Referring cancer patients to more experienced and successful hospitals for surgery could save lives

The study was reported online in the journal Forum for Health Economics and Policy.

The researchers reviewed data on two cancer operations that are at "opposite ends of the spectrum" -- colon and pancreatic resections, said paper author Vivian Ho, Rice University's Baker Institute Chair in Health Economics and a professor of economics. Pancreatic resection is performed much less often than colon resection, but it's a very complicated operation that can take 5 to 8 hours and has a much higher mortality rate. Colon resection is more straightforward, is performed much more often and has a much lower mortality rate.

"If all patients needing surgery for colon cancer were referred to hospitals that have consistently achieved mortality rates in the bottom half of all hospitals performing this operation, then the average mortality rate could fall from a rate of 3.8 percent to 2.4 percent," Ho said. "And if all patients who require surgical resection for pancreatic cancer were referred to hospitals performing 11 or more of these operations per year, mortality rates could fall by half, from a rate of 6 percent to 3 percent."

The analysis was based primarily on hospital records for all patients who received surgery for colon cancer or pancreatic cancer in California, Florida, New Jersey or New York between 2001 and 2005. This data was combined with hospital information from the American Hospital Association, the Medicare program and MarketScan Research Data. The researchers used this data to determine the association between the number of surgical operations performed each year and patient mortality rates for each cancer type. Regression analysis was used to adjust for multiple differences in patient characteristics that are important determinants of patient mortality.

The investigators then used their regression analyses to simulate how mortality rates might change if, for instance, patients at poorly performing hospitals were referred to the closest hospital that had achieved mortality rates (adjusted for differences in patient characteristics) in the lower half of the distribution relative to all other hospitals in their state between 2001 and 2005.

For colon cancer patients, higher-volume hospitals did not achieve lower mortality rates than hospitals that performed fewer colon resections per year. However, many hospitals performed consistently better than others in terms of lower patient mortality during the study period, Ho said.

"We were concerned that the centralization of cancer care that would result from referring patients to a smaller set of higher-volume hospitals could give these hospitals additional market power to raise prices," Ho said. "We also wondered whether higher-volume hospitals might have a different cost structure that would raise or lower costs per patient. We found no statistical evidence that hospitals that performed more of these cancer operations were able to charge higher prices to patients for these services. We found that costs per patient were indeed higher for hospitals performing more pancreatic cancer surgery. However, these higher costs were not passed on to patients as higher prices for patient care."

Ho recommended that mechanisms be constructed to refer cancer patients to those hospitals where they are likely to achieve better outcomes. "Some states already post information on their health department's website on the number of pancreatic cancer surgeries performed by each hospital per year, or inpatient mortality rates adjusted for patient characteristics. Private not-for-profit organizations such as the American Cancer Society and the American College of Surgeons could partner with public national and state organizations to replicate the information in our study and make it available to referring physicians and their patients."

The study was supported by a grant from the National Cancer Institute at the National Institutes of Health.