By Christina Frangou

Patients who underwent complex gastrointestinal surgery for cancer at institutions listed in the US News & World Report annual ranking of top hospitals were less likely to die from complications than patients treated at nonranked hospitals, according to a study published this month in the Journal of the American College of Surgeons (2021 Mar 18:S1072-7515[21]00163-0).

Overall, top-ranked hospitals had lower in-hospital mortality, at a rate of 1% versus 2.26% at nonranked hospitals.

The study’s findings are in contrast to those from a similar study two years ago that looked at surgical outcomes after less complex laparoscopic abdominal operations, including bariatric, colorectal and hiatal hernia procedures (JAMA Surg 2019;154[9]:861-866). The first study showed no difference in patient results between ranked and nonranked hospitals.

“The message is if you are a patient with gallbladder disease, go to your local general surgery provider. But if you need an operation where you might die from the operation, where you might have huge complications that mean you might spend a long time in hospital, go to a hospital that does a large number of these procedures,” said study co-author Ninh T. Nguyen, MD, the chair of surgery at the University of California, Irvine.

Using data from the Vizient clinical database, Dr. Nguyen and his colleagues assessed 6,662 patients who underwent elective esophagectomy, gastrectomy and pancreatectomy for malignances at U.S. academic centers and their affiliated community hospitals in 2018. Forty-two of the top 50 hospitals on the newspaper’s list are in the database.

The investigators compared patient outcomes at the ranked hospitals and those at 198 nonranked hospitals.

Patients experienced serious complications at similar rates at ranked and nonranked hospitals. But when complications occurred, patients at ranked hospitals were far less likely to die: In-hospital mortality after a complication at ranked hospitals was 8.19%, compared with 16.79% at nonranked hospitals.

“It’s not necessarily that your complication risk is lower, but the chance of dying from that complication is much less,” Dr. Nguyen said. “Experts know how to pick up on complications early on, which is key. It might not be because of the surgeon, but the entire team.”

After adjusting for patient characteristics such as severity of illness, death rates were still, on average, lower in the ranked hospitals.

The key factor at ranked hospitals is the high volume of complex cases performed at these institutions, the investigators said.

Ranked hospitals perform an outsized proportion of complex cancer operations in the United States. Nearly half of all gastrointestinal cancer operations—3,052—took place at the 42 ranked hospitals. Nonranked hospitals, which account for 82% of hospitals in the database, carried out 54% of procedures, or 3,608.

Top-ranked hospitals had an average annual case volume for these high-risk conditions four times higher than nonranked hospitals (72 vs. 18 cases).

Dr. Nguyen said he believes that patients do better in ranked hospitals because staff members at these institutions have more experience with detecting and managing serious complications, particularly postoperative anastomotic leaks or pancreatic leaks. They’re more likely to respond quickly and in ways that prevent patients from dying after complications, he said.

Many studies have shown an association between case volume and reduced mortality over the past three decades, especially for complex procedures. This study took a novel approach to examining the volume–outcomes relationship by delving into a hospital ranking system that is widely used by patients and heavily marketed by hospitals.

For 31 years, US News & World Report has published its annual list ranking hospitals across 16 specialties. The report lumps gastroenterology and GI surgery into a single specialty. Last year, the three top-ranked hospitals for gastroenterology and GI surgery were Mayo Clinic, Cedars-Sinai Medical Center and Cleveland Clinic.

Surgeons who were not affiliated with the study said the findings validate US News & World Report’s ranking system.

“This could potentially be very helpful for patients trying to decide where they might consider surgery. In that regard, it’s an important addition to the literature,” said Andrew P. Loehrer, an assistant professor of surgery at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., and Geisel School of Medicine, in Hanover, N.H.

There are limitations to the study. The researchers didn’t look at the specific factors are top-ranked hospitals that are associated with improved outcomes, things like nursing ratios or ICU capacity. If these components were identified, lower-performing hospitals could make changes to improve patient care, Dr. Loehrer noted.

He added that patients consider factors besides operative mortality when deciding where to go for surgery. They weigh variables such as proximity to home and their relationship with the surgical team. In addition, they don’t necessarily have a choice of where they can go, he said.

“There’s much more work to be done understanding how we can better improve the access and quality of care for all folks,” Dr. Loehrer said.

Niraj Gusani, MD, MSc, the chief of surgical oncology at the Baptist MD Anderson Cancer Center in Jacksonville, Fla., said the high volume of surgery done at top-ranked hospitals shows that complex operations have become more concentrated at larger hospitals as the evidence mounted to support a volume–outcomes relationship. That’s good for surgical patients, he said.

“The other key message here is that this is a paper about surgical outcomes but it’s also about cancer, and we need to think about all facets of cancer care,” Dr. Gusani said.