Elsevier

Surgery

Volume 147, Issue 5, May 2010, Pages 602-609
Surgery

Surgical Outcome Research
Hospital characteristics, clinical severity, and outcomes for surgical oncology patients

https://doi.org/10.1016/j.surg.2009.03.014Get rights and content

Background

Patients and payers wish to identify hospitals with good surgical oncology outcomes. Our objective was to determine whether differences in outcomes explained by hospital structural characteristics are mitigated by differences in patient severity.

Methods

Using hospital administrative and cancer registry records in Pennsylvania, we identified 24,618 adults hospitalized for cancer-related operations. Colorectal, prostate, endometrial, ovarian, head and neck, lung, esophageal, and pancreatic cancers were studied. Outcome measures were 30-day mortality and failure to rescue (FTR) (30-day mortality preceded by a complication). After severity of illness adjustment, we estimated logistic regression models to predict the likelihood of both outcomes. In addition to American Hospital Association survey data, we externally verified hospitals with National Cancer Institute (NCI) cancer center or Commission on Cancer (COC) cancer program status.

Results

Patients in hospitals with NCI cancer centers were significantly younger and less acutely ill on admission (P < .001). Patients in high volume hospitals were younger, had lower admission acuity, yet had more advanced cancer (P < .001). Unadjusted 30-day mortality rates were lower in NCI-designated hospitals (3.76% vs 2.17%;P = .01). Risk-adjusted FTR rates were significantly lower in NCI-designated hospitals (4.86% vs 3.51%;P = .03). NCI center designation was a significant predictor of 30-day mortality when considering patient and hospital characteristics (OR, 0.68; 95% CI, 0.47–0.97;P = .04). We did not find significant outcomes effects based on COC cancer program approval.

Conclusion

Patient severity of illness varies significantly across hospitals, which may explain the outcome differences observed. Severity adjustment is crucial to understanding outcome differences. Outcomes were better than predicted for NCI-designated hospitals.

Section snippets

Patients and methods

After human subjects exempt review, we performed secondary analysis of linked data created by merging inpatient claims from the Pennsylvania Health Care Cost Containment Council, the Pennsylvania Cancer Registry, and the American Hospital Association annual survey data. The list of National Cancer Institute's11 clinical and comprehensive cancer centers available from the NCI's website, and a list of approved cancer programs provided by the American College of Surgeons, were used to identify

Clinical severity by hospital characteristics

Table I presents differences in clinical severity and cancer severity by hospital characteristics (the clinical variables for the entire sample are presented in the first column). The mean age of the sample was 68.3 years, and approximately one third of study patients were below the age of 65. The majority of patients received colorectal or prostate resections.

Admission severity and cancer severity differed significantly by hospital characteristics. Patients in hospitals with NCI cancer centers

Discussion

We report significant differences in clinical severity, cancer severity, and outcomes for surgical oncology patients by hospital characteristics. Contrary to what might be expected, severity of illness does not appear uniformly higher in NCI cancer centers. However, NCI cancer centers in our study achieved lower mortality rates than would be expected on the basis of case mix. In other types of hospitals studied, more favorable mortality rates were found to be largely a product of less severely

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    Supported by National Institute of Nursing Research R01-NR04513, American Cancer Society, DSCN-03-202-01-SCN, the Oncology Nursing Society via the Pennsylvania Tobacco Settlement Funds, and a predoctoral training grant from the National Institute of Nursing Research, T32-NR07104.

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