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Top-ranked cancer hospitals outperform affiliates in surgical safety, mortality risk
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Patients who undergo complex cancer surgery at hospitals affiliated with top-ranked cancer centers have a significantly higher risk for mortality than patients who undergo such surgeries at the flagship institutions, according to research published in JAMA Network Open.
The results showed that in 49 networks studied, 83.7% of top-ranked hospitals outperformed their affiliates in terms of safety.
“The general public interprets affiliates as having the same quality of care,” Daniel J. Boffa, MD, associate professor of thoracic surgery at Yale School of Medicine and coauthor of the study, told HemOnc Today. “This study should speak to them and let them know they need to investigate to see if quality of care is the same at an affiliate hospital. There are important differences in safety between affiliates and flagship hospitals."
Brand identity, including perceptions of safety and quality, is an important factor when choosing a hospital for complex surgeries, researchers wrote.
“However, this brand sharing may confound patient choice, as patients may no longer be able to distinguish individual hospitals’ reputation for safety within cancer networks,” they added. “Despite public perception, there is currently no evidence to support (or refute) assumptions of care equivalency within cancer networks.”
The researchers used CMS data to examine 90-day mortality rates among 29,228 Medicare recipients who underwent complex cancer surgery at 59 hospitals ranked among the top 50 best for cancer by U.S. News and World Report between 2013 and 2016, and 343 affiliated hospitals. The study included patients aged 65 years or older who had nonemergency surgery for primary colon, lung, pancreatic, stomach or esophageal cancer between Jan. 1, 2013, and Oct. 1, 2016.
More of these patients underwent surgery at one of the top-ranked flagship hospitals (59.2%; mean age, 74.7 years; 50.2% men) than at the affiliated hospitals (40.8%; mean age, 76.2 years; 52.7% women). Patients who underwent surgery at an affiliate hospital had significantly higher likelihood of 90-day mortality than those who had surgery at flagship centers (OR = 1.4; 95% CI, 1.23-1.59).
Mortality odds varied based on the procedure, including for:
Colectomy: OR = 1.32 (95% CI, 1.12-1.56);
Lobectomy: OR = 1.34 (95% CI, 1.03-1.74);
Esophagectomy: OR = 1.48 (95% CI, 0.98-2.22);
Pancreaticoduodenectomy: OR = 1.59 (95% CI, 1.12-2.24); and
Gastrectomy: OR = 2.04 (95% CI, 1.41-2.95).
“The most complex surgeries are better managed at the flagship hospital,” Boffa told HemOnc Today. “There are exceptions, and some affiliates have excellent teams that achieve exceptional results. This is a generalized picture of what’s happening in the U.S., and people need to investigate what’s going on at their hospital.”
The top-ranked cancer hospitals outperformed their affiliates on safety at 41 of 49 networks (83.7%; 95% CI, 73.1-93.3) the investigators evaluated.
Boffa said the study results bolster the validity of the U.S. News and World Report rankings.
“This research does support the idea that top-ranked hospitals have safer-than-average outcomes,” he said, noting that the “vast majority of top-ranked hospitals were above average.”
Nearly one-third of complex cancer surgeries among the study population occurred within the care networks the investigators studied, and they cited this along with the sample’s restriction to the Medicare population as study limitations.
The researchers said their objective was to help patients and their providers make better-informed decisions about where to seek complex cancer surgeries.
“There is cause for concern that a proportion of the U.S. public could misinterpret brand sharing as indicating equivalent care,” they wrote. “Ultimately, leading cancer hospitals must assume some responsibility for leveraging relationships with their affiliated hospitals to ensure that the safety and quality of care is optimized at all hospitals that adopt their trusted brand.”
This study examines just one aspect of overall cancer care provided by top hospitals and their affiliates, and it is logical that top-ranked centers would have lower 90-day mortality rates because of greater expertise and the volume of procedures they perform, Lesly A. Dossett MD, MPH, assistant professor of surgery in the division of surgical oncology at the University of Michigan, wrote in an accompanying editorial.
She added that the study did not evaluate other aspects of cancer care, including less complex cancer surgeries, radiation therapy, cancer screening or survivorship care.
“It may be that outcomes for these more common operations and services are high value at smaller affiliates and that optimizing network quality relies primarily on appropriate triage and regionalization for complex surgery,” she wrote.
Determining which aspects of cancer care are more optimally performed at a location can help increase the quality of care for the overall network, Dossett asserted.
“In general, network affiliation has not lived up to its theoretical potential for improved quality in patients receiving surgery. But, for the growing number of patients with cancer and survivors who rely on multidisciplinary expertise across all phases of the cancer continuum, network affiliation offers great potential for access to the right specialist at the right time,” she wrote.
“Given that patients and families attribute quality with the brand name, it is incumbent on the networks to ensure that all branded affiliates live up to the reputation and quality of that name.” – by Drew Amorosi
Disclosure: Boffa reports nonfinancial support unrelated to the study from Epic Sciences. Please see the study for all other authors’ relevant financial disclosures. Dossett reports no relevant financial disclosures.
Perspective
Back to TopDavid Y.T. Chen, MD, FACS
This article examines the outcomes of complex cancer surgery procedures, as measured by a common patient safety measure (90-day mortality), performed at top-ranked cancer hospitals and the same operations performed at named affiliate hospitals that share the cancer hospital brand.
I believe this appropriately raises some concern about whether a patient who undergoes a complex cancer surgery should expect similar outcomes with an operation at a branded affiliate hospital and not at the main flagship. In most cases, the result does not appear to be as good.
Although there are some exceptions, in most hospital systems where a patient could choose to proceed with a complex cancer surgery at either the primary center or an affiliate, the odds of 90-day mortality were consistently higher for the same surgery performed at the affiliate location.
This is consistent with prior research that would suggest the outcomes of complex medical treatment rely on much more than a brand or label, and the outcomes of surgery often depend on multiple components of the processes of care, including surgeon experience, nursing care and hospital supporting systems. The quality of these elements may often be unequally established and in practice between the flagship and the affiliates.
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