Commentary on the Volume-Outcome Relationship in CRS/HIPEC for Peritoneal Carcinomatosis

Abstract

Background: Peritoneal carcinomatosis historically has a poor prognosis; however, Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) have shown improved outcomes. While a volume-outcome relationship is established in oncologic surgeries, its applicability to CRS/HIPEC remains unexplored. This study examines the impact of hospital volume on CRS/HIPEC outcomes. Methods: Using the national Vizient Clinical Database, this retrospective analysis evaluated 5,165 HIPEC cases from 149 hospitals between January 2020 and December 2022. Hospitals were stratified into tertiles based on procedural volume. Chi-squared analysis and one-way ANOVA assessed the associations between hospital volume and patient demographics, morbidity, mortality, ICU utilization, length of stay, readmission rates, and costs. Results: No significant differences were found in morbidity (low- 9.4% vs. medium- 7.1% vs. high- 9.0%, p = 0.71) or mortality rates across hospital volume tertiles (0.9% vs. 0.6% vs. 0.7%, p = 0.93). Postoperative ICU use was higher in low-volume hospitals, yet this factor did not affect the overall length of stay or costs. Hospitals with Magnet nursing status had lower observed mortality (0.5% vs 1.7%, p = 0.048), but Magnet status did not significantly affect post-operative complications. CMI was similar between low-, medium-, and high-volume hospitals. While Magnet status and CMI were influential, hospital volume alone was not indicative of patient outcomes. Costs remained consistent across all volumes, indicating a trend toward cost-effective care. Conclusion: The anticipated volume-outcome relationship for CRS/HIPEC is not supported by this study's findings. Outcomes were more closely related to institutional quality and case complexity rather than procedural volume. These results suggest a reconsideration of the current emphasis on regionalization, advocating for the expansion of high-quality CRS/HIPEC care beyond high-volume centers, potentially increasing accessibility for patients.