Spontaneous regionalization of esophageal cancer surgery: an analysis of the National Cancer Database.

Abstract

Esophagectomy patients are up to three times more likely to die after surgery when cared for at low-volume hospitals (LVHs). Increased awareness by patients and clinicians of the hazards of esophagectomy at LVHs, may inspire a "spontaneous regionalization" away from LVHs, yet the extent to which this has taken place is unclear. Retrospective analysis of patients undergoing esophagectomy for esophageal cancer in the National Cancer Database (NCDB) across two eras: 2004-2006 (Era 1) and 2010-2012 (Era 2). Primary outcomes included the proportion of patients at high-volume hospitals (HVHs) (≥13/year per Leapfrog Group), adjusted, and unadjusted 90-day mortality. The NCDB captured 5,968 esophagectomy patients in Era 1 and 5,580 in Era 2, a 6.5% decrease (P<0.001). Fewer hospitals performed esophagectomies in Era 2 (756 vs. 663, P=0.014), yet the proportion of patients treated at LVHs declined slightly between eras (73% vs. 70%, P<0.001). Patients with high-risk attributes (e.g., advanced age, multiple comorbidities, etc.) were disproportionately treated at LVHs in both eras (77% Era 1, P<0.001, 73% Era 2, P=0.017). However, the 90-day mortality rate for patients with high-risk attributes decreased considerably between Eras at LVHs (19.3% to 12.3%, P<0.001). Spontaneous regionalization of esophageal cancer surgery has not occurred on a large scale, yet for high-risk patients, the hazards of being cared for at LVHs have dissipated. Further study is needed to optimize alignment of esophagectomy patients and hospitals.