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The relationship between procedure volume and outcomes has long been recognized: studies have concluded that patients operated on by high-volume surgeons at high-volume hospitals have improved outcomes.1,2 This paradigm is also associated with ovarian cancer outcomes. But what affect does adherence to evidence-based guidelines have on these statistics?
Jason D. Wright, MD, and colleagues at the Columbia University College of Physicians and Surgeons, in New York City, sought to determine whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and ovarian cancer survival.3
Details of the study
Using the National Cancer Database (NCD), the research team identified 100,725 patients at 1,268 hospitals who were treated for invasive epithelial ovarian cancer between 2004 and 2013. Hospitals were stratified by annual case volume into quintiles: low-volume (≤2 cases; n = 299 [23.6%]), low-intermediate–volume (2.01–5 cases; n = 465 [36.7%]), intermediate-volume (5.01–9 cases; n = 157 [12.4%]), high-intermediate–volume (9.01–19.9 cases; n = 194 [15.3%]), and high-volume (≥20 cases; n = 153 [12.1%]).3
To measure quality, the authors defined hospital-level rates of 5 metrics based on clinical guidelines3:
- lymph node dissection performed for patients with stage I–IIIB tumors
- performance of omentectomy or cytoreduction for patients with advanced stage tumors
- use of chemotherapy among patients with early-stage, high-risk tumors
- omission of chemotherapy for women with early-stage, low-risk tumors
- use of chemotherapy (either neoadjuvant or adjuvant) for women with advanced-stage disease.
For each metric, the authors determined the rate of hospital-level compliance for all study-eligible patients. Then a composite variable of overall quality was derived using all 5 metrics. Based on the overall quality metric, hospitals were stratified into quartiles: low-quality, medium-low–quality, medium-high–quality, and high-quality.3
Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to quality metrics.3
Related article:
2017 Update on ovarian cancer
Trends and conclusions
Researchers found that compliance with quality metrics generally increased with hospital volume. Trends of increased compliance were observed with lymph node dissection for early-stage tumors, cytoreduction for advanced-stage tumors, and use of chemotherapy for advanced-stage tumors. No trends were evident for use of chemotherapy for high-risk, early-stage tumors. By contrast, a trend for higher-volume hospitals to administer chemotherapy for low-risk, early-stage tumors was discovered. Adherence with the composite overall quality metric was noted in 64.2% of low-volume centers and increased with each volume category to 82.2% at the highest-volume hospitals.3
Study results indicated that survival increased with increasing hospital volume and with adherence to the quality metrics. The association between volume and quality was then examined. For each volume category, survival increased with increasing adherence to the quality metrics. In the highest-volume group, 2-year adjusted survival rose from 75.5% (95% confidence interval [CI], 73.2%–77.8%) at the lowest-quality hospitals, to 78.6% (95% CI, 78.0%–79.1%) at the highest-quality hospitals. Similar trends were found for intermediate-volume hospitals and for 5-year survival. However, the relationship between adherence to quality metrics and survival was less consistent for the low-, low-intermediate–, and high-intermediate–volume hospitals.3
The authors concluded that both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer. Even though survival rates are improved at low-volume hospitals that are highly adherent to quality metrics, their survival rates are still lower than high-volume hospitals.
Read about the pros and cons of regionalization for high-risk ovarian cancer surgery.
Study limitations
The authors cite several limitations to this study:
- chosen quality metrics focused on care during initial treatment. Women with ovarian cancer are often treated for many years.
- the NCD lacks information on aspects like hospital infrastructure and staffing; there are probably other confounders that influence treatment and outcomes
- although NCD data have been validated, misclassification of a small number of patients may exist. Also, some hospitals did not treat patients who might be eligible for a quality metric and therefore were not included in this analysis.
- some study participants (13.7%) received treatment at multiple hospitals
- the volume cutpoints chosen by the research team were based on prior studies; there could be outcome variation within a volume strata.
Should high-risk surgeries be regionalized?
The association between higher surgical volume and improved outcomes has led to efforts to regionalize the care for high-risk operations to high-volume centers, say the authors. They conclude that this may be a reasonable strategy for some procedures. However, they suggest that regionalization presents practical difficulties:
- patients prefer to receive local care and are often unwilling to or cannot travel
- regionalization can worsen inequalities in access to care and may adversely affect low-volume hospitals
- high-volume centers do not exist in some areas of the country. A recent report suggested that 9% of the US female population had geographic barriers to receiving care from a gynecologic oncologist.4
Can low-volume facilities attain the same outcomes as high-volume centers?
