Twenty years ago as a newly trained oncologist, I faced the same challenge that many cancer patients and their families do as they try to figure out where to turn when my mother was diagnosed with ductal carcinoma in situ– or pre breast cancer. Her surgeon, who had come highly recommended by her family doctor,told her she needed to have a lymph node dissection, which can result in lifelong disability due to lymphedema or swelling of the arm. As an oncologist, I knew it was not recommended for ductal carcinoma in situ, but she resisted my suggestion to get a second opinion. Despite the fact that I—her daughter—am an oncologist, her first thought was, “I can’t go against what my family doctor told me to do.”
It is still not part of our general culture to question physicians and, in a sense, to discuss health care options. Many patients are shell shocked by a cancer diagnosis and don’t think beyond what they are immediately told to do or where they are told to go for treatment. Some highly motivated patients dig deeper to research their options for cancer treatment, but these motivated patients are still a minority.
California is now leading the way in publically reporting cancer surgery volume to make it easier for patients, as well as health care professionals, to access and compare information on the frequency of surgeries at different hospitals. I participated in the Advisory Group, informing an effort funded by the California HealthCare Foundation,to make cancer surgery volume data available for the first time for 341 California hospitals on www.CalQualityCare.org. Accompanying the release of these data is a new report, Safety in Numbers: Cancer Surgeries in California Hospitals,highlighting important findings about the frequency of surgeries by hospital for 11 types of cancer for which there is an association between low hospital volume of surgeries and increased mortality and complications.
While more research is needed to analyze and understand the linkage, this new access point facilitates conversation between patients and doctors as well as between health plans and hospitals. The new data identifies important areas to research and helps health plans to enter into dialogue with hospitals where low volume surgeries occur.
The idea of establishing thresholds — or minimum frequencies — for cancer surgeries is complex, but most of us can agree that a red flag goes up when a hospital is only performing a surgery once or twice a year. It is important for hospital administrators to ask why this occurs and consider referring patients to higher volume facilities. In some cases, an emergency surgery took place, but Safety in Numbers illustrates that low volume cancer surgeries are much more prevalent than many of us realized.
In fact, almost 75% of California hospitals performed surgery for one of the 11 types of cancer only one or two times in 2014. Most patients—between 60% and 81% depending on the cancer type—who had surgery at a hospital performing a low number of those surgeries in 2014 were within 50 miles of a hospital performing higher volumes.
Anthem health plans,in concert with the Blue Cross Blue Shield Association, have developed Centers of Excellence for rare and complex cancers. Anthem health plansassign case managers to patients with serious medical conditions to help those facing tough decisions find a qualified hospital specializing in their condition.The goal of Anthem health plans is to direct members to the Centers of Excellence, made available online. We already encourage consumers to have surgery at facilities experienced with their specialized condition and our case managers are trained in discussing the Centers for Excellence and assisting members in getting second opinions.
A key challenge is getting information into the hands of consumers quickly enough – they need to understand their options when they are making the decision about where to have surgery. Members often engage with case managers after surgery has occurred and as they continue in their treatment. As we explore ways to get important information about cancer treatment options upstream to consumers, efforts like this by the California HealthCare Foundation can help raise awareness.
Safety in Numbers provides both the evidence and the data to start including volume as a criteria in our Centers of Excellence research. While the centers have focused more broadly on different types of cancer, we can use these data as a basis and may start to focus on the outcome-surgery volume link. It is and will, however, continue to be difficult to identify specific thresholds as a criteria to determine treatment options. There are many factors contributing to patients’ options, such as the distance they may need to travel to different hospitals – though our health plans do cover such travel expenses.
While Safety in Numbers raises important questions about whether the medical community should establish thresholds for complex cancer surgeries, health plans can look for ways to move the dialogue with hospitals, physicians and patients. We must also look at what else high performing teams are doing that other hospitals can replicate, as there will always be many factors influencing surgery outcomes. It makes sense to avoid surgery altogether when possible. For example, combined treatment with chemotherapy and radiation has the same long-term survival as surgery for esophageal cancer. As we move to make available data on surgical outcomes, we need to make sure patients have the full range of treatment options presented to them so that they can make the best choice given their own life circumstances and preferences.
As research and understanding about surgery volume continues, it would be helpful for health plans to have access to measures linking surgery volumes to outcomes that are established by medical associations, such as the American College of Surgeons.Continuing research on surgery volume-outcome linkages, leveraging the new data now available on cancer surgery volume in California, and promoting dialogue on this issue will, ultimately, benefit patients and health care systems.
Jennifer Malin, MD, PhD, is Staff Vice President, Clinical Strategy at Anthem, Inc.