgeons and hospitals for their patients when a cancer diagnosis is made. They must be able to incorporate the performance data associated with better surgical outcomes and help patients to choose surgeons using an evidence-based approach. Table 1 lists the factors to consider before referring patients with cancer for surgical consultation.

Hospital volume

The relationship between hospital volume and better outcomes for complex surgical procedures is well documented in the medical literature.³

Operative mortality Studies have consistently shown that the operative mortality for patients undergoing complex surgical procedures, including lung resection, pancreatectomy, esophagectomy, liver resection, colorectal resection, and pelvic exenterations, is lower when the procedure is performed at centers with a high annual volume for each respective procedure.^4-7 The impact of hospital volume on surgical outcome can be dramatic. For example, Begg and colleagues reported that operative mortality for esophagectomy rose to 17.3% in low-volume hospitals compared to 3.4% in high-volume hospitals.⁵ For pancreatectomy, they found that high-volume hospitals had an operative mortality rate of 5.8%, whereas low-volume hospitals had greater than double that: 12.9%.

Late survival For patients undergoing cancer surgery, hospital volume can be associated with late survival as well as operative mortality. For example, Bach and colleagues found that patients who underwent surgery for lung cancer at higher-volume hospitals were 25% more likely to be alive after 5 years compared to patients who had had surgery at very low-volume hospitals.⁸ Similar results are reported for surgeries for cancers of the pancreas, colon, and breast.^9,10

Unfortunately, even with increased public reporting of performance data, few patients look for such information when deciding where to undergo high-risk elective surgery.¹¹ It has been suggested that the reason performance data has little influence on patients’ decisions is that many people rely on the judgments of their referring physicians. This highlights how important it is not only that performance data be accessible to patients and referring physicians but also that it be actually utilized. The relationship between hospital volume and operative mortality for major cancer procedures with high operative mortality is presented in Table 2.

Surgeon volume

Experience counts. Patients can improve their chances of survival, even at high-volume centers, by selecting surgeons who perform the operation more frequently.¹² Cancers of the prostate, breast, lung, colon, rectum, uterine corpus, and pancreas are estimated to be the most common cancers diagnosed in 2005.² All, with the exception of prostate and uterine cancers, are associated with either lower operative mortality or improved 5-year survival when surgery is performed by a high-volume surgeon.^3,12-16 In addition, cancers that are less common in the United States, such as those of the esophagus and stomach, also have lower operative mortality when surgery is performed by a high-volume surgeon.^12,14

When surgeon volume was assessed as a continuous variable, Birkmeyer and colleagues found that it was inversely related to operative mortality for cystectomy, lung resection, pancreatic resection, and esophagectomy.¹² Surgeon volume and operative mortality varied according to the procedure performed. Pancreatic resection had an adjusted odds ratio for operative death of 3.61 (95% CI: 2.44-5.33) for patients with a low-volume surgeon versus those with a high-volume surgeon, while the odds ratio for resections for lung cancer was 1.24 (95% CI: 1.08-1.44). Similar results were also reported in a study of more than 32,000 patients undergoing gastrectomy, colectomy, and lung lobectomy.¹⁴

When surgery performed by a high-volume surgeon was compared to that performed by a low-volume surgeon, the observed operative mortality rates for gastrectomy, colectomy, and lung lobectomy decreased by 6.07%, 2.58%, and 1.62%, respectively. The association between high-volume surgeons and better patient outcomes has been validated in other studies and supports volume-based referral initiatives.³

Surgeon characteristics

Surgeon volume is an independent factor in surgical mortality,^3,12 but there are other characteristics to consider. Subspecialty training also influences surgical mortality.^17-21 In a study of more than 6,000 gastrectomies performed between 1998 and 2002, an estimated 122 out of 542 (22.5%) hospital deaths could have been avoided if all patients were treated by subspecialty surgeons.¹⁸ In esophageal cancer, thoracic surgery training was an independent predictor of low mortality even after outcomes were adjusted for hospital and surgeon volumes.¹⁹ The adjusted mortality rates were 47% higher for general surgeons than for thoracic surgeons (P=.03). Similar results have been reported in lung cancer resections, colon cancer resections, and rectal cancer resections, with optimal outcomes for those procedures performed in high-volume centers by high-volume surgeons with surgical subspecialty training.^18-21

ICU physician staffing

The Leapfrog Group—a member-supported program consisting of a large consortium of Fortune 500 companies and other large private and public health care purchasers—was developed with the goal of improving the safety, quality, and affordability of health care.²² One focus of the group is the evidence-based practice of full-time intensivist staffing in ICUs, as well as the organizational structure of the ICU.²² Intensivists are board-certified physicians who are certified in critical care medicine, completed a critical care fellowship, or completed training before subspecialty training in critical care became available and provide at least 6 weeks of critical care annually.²³ The organizational structure is based on open or closed units. In closed ICUs, patients are cared for exclusively by critical care specialists, as opposed to open units where critical care specialists provide care on a consultation basis. When the organizational structure of an ICU and physician staffing are examined, high-intensivist staffing (ICUs where intensivists manage or comanage all patients) is associated with a 40% reduction in ICU mortality when compared to low-intensivist staffing (where intensivists manage or comanage some or none of the patients).²⁴

Nurse staffing levels

Registered nurses provide 24-hour surveillance and assessment of hospitalized patients on an ongoing basis and are vital to providing high-quality hospital care. One group showed that in hospitals with high patient-to-nurse ratios, surgical patients had higher risk adjusted 30-day mortality rates.²⁵ Patient mortality increased by approximately 7% for every additional patient in the average nurse’s workload of four patients. The difference between four and eight patients was associated with a 31% increase in mortality. The study was not specific to cancer surgery, but it did include 28,558 patients with a diagnosis of cancer (12.3%).

