title: High volume improves outcomes: The argument for centralization of rectal cancer surgery.
abstract: BACKGROUND
  Centralization of care to "centers of excellence" in Europe has led to improved oncologic outcomes; however, little is known regarding the impact of nonmandated regionalization of rectal cancer care in the United States.
  
  
  METHODS
  The Statewide Planning and Research Cooperative System (SPARCS) was queried for elective abdominoperineal and low anterior resections for rectal cancer from 2000 to 2011 in New York with the use of International Classification of Diseases, Ninth Revision codes. Surgeon volume and hospital volume were grouped into quartiles, and high-volume surgeons (≥ 10 resections/year) and hospitals (≥ 25 resections/year) were defined as the top quartile of annual caseload of rectal cancer resection and compared with the bottom 3 quartiles during analyses. Bivariate and multilevel regression analyses were performed to assess factors associated with restorative procedures, 30-day mortality, and temporal trends in these endpoints.
  
  
  RESULTS
  Among 7,798 rectal cancer resections, the overall rate of no-restorative proctectomy and 30-day mortality decreased by 7.7% and 1.2%, respectively, from 2000 to 2011. In addition, there was a linear increase in the proportion of cases performed by both high-volume surgeons and high-volume hospitals and a decrease in the number of surgeons and hospitals performing rectal cancer surgery. High-volume surgeons at high-volume hospitals were associated independently with both less nonrestorative proctectomies (odds ratio 0.65, 95% confidence interval 0.48-0.89) and mortality (odds ratio 0.43, 95% confidence interval 0.21-0.87) rates. No patterns of significant improvement within the volume strata of the surgeon and hospitals were observed over time.
  
  
  CONCLUSIONS
  This study suggests that the current trend toward regionalization of rectal cancer care to high-volume surgeons and high-volume centers has led to improved outcomes. These findings have implications regarding the policy of health care delivery in the United States, supporting referral to high-volume centers of excellence.
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY. Electronic address: christopher_aquina@urmc.rochester.edu.
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Aquina
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY.
authors.forename: Christian P
authors.initials: CP
authors.lastname: Probst
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY.
authors.forename: Adan Z
authors.initials: AZ
authors.lastname: Becerra
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY.
authors.forename: James C
authors.initials: JC
authors.lastname: Iannuzzi
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY.
authors.forename: Kristin N
authors.initials: KN
authors.lastname: Kelly
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY.
authors.forename: Bradley J
authors.initials: BJ
authors.lastname: Hensley
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY.
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Rickles
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY.
authors.forename: Katia
authors.initials: K
authors.lastname: Noyes
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY.
authors.forename: Fergal J
authors.initials: FJ
authors.lastname: Fleming
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise (S.H.O.R.E.), University of Rochester Medical Center, Rochester, NY.
authors.forename: John R T
authors.initials: JR
authors.lastname: Monson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D002497:Centralized Hospital Services / Q000458:organization & administration*; D003082:Colectomy / Q000379:methods / Q000401:mortality; D016208:Databases, Factual; D018572:Disease-Free Survival; D017558:Elective Surgical Procedures / Q000706:statistics & numerical data; D004638:Emergency Treatment / Q000706:statistics & numerical data; D005260:Female; D061847:Hospitals, High-Volume; D006801:Humans; D008297:Male; D008875:Middle Aged; D009518:New York; D011379:Prognosis; D015397:Program Evaluation; D058996:Quality Improvement; D012004:Rectal Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate