title: Hospital Volume and Survival After Hepatocellular Carcinoma Diagnosis.
abstract: The association between hospital volume and outcome following high-risk low volume cancer surgery is well documented. However, this association is not well understood in cancer patients undergoing non-surgical therapies. We explored this association in a cohort of newly diagnosed patients with hepatocellular carcinoma (HCC).
  
  
  
  Data from the 2000 through 2011 in Texas Cancer Registry were used to study adults with newly diagnosed HCC (17,231 patients from 322 hospitals). Hospital volume was stratified into low and high volume using Contal's outcome-based method. A multivariable Cox regression with shared frailty was used to evaluate the association between hospital volume and overall survival. The relationship between treatment modality and hospital volume was explored using mixed effects logistic regression.
  
  
  
  The majority (61%) of HCC patients were seen in 21 high-volume hospitals. An annual hospital volume cutoff point of 24 patients was determined to stratify between high- and low-volume hospitals. Patients at high-volume hospitals presented more commonly with localized disease (56 vs. 50%, P<0.01) and were more likely to receive curative therapies including surgical resection, liver transplantation, or ablation (22 vs. 12%, P<0.01). High-volume hospitals were significantly associated with improved survival (HR=0.96, 95% CI=0.94-0.98). In multivariable analysis, hospital volume was associated with increased overall treatment utilization (OR=1.3, 95% CI=1.2-1.4).
  
  
  
  Hospital volume is associated with improved overall survival, particularly in localized HCC. Improved survival may be mediated by increased utilization of treatments in high HCC volume hospitals.
authors.affiliation: Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Ali A
authors.initials: AA
authors.lastname: Mokdad
authors.affiliation: Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Hong
authors.initials: H
authors.lastname: Zhu
authors.affiliation: Department of Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Jorge A
authors.initials: JA
authors.lastname: Marrero
authors.affiliation: Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: John C
authors.initials: JC
authors.lastname: Mansour
authors.affiliation: Department of Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Amit G
authors.initials: AG
authors.lastname: Singal
authors.affiliation: Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Adam C
authors.initials: AC
authors.lastname: Yopp
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000401:mortality / Q000473:pathology / Q000628:therapy; D003131:Combined Modality Therapy / Q000379:methods / Q000706:statistics & numerical data; D000072700:Conservative Treatment / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D006498:Hepatectomy / Q000706:statistics & numerical data*; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data; D006801:Humans; D008113:Liver Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000473:pathology / Q000628:therapy; D016031:Liver Transplantation / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010043:Outcome and Process Assessment, Health Care; D012042:Registries; D016019:Survival Analysis; D013781:Texas / Q000453:epidemiology