Overall, the nurse-to-patient ratio is an important factor in the quality of hospital care and may be useful for patients and providers when deciding where to undergo surgery. For interested patients, U.S. News and World Report annually publishes rankings for the top 50 cancer hospitals in the United States, and one of the rating categories is nurse-to-patient ratio.²⁶

Comprehensive cancer centers

The National Cancer Institute (NCI) and the National Comprehensive Cancer Network (NCCN) provide some clarity for patients seeking treatment at centers of excellence.^27,28 Hospitals demonstrating excellence in three different areas—research, cancer prevention, and clinical services—may be designated NCI comprehensive cancer centers.²⁹ Currently, 39 comprehensive cancer centers provide care to patients in 31 different states.²⁷ The NCCN is an alliance of 19 of the world’s leading cancer centers.²⁸ It is an authoritative source that provides information that patients and health care professionals need to make evidence-based decisions. The NCCN recognizes the benefit of patients being treated at high-volume centers and has developed a specialty oncology network to help facilitate patient access to its member organizations. Table 3 provides the Web addresses of the NCI, the NCCN, and other organizations that investigate cancer surgery outcome or provide information for cancer patients.

Example: Gastric cancer

Here is a detailed example of how hospital and surgeon characteristics can influence patient outcomes and serve as a driving force for regionalization of cancer care.

The standard of care for gastric cancer in the United States is surgical resection followed by adjuvant chemoradiotherapy.³⁰ The NCCN recommends that all patients with localized gastric cancer be evaluated by a multidisciplinary team and undergo removal or examination of at least 15 lymph nodes during surgical resection.²⁸ The majority of patients in the United States, however, undergo inadequate surgical resection and have fewer than 15 lymph nodes sampled.³¹ It has been proposed that this is a result of gastrectomies being performed by general surgeons who are not familiar with gastric resections or by surgical oncologists who have limited experience with gastric cancer.³²

In New York State, the operative mortality rate of low-volume hospitals performing fewer than 15 gastric cancer resections per year was 11.2%, compared to a mortality rate of 2.85% in centers that performed more than 62 gastric resections per year.¹⁴ In the same study, the group of surgeons who performed two or fewer gastrectomies annually had an operative mortality of 8.8%, whereas those who performed more than 11 procedures per year had an operative mortality rate of 2.76%.¹⁴ The benefit in operative mortality in this study could not be attributed to either hospital volume or surgeon volume alone, as both factors appeared to influence mortality. The lower operative mortality of high-volume centers has been confirmed in other studies, which have shown high-volume centers to have 1% to 6% lower operative mortality.^4,12

Hospital and surgeon volume are not the only factors that influence outcome in gastric cancer surgery. An additional benefit is seen at NCI-designated cancer centers, which have an overall operative mortality rate of 6.5% compared to 10.5% at similar high-volume hospitals that are not NCI-designated cancer centers.²⁹ Moreover, NCI-designated centers have a 5-year mortality rate of 68%, which is superior to that of non-NCI-designated centers (71%).²⁹ The adjusted hazard ratio was 0.91 (95% CI: 0.83-0.99) in favor of NCI-designated centers.²⁹ It has been proposed that the benefit to patients undergoing major cancer surgery at NCI-designated centers is a result of high hospital volume and high volume for surgeons who have subspecialty training. The better outcomes at NCI-designated centers could also have been attributable to the centers that staffed ICUs with specialists in critical care, utilized multidisciplinary tumor boards, adopted new and beneficial therapies earlier than other hospitals, and varied less in processes of care.²⁹

Despite the rapid decline in the incidence of gastric cancer in the United States, it remains the eighth leading cause of cancer mortality.² The poor prognosis of gastric cancer further underscores the importance of a primary care clinician making the appropriate referral, and it should be a catalyst to encourage low-volume centers and inexperienced surgeons to stop performing these procedures.¹⁴

Recommendations

Primary care providers can improve the quality of care for patients with cancer by referring them to surgeons and hospitals with high volumes and surgical expertise. Patients should be educated about the hospital and surgeon characteristics associated with low operative mortality so that they have the best opportunity for a good outcome. Unfortunately, not all patients can receive care at a large comprehensive cancer center. In this case, it is the responsibility of surgeons and health care researchers to identify the beneficial characteristics of high-volume hospitals, high-volume surgeons, and subspecialty trained surgeons so that outcomes can be improved in low-volume centers with less experienced surgeons.

REFERENCES

© 2007 Haymarket Media, Inc. and the American Academy of Physician Assistants. All rights reserved.
Use of jaapa.com subject to License agreement. Please read our Disclaimer and Privacy policy.