The authors pose an important question: Can lower-volume facilities that deliver high-quality care achieve the same outcomes as higher-volume centers? With the difficulties associated with regionalization, many advocates seek strategies to raise the quality of care at low-volume centers, they say. The authors note that, “although outcomes improve at low-volume centers that are highly compliant with the quality metrics examined, survival at these centers is still lower than at high-volume centers.”3 The authors suggest that there are factors other than adherence to guidelines that play a role in how hospital volume affects ovarian cancer outcomes.3
Practice considerations
“Because the best outcomes appear to be achieved at high-volume hospitals, efforts to promote volume-based referral for women with ovarian cancer are reasonable,” the authors conclude.3 However, in practicality, many women will not be able to receive care at high-volume centers, they concede. “For low-volume centers, targeted quality improvement efforts and strict adherence to quality guidelines may help to optimize outcomes for women with ovarian cancer.”3
Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
- Birkmeyer JC, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Eng J Med. 2002;346(15):1128–1137.
- Birkmeyer JC, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. New Engl J Med. 2003;349(22):2117–2127.
- Wright JD, Chen L, Hou JY, et al. Association of hospital volume and quality of care with survival for ovarian cancer. Obstet Gynecol. 2017;130(3):545–553.
- Shalowitz DI, Vinograd AM, Giuntoli RL II. Geographic access to gynecologic cancer care in the United States. Gynecol Oncol. 2015;138(1):115–120.
The relationship between procedure volume and outcomes has long been recognized: studies have concluded that patients operated on by high-volume surgeons at high-volume hospitals have improved outcomes.1,2 This paradigm is also associated with ovarian cancer outcomes. But what affect does adherence to evidence-based guidelines have on these statistics?
Jason D. Wright, MD, and colleagues at the Columbia University College of Physicians and Surgeons, in New York City, sought to determine whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and ovarian cancer survival.3
Details of the study
Using the National Cancer Database (NCD), the research team identified 100,725 patients at 1,268 hospitals who were treated for invasive epithelial ovarian cancer between 2004 and 2013. Hospitals were stratified by annual case volume into quintiles: low-volume (≤2 cases; n = 299 [23.6%]), low-intermediate–volume (2.01–5 cases; n = 465 [36.7%]), intermediate-volume (5.01–9 cases; n = 157 [12.4%]), high-intermediate–volume (9.01–19.9 cases; n = 194 [15.3%]), and high-volume (≥20 cases; n = 153 [12.1%]).3
To measure quality, the authors defined hospital-level rates of 5 metrics based on clinical guidelines3:
- lymph node dissection performed for patients with stage I–IIIB tumors
- performance of omentectomy or cytoreduction for patients with advanced stage tumors
- use of chemotherapy among patients with early-stage, high-risk tumors
- omission of chemotherapy for women with early-stage, low-risk tumors
- use of chemotherapy (either neoadjuvant or adjuvant) for women with advanced-stage disease.
For each metric, the authors determined the rate of hospital-level compliance for all study-eligible patients. Then a composite variable of overall quality was derived using all 5 metrics. Based on the overall quality metric, hospitals were stratified into quartiles: low-quality, medium-low–quality, medium-high–quality, and high-quality.3
Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to quality metrics.3
Related article:
2017 Update on ovarian cancer
Trends and conclusions
Researchers found that compliance with quality metrics generally increased with hospital volume. Trends of increased compliance were observed with lymph node dissection for early-stage tumors, cytoreduction for advanced-stage tumors, and use of chemotherapy for advanced-stage tumors. No trends were evident for use of chemotherapy for high-risk, early-stage tumors. By contrast, a trend for higher-volume hospitals to administer chemotherapy for low-risk, early-stage tumors was discovered. Adherence with the composite overall quality metric was noted in 64.2% of low-volume centers and increased with each volume category to 82.2% at the highest-volume hospitals.3
Study results indicated that survival increased with increasing hospital volume and with adherence to the quality metrics. The association between volume and quality was then examined. For each volume category, survival increased with increasing adherence to the quality metrics. In the highest-volume group, 2-year adjusted survival rose from 75.5% (95% confidence interval [CI], 73.2%–77.8%) at the lowest-quality hospitals, to 78.6% (95% CI, 78.0%–79.1%) at the highest-quality hospitals. Similar trends were found for intermediate-volume hospitals and for 5-year survival. However, the relationship between adherence to quality metrics and survival was less consistent for the low-, low-intermediate–, and high-intermediate–volume hospitals.3
The authors concluded that both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer. Even though survival rates are improved at low-volume hospitals that are highly adherent to quality metrics, their survival rates are still lower than high-volume hospitals.
