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Quality

Plenary Session 2

77: Evolution of the Volume Outcome Association in Complex Cancer Surgery- Should Volume Thresholds be Reconsidered?

Friday, March 22, 2024
3:42pm – 3:54pm ET
Location: Georgia Ballroom
Disclosure(s):
Akash Kartik, MBBS: No financial relationships to disclose
Introduction: The association between hospital volume and patient outcomes for complex cancer surgery is well established and forms the basis for minimum case volume recommendations (MCVR) for hospitals. However, this association is dynamic and has changed over time due to advancements in peri-operative care. We hypothesize that the volume outcome association has evolved to the extent that current MCVR should be re-evaluated.


Methods: Patients who underwent surgical resection for esophageal, gastric, liver, lung, pancreas, and rectal cancer from 2005 to 2019 were identified from the National Cancer Database. Temporal changes in the volume-outcome relationship for each surgical procedure  were evaluated with three separate volume-outcome curves: 2005 (orange), 2019 (blue), and 2005-2019 (black). Multilevel mixed-effects logistic regression was performed to identify benchmark 30-day mortality for each cancer following surgery (red line).


Results: A left shift in the volume-outcome curves was seen for all cancer surgery types from 2005 to 2019, indicating a decrease in 30-day mortality for the same number of cases annually over time (Figure). This decrease in mortality was not proportional and was higher in hospitals below MCVR, compared to those above MCVR (delta difference in average 30-day mortality from 2005 to 2019 in hospitals below and above MCVR: -0.11% lung, -0.45% esophagus, -0.5% rectum, -1.16% pancreas, -2.58% stomach, and -2.91% liver). For esophageal, pancreatic, and stomach surgery, the number of cases needed to achieve benchmark 30-day mortality in 2019 was lower than in 2005 (21 vs. 87, 10 vs. 30, and 7 vs. 74 respectively). For lung, liver and rectal cancer surgery the curves shifted leftwards to the extent that all volume categories were below benchmark 30-day mortality. 


Conclusions: The volume outcome association for complex cancer surgery has evolved in the last two decades. Differential improvement in 30-day mortality between high and low volume hospitals means that a lower number of cases is needed to achieve the same benchmark 30-day mortality in 2019 than in 2005. Current MCVR should be reconsidered to ensure access to complex cancer surgery without compromising on outcomes.

Learning Objectives:

  • Understand the volume-outcome association
  • Describe the evolution of the volume-outcome association over time
  • Make recommendations regarding minimum case volume thersholds