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Background Accountable Care Organizations (ACOs) were established to improve care and outcomes for beneficiaries requiring highly coordinated, complex care. Our objective was to evaluate the association between hospital ACO participation and outcomes of major surgical oncology procedures. Methods We performed a retrospective cohort study of Medicare beneficiaries >65 years old undergoing a major surgical resection for colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung or prostate cancer from 2011 through 2013. We implemented a difference-in-differences analysis comparing the post-implementation period (January 2013 through December 2013) to the baseline period (January 2011 through December 2012), to assess the impact of hospital ACO participation on 30-day mortality, complications, readmissions and length of stay. Results Among 384,519 patients undergoing major cancer surgery at 106 ACO hospitals and 2,561 control hospitals, we identified a 30-day mortality rate of 3.4%, readmission rate of 12.5%, complication rate of 43.8% and prolonged LOS rate of 10.0% in control hospitals, with similar rates in ACO hospitals. We noted secular trends, with reductions in perioperative adverse events in control hospitals between the baseline and post-implementation periods: mortality (0.1% percentage point reduction, p=0.19), readmissions (0.4%, p=0.001), complications (1.0%, p<0.001) and prolonged LOS (1.1%, p<0.001). After accounting for these secular trends, we identified no significant effect of hospital participation in an ACO on the frequency of perioperative outcomes (difference-in-differences estimator p-values 0.24–0.72). Conclusions Early hospital participation in the MSSP ACO program was not associated with greater reductions in adverse perioperative outcomes for patients undergoing major cancer surgery compared to control hospitals.

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