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Implementation of Minimum Hospital Volume Standards Could Impact Ovarian Cancer Surgical Care

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Key Points

  • On average, hospitals performing five or fewer ovarian cancer surgeries had higher than expected mortality rates at 6 months, 1 year, 2 years, and 5 years after surgery, but individually, a large number of low-volume hospitals had better than expected mortality rates. For example, among hospitals that performed three or fewer surgeries in the previous year, 51% had lower than expected 2-year mortality rates.
  • Implementing a minimum-volume standard of three or more surgeries a year would have eliminated 35% of hospitals that treated 7.7% of all patients with ovarian cancer in 2015—yet this restriction would have avoided only one death for every 300 patients treated.
  • Researchers mentioned these restrictions may affect rural and underserved patients specifically. 

Limiting ovarian cancer surgery to high-volume hospitals could improve survival but may also reduce access for many rural and underserved patients, a study from researchers at Columbia University Vagelos College of Physicians and Surgeons has found. The findings were published by Wright et al in Obstetrics & Gynecology.

Ovarian cancer surgery is a complex procedure with a high risk of complications. Studies have shown that patients undergoing cancer surgery often have better outcomes when treated at hospitals that perform these procedures routinely. 

In the study, although mortality was higher than average at hospitals that performed three or fewer procedures, more than 75% of low-volume hospitals had outcomes that were better than expected at 60 days, and 51% had outcomes that were better than expected at 2 years based on their patient population. Applying a minimum-volume cutoff of three procedures would prevent nearly 35% of hospitals, mainly in rural areas, from performing ovarian cancer surgery—affecting nearly 8% of patients nationwide.

“Our study shows that hospitals considering implementing minimum-volume standards for cancer surgery could unintentionally prevent many patients from getting timely care for a minimal increase in survival,” explained senior study author Jason Wright, MD, Associate Professor of Gynecologic Oncology at Columbia University Vagelos College of Physicians and Surgeons. “There’s a strong rationale for implementing minimum-volume standards at hospitals that perform cancer surgeries—large procedures that require experience and a very specialized skill set,” Dr. Wright continued. “But while some hospital systems are voluntarily implementing minimum-volume standards, we haven’t determined the optimal volume for hospitals performing complex cancer procedures or how applying minimum-volume standards would affect access to care for women with ovarian cancer, especially in rural areas.”

Methods

The researchers pulled data from the National Cancer Database, which contained information on 136,196 women who were diagnosed with invasive ovarian cancer between 2005 and 2015 and the 1,321 hospitals that treated them. They compared the hospitals’ actual (observed) mortality rates with expected mortality rates (based on the characteristics of each hospital’s caseload) and modeled how eliminating low-volume hospitals would affect outcomes.

Findings

Nearly 50% of hospitals performed five or fewer ovarian cancer surgeries in 2015, treating approximately 13% of all women with newly diagnosed ovarian cancer.

On average, hospitals performing five or fewer of these procedures had higher than expected mortality rates at 6 months, 1 year, 2 years, and 5 years after surgery. The biggest differences in mortality occurred in the first 6 months to 2 years after surgery, when the risk of complications is higher. 

However, individually, a large number of low-volume hospitals had better than expected mortality rates. For example, among hospitals that performed three or fewer surgeries in the previous year, 51% had lower than expected 2-year mortality rates.

Implementing a minimum-volume standard of three or more surgeries a year would have eliminated 35% of hospitals that treated 7.7% of all patients with ovarian cancer in 2015—yet this restriction would have avoided only one death for every 300 patients treated.

“An arbitrary minimum-volume standard may be unnecessarily punitive for low-volume centers with good outcomes,” said Dr. Wright. “We have previously found that outcomes are better at low-volume centers that rigorously adhere to evidence-based treatment guidelines for ovarian cancer, suggesting that metrics other than volume may be more appropriate.”

Disclosures: For full disclosures of the study authors, visit journals.lww.com.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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