Abstract PR004: Urban/rural differences in receiving cancer surgery at high-volume hospitals and sensitivity to hospital volume thresholds

Abstract

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.

Rural Versus Urban Cancer Care: Unpacking the Centralization Dilemma and the Impact of the COVID-19 Pandemic

“…10,11 As such, these operations have not been the focus of centralization and are more often performed as a wide variation of hospital types and locations. The findings in the study by Ramian et al 4 were consistent with this trend, as patients from rural areas with these cancer diagnoses were less likely to have surgery at high-volume hospitals.…”

“…12 As such, efforts to centralize rectal surgery have been more varied compared with pancreatic and esophageal operations. In turn, the variable findings reported by Ramian et al 4 may reflect this partial centralization of rectal cancer.…”

“…One interesting observation in the study by Ramian et al 4 is related to rectal cancer. Specifically, when the volume threshold was set as top 10% of hospitals, rural patients were more likely to have their operation at a high-volume hospital; however, when more liberal volume thresholds were used as the cutoff values (ie, 20%, 25%, 30%), the converse effect was observed.…”

“…Ramian et al 4 raise several interesting questions that should be further investigated. Understanding referral practices in rural and urban settings is important.…”

“…Given that cancer care is very multidisciplinary, were patients from rural areas more likely to receive neoadjuvant or adjuvant therapies at a high-volume surgery hospital versus individuals treated at low-volume hospitals? In addition, Ramian et al 4 only focused on surgical procedures related to cancer as the diagnostic indication. One might presume that the same trends would be noted for other surgical procedures such as complex cardiac and vascular cases.…”