Read about the pros and cons of regionalization for high-risk ovarian cancer surgery.
Study limitations
The authors cite several limitations to this study:
- chosen quality metrics focused on care during initial treatment. Women with ovarian cancer are often treated for many years.
- the NCD lacks information on aspects like hospital infrastructure and staffing; there are probably other confounders that influence treatment and outcomes
- although NCD data have been validated, misclassification of a small number of patients may exist. Also, some hospitals did not treat patients who might be eligible for a quality metric and therefore were not included in this analysis.
- some study participants (13.7%) received treatment at multiple hospitals
- the volume cutpoints chosen by the research team were based on prior studies; there could be outcome variation within a volume strata.
Should high-risk surgeries be regionalized?
The association between higher surgical volume and improved outcomes has led to efforts to regionalize the care for high-risk operations to high-volume centers, say the authors. They conclude that this may be a reasonable strategy for some procedures. However, they suggest that regionalization presents practical difficulties:
- patients prefer to receive local care and are often unwilling to or cannot travel
- regionalization can worsen inequalities in access to care and may adversely affect low-volume hospitals
- high-volume centers do not exist in some areas of the country. A recent report suggested that 9% of the US female population had geographic barriers to receiving care from a gynecologic oncologist.4
Can low-volume facilities attain the same outcomes as high-volume centers?
The authors pose an important question: Can lower-volume facilities that deliver high-quality care achieve the same outcomes as higher-volume centers? With the difficulties associated with regionalization, many advocates seek strategies to raise the quality of care at low-volume centers, they say. The authors note that, “although outcomes improve at low-volume centers that are highly compliant with the quality metrics examined, survival at these centers is still lower than at high-volume centers.”3 The authors suggest that there are factors other than adherence to guidelines that play a role in how hospital volume affects ovarian cancer outcomes.3
Practice considerations
“Because the best outcomes appear to be achieved at high-volume hospitals, efforts to promote volume-based referral for women with ovarian cancer are reasonable,” the authors conclude.3 However, in practicality, many women will not be able to receive care at high-volume centers, they concede. “For low-volume centers, targeted quality improvement efforts and strict adherence to quality guidelines may help to optimize outcomes for women with ovarian cancer.”3
Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
The relationship between procedure volume and outcomes has long been recognized: studies have concluded that patients operated on by high-volume surgeons at high-volume hospitals have improved outcomes.1,2 This paradigm is also associated with ovarian cancer outcomes. But what affect does adherence to evidence-based guidelines have on these statistics?
Jason D. Wright, MD, and colleagues at the Columbia University College of Physicians and Surgeons, in New York City, sought to determine whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and ovarian cancer survival.3
Details of the study
Using the National Cancer Database (NCD), the research team identified 100,725 patients at 1,268 hospitals who were treated for invasive epithelial ovarian cancer between 2004 and 2013. Hospitals were stratified by annual case volume into quintiles: low-volume (≤2 cases; n = 299 [23.6%]), low-intermediate–volume (2.01–5 cases; n = 465 [36.7%]), intermediate-volume (5.01–9 cases; n = 157 [12.4%]), high-intermediate–volume (9.01–19.9 cases; n = 194 [15.3%]), and high-volume (≥20 cases; n = 153 [12.1%]).3
To measure quality, the authors defined hospital-level rates of 5 metrics based on clinical guidelines3:
- lymph node dissection performed for patients with stage I–IIIB tumors
- performance of omentectomy or cytoreduction for patients with advanced stage tumors
- use of chemotherapy among patients with early-stage, high-risk tumors
- omission of chemotherapy for women with early-stage, low-risk tumors
- use of chemotherapy (either neoadjuvant or adjuvant) for women with advanced-stage disease.
