Hospital characteristics, clinical severity, and outcomes for surgical oncology patients.
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.


CONCLUSIONS
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.
Friese
Christopher R
CR
Division of Nursing Business and Health Systems, School of Nursing, University of Michigan, Ann Arbor, MI 48109-5482, USA. cfriese@umich.edu
Earle
Craig C
CC
Silber
Jeffrey H
JH
Aiken
Linda H
LH
D000368:Aged; D002173:Cancer Care Facilities / Q000592:standards / Q000706:statistics & numerical data*; D015897:Comorbidity; D006742:Hospital Bed Capacity / Q000592:standards / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006784:Hospitals, Teaching / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D008875:Middle Aged; D009369:Neoplasms / Q000401:mortality* / Q000601:surgery*; D017063:Outcome Assessment, Health Care; D010414:Pennsylvania / Q000453:epidemiology; D011237:Predictive Value of Tests; D012042:Registries; D012307:Risk Factors; D012720:Severity of Illness Index; D013503:Surgery Department, Hospital / Q000592:standards / Q000706:statistics & numerical data
Health Serv Res. 1991 Oct;26(4):407-24
1917499
Med Care. 2007 Oct;45(10):918-25
17890988
J Am Coll Surg. 1997 Oct;185(4):341-51
9328382
N Engl J Med. 1989 Dec 21;321(25):1720-5
2594031
J Clin Oncol. 2000 Jun;18(11):2327-40
10829054
Inquiry. 1985 Winter;22(4):377-87
2934332
JAMA. 2003 Sep 24;290(12):1617-23
14506121
Int J Health Serv. 1998;28(3):467-86
9711476
Milbank Q. 2002;80(3):569-93, v
12233250
Ann Intern Med. 2003 Oct 21;139(8):649-57
14568853
Surgery. 2005 Nov;138(5):837-43
16291383
Health Serv Res. 2008 Aug;43(4):1145-63
18248404
JAMA. 1988 Dec 2;260(21):3159-63
3184394
Health Aff (Millwood). 1998 Nov-Dec;17(6):194-205
9916369
Arch Surg. 2003 Jul;138(7):721-5; discussion 726
12860752
Med Care. 1992 Jul;30(7):615-29
1614231
J Surg Oncol. 2003 Jun;83(2):68-78; discussion 78-9
12772198
J Natl Cancer Inst. 2003 May 21;95(10):708-16
12759388
Cancer. 2005 Feb 1;103(3):435-41
15622523
JAMA. 2002 Oct 23-30;288(16):1987-93
12387650
Radiology. 1982 Apr;143(1):29-36
7063747
J Natl Cancer Inst. 2003 Sep 17;95(18):1370-5
13130112