Dr. Bob Carter of UCSD scrubs in for a potentially life-saving brain surgery, for which higher volume of procedures leads to better outcomes. Sept. 7, 2016. Megan Wood, inewsource.
Dr. Bob Carter of UCSD scrubs in for a potentially life-saving brain surgery, for which higher volume of procedures leads to better outcomes. Sept. 7, 2016. Megan Wood, inewsource.

Getting diagnosed with cancer is scary enough. But if surgery is involved, with all its potential complications, any patient wants to find the best hospital.

Unfortunately, there’s no certain way to tell. But CalQualityCare.org, operated by the California Health Care Foundation, can give a strong clue. Most experts agree that for specific procedures such as lung, pancreas, esophageal or rectal cancer surgeries, higher volume hospitals have better outcomes and lower mortality.

The Oakland-based nonprofit used a state database to see each hospital’s volume for 11 cancer surgery types. It found that in 2014, an alarming number of San Diego County hospitals did far fewer specific cancer surgeries than what is recommended.

“If a hospital is only doing one or two of any kind of cancer surgery every year, that’s very, very low volume, and it’s likely having far more complications,” said Dr. Bruce Spurlock, board chairman of the California Hospital Assessment and Reporting Taskforce, which in November helped produced a CHCF report on the topic: “Safety in Numbers: Cancer Surgeries in California Hospitals.”

Those hospitals “should go out of business” for that cancer surgery type, and refer those patients to a higher volume hospital, he said.

Maryann O’Sullivan, the report’s author, agreed. “Providers should stop doing these low volume surgeries and, in the meantime, patients should seek out higher volume hospitals for their cancer surgeries.”

Looking at hospitals in San Diego County, Spurlock noticed too many hospitals are only doing five or six a year.


Graphic: Joe Yerardi | inewsource
Sources: California Health Care Foundation, California Office of Statewide Health Planning and Development

For example, the database shows that five of the nine hospitals performing pancreas surgery in San Diego County did only one or two that year. Three of the six hospitals that perform esophagus cancer surgeries did one or two. And five of the 12 hospitals performing stomach cancer surgeries did just one or two.

One hospital, Scripps Encinitas, performed just one surgery for liver, pancreas, prostate and stomach cancer in 2014. Scripps Memorial did only one bladder cancer surgery, one pancreas surgery and three prostate cancer surgeries.

In response, Scripps officials said that with its new MD Anderson partnership, it is “assessing this complicated issue, just as we are looking at all of our cancer care delivery, to evaluate how we move forward with our new integrated cancer program.”

The CHCF report found “that for most types of cancer surgery, there’s a high volume hospital center within 50 miles” of a patient’s residence, Spurlock said.

A national trend

One group of health systems launched a “take the volume pledge” campaign last year to persuade low-volume hospitals, including some of its own 15 affiliates, to stop doing those procedures.

Dartmouth-Hitchcock Medical Center, Johns Hopkins Hospital and the University of Michigan Health System don’t want their hospitals or surgeons performing four types of cancer surgeries unless they meet certain volume thresholds. Those volumes are 20 esophagus cancer, 40 lung cancer, 20 pancreas cancer, and 15 rectal cancer surgeries a year. New York state’s Medicaid program won’t reimburse a hospital for breast cancer surgery unless it performs at least 30.

Dr. John Birkmeyer, a general surgeon and executive vice president at Dartmouth-Hitchcock, called surgeons who perform too few surgeries “hobbyists.”

With a possible exception of colon cancer surgery, which is less sensitive to a surgeon’s volume, Birkmeyer advised that patients “definitely shouldn’t have surgery by anyone who doesn’t do them at least five or six times a year, and more is better.” And for breast cancer surgery, literature suggests a minimum of 50 procedures annually.

In San Diego County, no hospital met the “volume pledge” group’s esophagus cancer surgery threshold. Nine failed to meet lung cancer thresholds, nine failed to meet pancreas cancer thresholds and 10 failed to meet rectal cancer thresholds and two hospitals failed to meet New York’s minimum threshold for breast cancer surgery.

UCSD Health System was the only hospital system in the county that maintained high volume for all 11 cancer types, although it had lower than the recommended threshold for esophagus cancer surgery volume.

One argument hospitals make to defend low volume is that some of their surgeons might operate at multiple hospitals.

But Spurlock said it’s crucial for the whole hospital team to gain necessary experience. “The hospital staff have to be able to understand the surgery too; they have to know the instruments, the complications. It’s not just a surgeon issue,” he said.

Spurlock said his group has heard a lot of pushback to publishing volume data, especially from those low volume providers. For example, many surgeons “take great pride in performing pancreas cancer surgery because it’s very difficult, and they learned it when they were a resident or fellow. But if they only do one or two every year, they’re not going to be good at it.”

For more on this topic, see Cheryl Clark’s story in MedPage Today, a national publication read by health care providers.

Cheryl Clark is a contributing healthcare reporter at inewsource. To contact her with questions, tips or corrections, email clarkcheryl@inewsource.org.