Shining the Light on Cancer Surgery Volume

flying cadeuciiNew data just released on cancer surgery volume in California hospitals advance an important and complex discussion about how the frequency with which a cancer surgery is performed at a hospital might influence patient, care team and hospital decisions. An effort funded by the California HealthCare Foundation has recently made these data available for the first time for 341 California hospitals on www.CalQualityCare.org. Having these data readily available opens the door to important inquiries the hospital community is investigating closely. Transparency about cancer surgery volume is, however, just one step toward better understanding and practice. More data and close deliberation are needed, and we must take caution to avoid premature conclusions with insufficient evidence.

Accompanying the release of these data is a new report, Safety in Numbers: Cancer Surgeries in California Hospitals,highlighting important findings about the frequency and location of surgeries for 11 types of cancer.The report reveals that many hospitals performed certain cancer surgeries only once or twice in 2014 and that many cancer patients were within 50 miles of another hospital performing their needed surgery with greater frequency. The report is spurring productive discussion.  However,as it is descriptive of cancer surgery volume alone and does not capture patient outcome, it calls on the hospital community to gather more evidence to inform decision-making. As conveners and catalysts for hospital improvement, the California Hospital Association and the Hospital Quality Institute, along with other leaders, are capturing this opportunity to advance the research and dialogue on cancer surgery volume.

Healthcare professionals have long discussed the relationship between surgery volume and patient outcomes, along with a myriad of other influencing factors.Is there a threshold defining when a hospital is performing so few of a certain cancer surgery that patients should instead be sent to the closest hospital performing the surgery at a higher volume? There isn’t – yet. Should there be such guidelines? Ideally, but it’s complicated.More questions need to be asked to find the answers.Safety in Numbers gives us some direction on what questions to ask and shines a light on variation in cancer surgery volume not previously or widely understood.

As health care systems and data collection become more sophisticated with better electronic medical records and other advancements, we can look forward to greater insight with increasingly precise data. Many factors influencehow surgeries are coded and counted, impacting how the data are interpreted. Hospitals are looking at surgery volume and patient outcome data closely and considering what changes may be needed for patient care options. For example, CHA is collaborating with cancer registries, which are providing valuable new data to inform analysis.HQI is working closely with the practitioners and executives at hospitals throughout CA to examine variables highlighted in the report.  CHA, HQI and other leaders, such as the American College of Surgeons, have an on-going dialogue and research efforts about surgery volume and patient outcomes. With more literature and data will come more sophistication in our ability to interpret what cancer surgery volume tells us.

Other critical factors to consider include physician competency and patient demographics. While practice may generally make perfect, frequencies is just one of a number of variables correlating with skill. Hospitals have on-going training and credentialing processes and review the performance and competency of both surgeons and hospital staff.The patient and family voice is also an essential perspective to listen to and consider in exploring recommendation about cancer surgery volume thresholds. Socio-economic and geographic considerations often influence where a patient can access surgery and where loved ones can be present to help. A hospital that is 50 or 100 miles away, requiring more travel and perhaps lodging expenses for family, can create a hardship versus the ease of a nearby facility. These factors have to be taken into account when assessing patients’ best options.

A few health care systems are introducing surgery volume thresholds, such as Johns Hopkins. It is noteworthy that systems like Johns Hopkins are concentrated closer together in urban areas. Many health systems in California, like many parts of the country, face large rural areas with great distances between facilities. These geographic factors will also influence what guidelines might be suitable for different health care systems. It is important to keep in mind that what may work best in one health care system may not be best in another, just as what is best for one patient may not be for another.

HQI is supporting and working with the American College of Surgeons and other professional associations to improve quality of care and assess surgical safety, one of HQI’s top priorities. As key players are discussing this issue in greater detail today than in the past, we see significant new potential for a thoughtful, constructive process. We are at the start of a long journey toward finding the best approaches for addressing cancer surgery volume variation. The release of this new data is an important step on this journey.

Julianne Morath, RN MS, CPPS, is President and CEO of the Hospital Quality Institute and David Perrott, MD, DDS, MBA, FACS,is Senior Vice President and Chief Medical Officer for the California Hospital Association

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