
==== Front
Ann Surg Oncol
Ann Surg Oncol
Annals of Surgical Oncology
1068-9265
1534-4681
Springer International Publishing Cham

39138768
15441
10.1245/s10434-024-15441-3
ASO Author Reflections
ASO Author Reflections: Comparison of Hospital Volume and Risk-Standardized Mortality Rate as a Proxy for Hospital Quality in Complex Oncologic Hepatopancreatobiliary Surgery
Julian William T. MS 1
http://orcid.org/0000-0003-3341-9521
Ocuin Lee M. MD FACS lee.ocuin@uhhospitals.org
lee.ocuinmd@gmail.com

2
1 https://ror.org/051fd9666 grid.67105.35 0000 0001 2164 3847 Case Western Reserve University School of Medicine, Cleveland, OH USA
2 grid.443867.a 0000 0000 9149 4843 Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH USA
13 8 2024
13 8 2024
2024
31 10 65866587
24 4 2024
24 4 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
issue-copyright-statement© Society of Surgical Oncology 2024
==== Body
pmcPast

The high morbidity and mortality associated with oncologic hepatopancreatobiliary (HPB) surgery has drawn attention to the heterogeneity of outcomes across centers, and centralization to higher-volume centers has been proposed.1 The relationship between hospital volume and surgical outcomes has been well established, but patient redistribution and centralization remain controversial, both in scale and scope.2 While centralization efforts in Europe and Canada have been met with a decrease in overall mortality, the feasibility of such initiatives in the United States (US) is contentious due to logistical constraints to patients and hospitals, as well as the diverse geographic and insurance landscapes throughout the US.3 Additionally, population and case mix differences have made direct comparisons of hospital quality difficult. Risk-standardized mortality rates (RSMR), which can adjust for differences in patient populations, procedure mix, and case volume, have been adopted as another proxy of hospital quality. Currently, no comparison of surgical volume and RSMR exists for oncologic HPB surgery in the US, particularly in the context of patient redistribution.

Present

Recent studies have indicated that RSMR may outperform hospital surgical volume as a proxy for overall hospital quality. A 2016 study of patients undergoing oncologic surgery in Germany concluded that RSMR outperformed hospital volume in reducing patient mortality and minimizing the logistic burden.4 However, given geographical, structural, and institutional differences between Germany and the US, the applicability of their findings, particularly to high-morbidity and mortality HPB surgical procedures, is unclear.

Comparison of RSMR and surgical volume throughout the US for patients undergoing surgery for liver, biliary tract cancer (BTC), and pancreas cancer demonstrated that both high-volume centers (HVCs) and high-performance centers designated by RSMR had the lowest rates of patient mortality at 90 days for all types of cancers studied. However, stratification by volume demonstrated heterogeneity of outcomes, with approximately 15–20% of HVCs not classified as high-performance centers, and approximately 30% of low-volume centers and 45% of medium-volume centers classified as high-performance centers by RSMR. Additionally, simulated redistribution within US census regions demonstrated that an RSMR-based approach more effectively reduced mortality, with a higher reduction in mortality per patient moved compared with volume-based redistribution, while redistributing patients to more centers.5 These data suggest that RSMR may be a better proxy for hospital quality than hospital volume alone. Importantly, patient demographics and case mixes were comparable across volume and RSMR stratifications, suggesting that facility-specific factors rather than patient selection may be more important in patient outcomes.

Future

Discussions about patient redistribution both in the context of patient mortality and cost savings continue. Currently, limitations of our study and other studies include the inability to accurately calculate the logistical constraints imposed by redistribution. Future studies must have access to geographic information of both the patient and treating facility to adequately assess the impact of the logistic burden associated with possible patient redistribution. Furthermore, facility-specific factors contributing to high-performance status should be investigated, which could be generalized to other hospitals and help offset the need for redistribution.

Funding

No sources of funding were used to assist in the preparation of this manuscript.

Disclosures

William T. Julian and Lee M. Ocuin have no conflicts of interest to declare in relation to this manuscript.

This article refers to: Julian WT, Elshami M, Ammori JB, Hardacre JM, Winter JM, Ocuin LM. Comparison of hospital volume and risk-standardized mortality rate as a proxy for hospital quality in complex oncologic hepatopancreatobiliary surgery. Annals Surgical Oncology. 2024. 10.1245/s10434-024-15361-2.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Ihse I The volume-outcome relationship in cancer surgery: a hard sell Ann Surg. 2003 238 6 777 781 10.1097/01.sla.0000098616.19622.af 14631214
Ihse I. The volume-outcome relationship in cancer surgery: a hard sell. Ann Surg. 2003;238(6):777–81. 10.1097/01.sla.0000098616.19622.af.14631214
2. Finlayson EVA Hospital volume and operative mortality in cancer surgery: a national study Arch Surg. 2003 138 7 721 10.1001/archsurg.138.7.721 12860752
Finlayson EVA. Hospital volume and operative mortality in cancer surgery: a national study. Arch Surg. 2003;138(7):721. 10.1001/archsurg.138.7.721.12860752
3. 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 4678 10.1200/JCO.2008.20.1715 19720926
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. 10.1200/JCO.2008.20.1715.19720926
4. Baum P Lenzi J Diers J Risk-adjusted mortality rates as a quality proxy outperform volume in surgical oncology—a new perspective on hospital centralization using national population-based data J Clin Oncol. 2022 40 10 1041 1050 10.1200/JCO.21.01488 35015575
Baum P, Lenzi J, Diers J, et al. Risk-adjusted mortality rates as a quality proxy outperform volume in surgical oncology—a new perspective on hospital centralization using national population-based data. J Clin Oncol. 2022;40(10):1041–50. 10.1200/JCO.21.01488.35015575
5. Julian WT Elshami M Ammori JB Hardacre JM Winter JM Ocuin LM Comparison of hospital volume and risk-standardized mortality rate as a proxy for hospital quality in complex oncologic hepatopancreatobiliary surgery Ann Surg Oncol. 2024 10.1245/s10434-024-15361-2 39138768
Julian WT, Elshami M, Ammori JB, Hardacre JM, Winter JM, Ocuin LM. Comparison of hospital volume and risk-standardized mortality rate as a proxy for hospital quality in complex oncologic hepatopancreatobiliary surgery. Ann Surg Oncol. 2024. 10.1245/s10434-024-15361-2.39138768
