Research Objective: There is strong evidence that hospital volume is associated with improved outcomes for patients undergoing surgery for cancer across a number of common cancers, yet there is no consensus on how to classify hospitals as high-volume. Further, lack of access to high-volume hospitals (HVHs) may contribute to rural-urban disparities in cancer outcomes. This study examines urban/rural differences in receipt of cancer surgery at HVHs and sensitivity to volume thresholds used. Study Design: We used logistic regression models to examine the association between cancer surgery at a HVH and individual and area factors using different volume thresholds that are commonly used in the literature: top 10%, 20%, 25%, and 30%. Population Studied: Using 2017-2020 statewide Pennsylvania Health Care Cost Containment Council (PHC4) inpatient data, we identified patients ages 18+ with a diagnosis of 10 cancers (lung, pancreas, breast, brain, rectum, bladder, colon, esophagus, prostate, stomach) who underwent a cancer-related surgery. Principal Findings: We found variability in the number of hospitals classified as high-volume as well as the percentage of surgeries performed at HVH. Across the 10 cancers examined, the relationship between rural residence and treatment in a HVH varied by cancer type, and for some cancers, varied depending on the volume threshold used. There was a consistent negative relationship between rural residence and surgery at a high-volume hospital for breast and lung cancer; for colon and prostate cancers the association was generally negative but only significant using certain high-volume thresholds. For esophageal and pancreatic cancer, there was a positive relationship between rural residence and surgery at a HVH and therefore, compared to urban counties, patients with esophageal and pancreatic cancer in rural counties were more likely to be treated at a HVH. Among less prevalent cancers (bladder, stomach, rectum and brain) there was less consistency in the relationship between rural residence and treatment at a HVH across different thresholds. Conclusions: For many cancers, rural patients are less likely to receive care at HVHs, though the relationship differs across cancers and depending on volume threshold examined. Findings highlight the complexity of examining patterns of cancer care at HVHs, and the importance of protocols outlining minimum procedural volume thresholds. Positive relationships between rural residence and treatment at a HVH may result from selection effects if rural patients are less likely to receive surgery overall. Implications for Policy or Practice: There has been interest in using treatment at HVHs as a quality metric for determining reimbursement, including for breast cancer in the New York Medicaid program in recent years. Our findings highlight the complexity of developing such programs for other cancers. This study informs protocols focusing on high-volume thresholds and have implications for surgical education and training. Citation Format: Haleh Ramian, Lindsay Sabik, Zhaojun Sun, Jonathan Yabes, Bruce Jacobs. Urban/rural differences in receiving cancer surgery at high-volume hospitals and sensitivity to hospital volume thresholds [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PR004.

ImportanceDisruptions in cancer surgery during the COVID-19 pandemic led to widespread deferrals and cancellations, creating a surgical backlog that presents a challenge for health care institutions moving into the recovery phase of the pandemic.ObjectiveTo describe patterns in surgical volume and postoperative length of stay for major urologic cancer surgery during the COVID-19 pandemic.Design, Setting, and ParticipantsThis cohort study identified 24 001 patients 18 years or older from the Pennsylvania Health Care Cost Containment Council database with kidney cancer, prostate cancer, or bladder cancer who received a radical nephrectomy, partial nephrectomy, radical prostatectomy, or radical cystectomy between the first quarter (Q1) of 2016 and Q2 of 2021. Postoperative length of stay and adjusted surgical volumes were compared before and during the COVID-19 pandemic.Main Outcomes and MeasuresThe primary outcome was adjusted surgical volume for radical and partial nephrectomy, radical prostatectomy, and radical cystectomy during the COVID-19 pandemic. The secondary outcome was postoperative length of stay.ResultsA total of 24 001 patients (mean [SD] age, 63.1 [9.4] years; 3522 women [15%], 19 845 White patients [83%], 17 896 living in urban areas [75%]) received major urologic cancer surgery between Q1 of 2016 and Q2 of 2021. Of these, 4896 radical nephrectomy, 3508 partial nephrectomy, 13 327 radical prostatectomy, and 2270 radical cystectomy surgical procedures were performed. There were no statistically significant differences in patient age, sex, race, ethnicity, insurance status, urban or rural status, or Elixhauser Comorbidity Index scores between patients who received surgery before and patients who received surgery during the pandemic. For partial nephrectomy, a baseline of 168 surgeries per quarter decreased to 137 surgeries per quarter in Q2 and Q3 of 2020. For radical prostatectomy, a baseline of 644 surgeries per quarter decreased to 527 surgeries per quarter in Q2 and Q3 of 2020. However, the likelihood of receiving radical nephrectomy (odds ratio [OR], 1.00; 95% CI, 0.78-1.28), partial nephrectomy (OR, 0.99; 95% CI, 0.77-1.27), radical prostatectomy (OR, 0.85; 95% CI, 0.22-3.22), or radical cystectomy (OR, 0.69; 95% CI, 0.31-1.53) was unchanged. Length of stay for partial nephrectomy decreased from baseline by a mean of 0.7 days (95% CI, −1.2 to −0.2 days) during the pandemic.Conclusions and RelevanceThis cohort study suggests that partial nephrectomy and radical prostatectomy surgical volume decreased during the peak waves of COVID-19, as did postoperative length of stay for partial nephrectomy.

PURPOSE: With the introduction of the Oncology Care Model and plans for the transition to Oncology Care First, alternative payment models (APMs) are an increasingly important piece of the oncology care landscape. Evidence is mixed on the Oncology Care Model's impact on utilization and costs, but as policymakers consider expansion of similar models, it is critical to understand the characteristics of hospitals that may be differentially affected. METHODS: We used 2007-2016 SEER-Medicare data to identify patients with breast and prostate cancer receiving chemotherapy, endocrine therapy (breast), or androgen deprivation therapy (prostate). For each hospital, we calculated 6-month expected mortality, emergency department (ED) visits, inpatient admissions, and costs, all commonly collected APM outcomes. After calculating observed-to-expected rates for each outcome by hospital, we estimated the association between observed-to-expected rates and characteristics of each hospital to understand hospital characteristics that might be associated with higher- or lower-than-expected rates of each outcome. RESULTS: Hospitals with > 15% rural patients had significantly higher-than-expected mortality (0.31 points higher, P < .001) and ED visit rates (0.10 points higher, P = .029) as well as significantly lower costs (0.06 points lower, P = .004). Hospitals unaffiliated with a medical school also experienced significantly higher-than-expected mortality and ED visits. Hospitals eligible for disproportionate share hospital payment experienced significantly higher ED visits but lower costs. For-profit hospitals experienced higher-than-expected mortality. CONCLUSION: Rural hospitals and those unaffiliated with a medical school may require special consideration as APMs expand in oncology care. Designated cancer centers and larger hospitals may be advantaged.