Complex Surgery Mortality Higher in Affiliated Cancer Centers

Pam Harrison

April 16, 2019

Mortality rates 90 days following complex cancer surgery are significantly higher in network affiliate hospitals than they are in top-ranked cancer centers in the United States, a cross-sectional study indicates.

"Conceptually, the network model has the potential to bring many of the advantages of the top-ranked cancer hospitals closer to patients," lead author Daniel Boffa, MD, Yale School of Medicine, New Haven, Connecticut told Medscape Medical News in an email.

"This is a critical evolution in cancer care because many patients lack the motivation and resources to travel," he added. 

"But we have found through survey studies that a significant proportion of the public assumes that the safety of complex surgery is the same across all hospitals that share the same brand — and patients should stop making this assumption [as] our current study highlights [the fact] that care differences remain within the networks," Boffa stressed. 

The study was published online April 12 in JAMA Network Open.

The investigators used Centers for Medicare & Medicaid Services data (2012-2016) on 17,300 patients, mean age 74.7 years, who underwent complex cancer surgery at 59 of the nation's top-ranked hospitals, and 11,928 patients, mean age 76.2 years, who received the same surgeries at 343 affiliated hospitals.

The team reports that surgery performed at affiliated hospitals was associated with a 40% higher 90-day mortality rate (odds ratio, 1.40; P < .001), with odds ratios ranging from 1.32 (P = .001) for colectomy to 2.04 (P < .001) for gastrectomy.

The researchers also reviewed safety data. When each top-ranked cancer hospital was compared with its collective affiliates, the top-ranked hospital was safer than the affiliates in 41 of 49 studied networks (83.7%).

Patients were over the age of 65 and had a primary diagnosis of lung, colon, pancreas, stomach, or esophageal cancer.

Patients subsequently underwent complex cancer surgeries including pulmonary lobectomy, colectomy, pancreaticoduodenectomy or the so-called "Whipple" procedure, gastrectomy, or esophagectomy.

The top-ranked hospitals included 59 hospitals rated as the best cancer centers in the US by U.S. News and World Report at least once between 2013 and 2016.

The median number of affiliate hospitals for each of the top-ranked centers was 4, but 6 of the top-ranked hospitals had no affiliates, as investigators point out.  

"A key objective of this study was to evaluate a cohort of prominent hospitals recognized by the general public for excellence in cancer care, whose hospital brands have the greatest potential to influence patient choice for care," Boffa and colleagues note.

As the authors point out, these rankings fuel the reputation of major hospitals and are often advertised by the hospital itself as a way to influence a patient's choice of where he or she will seek cancer care.

The team looked at five individual procedures and the only procedure that did not have a statistically significant difference between the top center and its affiliates was esophagectomy.

Table. Odds Ratio of 90-day mortality rates at affiliated hospitals compared with top-ranked cancer centers


Odds Ratio

P value


















Affiliate Hospitals Have Lots of Talent

Standardized Mortality Ratios (SMR) were calculated for 49 out of the 59 top-ranked hospitals along with their collective affiliates.

Compared with the national average, 79.6% of the top-ranked hospitals performed significantly better than expected, with an SMR lower than that for their collective affiliates in 83.7% of the top-ranked hospitals.

When investigators compared the safety of each top-ranked hospital with that of each of its affiliates, they found the top-rated hospitals outperformed 84.5% of their affiliates, although smaller surgical volumes in the affiliate hospitals may have confounded this finding.

Researchers acknowledge that the higher mortality rates observed at the network affiliate hospitals are "not entirely surprising" given that affiliate hospitals are usually smaller, less likely to be teaching hospitals, and less likely to carry out as many complex surgical procedures as do the top-rated hospitals.

Nevertheless, they felt the implications of their findings are vital as it has been reported that the status of a smaller hospital and its affiliation with a "brand name" hospital may lead many patients to believe that the quality of care provided by the affiliate hospital is equivalent to the care provided by top cancer hospitals.

"We absolutely do not feel that all care should be done at the top-ranked hospital," Boffa stressed.

Indeed, affiliate hospitals often have "incredibly talented" surgeons who take excellent care of their patients, he added.

We absolutely do not feel that all care should be done at the top-ranked hospital. Dr Daniel Boffa

However, complex surgery can really stretch a hospital's on-site resources to manage any complications that do arise.

Since the current trend in the US is to increasingly place the financial burden of complications on the hospital itself, "one could envision a model in which the practice of selective referral of particularly complex cases to the top-ranked hospital had balanced fiscal implications," Boffa suggested.

Large Portion of Income

Asked by Medscape Medical News to comment further on the study, Lesly Dossett, MD, from the Department of Surgery at the University of Michigan in Ann Arbor, pointed out that smaller affiliate hospitals probably wouldn't be forfeiting a large portion of their income if they referred patients who require the most complex of cancer surgeries. This is because, in most cases, affiliate hospitals are not doing that many cases of complex cancer surgery in any given year.

Dossett wrote an editorial accompanying the new study. In it, she explained that affiliate networks performed only about 18% of all esophagectomies included in the current analysis and about 25% of all gastrectomies, each of which had the largest gap in surgical mortality rates between the affiliate hospital and the top-rated cancer centers.

Furthermore, Dossett agreed with Boffa that if a patient does develop a complication following a complex operation, he or she is likely to be more costly to that affiliate hospital than the surgical fee may have warranted. This may especially be true as hospitals move to alternative payment models where they will be paid for an episode of care rather than the current individual fee-for-service approach.

Patients could also receive virtually all other aspects of cancer care at the affiliate hospital except for the complex surgery, so most of the care required by a patient with cancer could be reasonably offered by smaller community hospitals.

"I think it comes down to understanding the entire cancer continuum and which components of it really need a tertiary care center and all the specialists and resources patients might need, which are very hard to duplicate in the smaller community hospital," Dossett noted.

"For the growing number of patients with cancer and survivors who rely on multidisciplinary expertise across all phases of the cancer continuum, network affiliation offers great potential for access to the right specialist at the right time," she writes.

Boffa reports receiving nonfinancial support from Epic Sciences. Dossett has disclosed no relevant financial relationships.

JAMA Netw Open. Published online April 12, 2019. Full text, Editorial  

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