For each metric, the authors determined the rate of hospital-level compliance for all study-eligible patients. Then a composite variable of overall quality was derived using all 5 metrics. Based on the overall quality metric, hospitals were stratified into quartiles: low-quality, medium-low–quality, medium-high–quality, and high-quality.3
Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to quality metrics.3
Related article:
2017 Update on ovarian cancer
Trends and conclusions
Researchers found that compliance with quality metrics generally increased with hospital volume. Trends of increased compliance were observed with lymph node dissection for early-stage tumors, cytoreduction for advanced-stage tumors, and use of chemotherapy for advanced-stage tumors. No trends were evident for use of chemotherapy for high-risk, early-stage tumors. By contrast, a trend for higher-volume hospitals to administer chemotherapy for low-risk, early-stage tumors was discovered. Adherence with the composite overall quality metric was noted in 64.2% of low-volume centers and increased with each volume category to 82.2% at the highest-volume hospitals.3
Study results indicated that survival increased with increasing hospital volume and with adherence to the quality metrics. The association between volume and quality was then examined. For each volume category, survival increased with increasing adherence to the quality metrics. In the highest-volume group, 2-year adjusted survival rose from 75.5% (95% confidence interval [CI], 73.2%–77.8%) at the lowest-quality hospitals, to 78.6% (95% CI, 78.0%–79.1%) at the highest-quality hospitals. Similar trends were found for intermediate-volume hospitals and for 5-year survival. However, the relationship between adherence to quality metrics and survival was less consistent for the low-, low-intermediate–, and high-intermediate–volume hospitals.3
The authors concluded that both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer. Even though survival rates are improved at low-volume hospitals that are highly adherent to quality metrics, their survival rates are still lower than high-volume hospitals.
Read about the pros and cons of regionalization for high-risk ovarian cancer surgery.
Study limitations
The authors cite several limitations to this study:
- chosen quality metrics focused on care during initial treatment. Women with ovarian cancer are often treated for many years.
- the NCD lacks information on aspects like hospital infrastructure and staffing; there are probably other confounders that influence treatment and outcomes
- although NCD data have been validated, misclassification of a small number of patients may exist. Also, some hospitals did not treat patients who might be eligible for a quality metric and therefore were not included in this analysis.
- some study participants (13.7%) received treatment at multiple hospitals
- the volume cutpoints chosen by the research team were based on prior studies; there could be outcome variation within a volume strata.
Should high-risk surgeries be regionalized?
The association between higher surgical volume and improved outcomes has led to efforts to regionalize the care for high-risk operations to high-volume centers, say the authors. They conclude that this may be a reasonable strategy for some procedures. However, they suggest that regionalization presents practical difficulties:
- patients prefer to receive local care and are often unwilling to or cannot travel
- regionalization can worsen inequalities in access to care and may adversely affect low-volume hospitals
- high-volume centers do not exist in some areas of the country. A recent report suggested that 9% of the US female population had geographic barriers to receiving care from a gynecologic oncologist.4
Can low-volume facilities attain the same outcomes as high-volume centers?
The authors pose an important question: Can lower-volume facilities that deliver high-quality care achieve the same outcomes as higher-volume centers? With the difficulties associated with regionalization, many advocates seek strategies to raise the quality of care at low-volume centers, they say. The authors note that, “although outcomes improve at low-volume centers that are highly compliant with the quality metrics examined, survival at these centers is still lower than at high-volume centers.”3 The authors suggest that there are factors other than adherence to guidelines that play a role in how hospital volume affects ovarian cancer outcomes.3
Practice considerations
“Because the best outcomes appear to be achieved at high-volume hospitals, efforts to promote volume-based referral for women with ovarian cancer are reasonable,” the authors conclude.3 However, in practicality, many women will not be able to receive care at high-volume centers, they concede. “For low-volume centers, targeted quality improvement efforts and strict adherence to quality guidelines may help to optimize outcomes for women with ovarian cancer.”3
Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
- Birkmeyer JC, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Eng J Med. 2002;346(15):1128–1137.
- Birkmeyer JC, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. New Engl J Med. 2003;349(22):2117–2127.
- Wright JD, Chen L, Hou JY, et al. Association of hospital volume and quality of care with survival for ovarian cancer. Obstet Gynecol. 2017;130(3):545–553.
- Shalowitz DI, Vinograd AM, Giuntoli RL II. Geographic access to gynecologic cancer care in the United States. Gynecol Oncol. 2015;138(1):115–120.
- Birkmeyer JC, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Eng J Med. 2002;346(15):1128–1137.
- Birkmeyer JC, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. New Engl J Med. 2003;349(22):2117–2127.
- Wright JD, Chen L, Hou JY, et al. Association of hospital volume and quality of care with survival for ovarian cancer. Obstet Gynecol. 2017;130(3):545–553.
- Shalowitz DI, Vinograd AM, Giuntoli RL II. Geographic access to gynecologic cancer care in the United States. Gynecol Oncol. 2015;138(1):115–120.