American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Unclear benefits from regionalization of surgical oncology

OCTOBER 24, 2018
Clinical Congress Daily Highlights, Wednesday Second Edition

Many studies have shown that hospitals with low volumes of surgical operations have higher mortality. This volume-to-outcomes relationship has also been shown to impact length of hospitalization across certain case types, and can be a factor for individual surgeons. Some studies have shown that mortality is higher for surgeons with low volume, regardless of hospital volume.

Such findings have inspired proposals to regionalize surgical oncology care, concentrating cases among fewer locations and providers. Wednesday’s panel session provided diverse perspectives on the value and efficacy of implementing regionalization.

Sandra L. Wong, MD, FACS, Dartmouth-Hitchcock, Lebanon, NH, described the Northern New England collaborative, which instituted shared learning between surgeons to improve mortality. She also noted that several European countries, including France, Germany, and Switzerland, have already moved to implement enforced hospital or surgeon minimums. Within the U.S., she described a self-regulated initiative led by Dartmouth-Hitchcock Medical Center, Johns Hopkins Hospital and Health System, and the University of Michigan Health System, which pledged to enforce its own hospital and physician minimums. She said that while these programs were difficult and controversial, she believes that proactive measures to improve surgical outcomes through volume are needed, saying, “we have to act. If we don’t do it as surgeons, somebody will do it to us, and it’s imperative we have a seat at the table as we’re talking about this.”

Providing perspective from a small community hospital, Michael D. Sarap, MD, FACS, Southeastern Med Hospital, Cambridge, OH, spoke about the many patient factors affecting decisions about locations of care, and that regionalization is not necessarily a practical approach. He pointed out that despite the millions of advertising dollars spent by many of the largest cancer centers, the baseline of care rendered at Commission on Cancer-accredited programs is such that patients generally do not need to seek out a particular location except in very complex cases. He argued that smaller community hospitals may address other aspects of quality – such as patient-centered care and timeliness – more effectively. For example, he noted that many large academic centers have long wait times, sometimes more than one month, suggesting that they are already struggling to handle the volume of patients they have even without implemented regionalization.

Kamal M.F. Itani, MD, FACS, chief of surgery, Veterans Affairs Boston Healthcare System, presented an example of regionalization implemented in the Veterans Affairs Healthcare (VA) system. The program classified centers qualified for standard, intermediate, and complex procedures and examined clinical outcomes as a result. Dr. Itani stated that overall, this ultimately led to creation of programs of excellence within the VA and improvement in quality of cancer care and surgical outcomes. However, he also noted that it led to increased use of community care outside the VA system for certain types of surgeries, which could lead to increased healthcare costs.

David R. Urbach, MD, FACS, Women’s College Hospital, Toronto, Canada, provided an example of regionalization implemented in the province of Ontario. In 2007, Ontario implemented a policy to regionalize lung cancer surgery at 14 designated hospitals and assessed multiple clinical outcomes. Using an interrupted time-series analysis to distinguish the effect of the program from natural trends, the study found that the policy increased regionalization and had a slight effect on length of stay. However, it did not appear to have an impact on mortality, complications, reoperations, or readmissions. While noting that prior to the program, lung cancer surgery was already largely naturally centralized, he said “it’s not necessarily obvious that active centralization will always lead to the intended clinical benefits that we see in the cross-section volume outcomes studies, and ultimately effectiveness of these policies will depend a lot on the nature of the health system.”

Additional information

The panel session, Regionalization of Surgical Oncology Care: Pros and Cons, was held October 24, at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast and audio information is available online at

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