Central Surgical Association| Volume 160, ISSUE 4, P839-849, October 2016

Characterizing the role of a high-volume cancer resection ecosystem on low-volume, high-quality surgical care

Published:August 11, 2016DOI:


      Our objective was to determine the hospital resources required for low-volume, high-quality care at high-volume cancer resection centers.


      Patients who underwent esophageal, pancreatic, and rectal resection for malignancy were identified using Healthcare Cost and Utilization Project State Inpatient Database (Florida and California) between 2007 and 2011. Annual case volume by procedure was used to identify high- and low-volume centers. Hospital data were obtained from the American Hospital Association Annual Survey Database. Procedure risk-adjusted mortality was calculated for each hospital using multilevel, mixed-effects models.


      A total of 24,784 patients from 302 hospitals met the inclusion criteria. Of these, 13 hospitals were classified as having a high-volume, oncologic resection ecosystem by being a high-volume hospital for ≥2 studied procedures. A total of 11 of 31 studied hospital factors were strongly associated with hospitals that performed a high volume of cancer resections and were used to develop the High Volume Ecosystem for Oncologic Resections (HIVE-OR) score. At low-volume centers, increasing HIVE-OR score resulted in decreased mortality for rectal cancer resection (P = .038). HIVE-OR was not related to risk-adjusted mortality for esophagectomy (P = .421) or pancreatectomy (P = .413) at low-volume centers.


      Our study found that in some settings, low-volume, high-quality cancer surgical care can be explained by having a high-volume ecosystem.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Luft H.S.
        • Bunker J.P.
        • Enthoven A.C.
        Should operations be regionalized? The empirical relation between surgical volume and mortality.
        N Engl J Med. 1979; 301: 1364-1369
        • Birkmeyer J.D.
        • Siewers A.E.
        • Finlayson E.V.
        • Stukel T.A.
        • Lucas F.L.
        • Batista I.
        • et al.
        Hospital volume and surgical mortality in the United States.
        N Engl J Med. 2002; 346: 1128-1137
        • Karthikesalingam A.
        • Hinchliffe R.J.
        • Loftus I.M.
        • Thompson M.M.
        • Holt P.J.
        Volume-outcome relationships in vascular surgery: the current status.
        J Endovasc Ther. 2010; 17: 356-365
        • Faiz O.
        • Brown T.
        • Bottle A.
        • Burns E.M.
        • Darzi A.W.
        • Aylin P.
        Impact of hospital institutional volume on postoperative mortality after major emergency colorectal surgery in English National Health Service trusts, 2001 to 2005.
        Dis Colon Rectum. 2010; 53: 393-401
        • Finlayson E.V.
        • Goodney P.P.
        • Birkmeyer J.D.
        Hospital volume and operative mortality in cancer surgery: a national study.
        Arch Surg. 2003; 138: 721-725
        • Katz J.N.
        • Barrett J.
        • Mahomed N.N.
        • Baron J.A.
        • Wright R.J.
        • Losina E.
        Association between hospital and surgeon procedure volume and the outcomes of total knee replacement.
        J Bone Joint Surg Am. 2004; 86-A: 1909-1916
        • Wouters M.W.
        • Gooiker G.A.
        • van Sandick J.W.
        • Tollenaar R.A.
        The volume-outcome relation in the surgical treatment of esophageal cancer.
        Cancer. 2012; 118: 1754-1763
        • Wong S.L.
        • Revels S.L.
        • Yin H.
        • Stewart A.K.
        • McVeigh A.
        • Banerjee M.
        • et al.
        Variation in hospital mortality rates with inpatient cancer surgery.
        Ann Surg. 2015; 261: 632-636
        • Luft H.S.
        • Hunt S.S.
        • Maerki S.C.
        The volume-outcome relationship: practice-makes-perfect or selective-referral patterns?.
        Health Serv Res. 1987; 22: 157-182
        • Funk L.M.
        • Gawande A.A.
        • Semel M.E.
        • Lipsitz S.R.
        • Berry W.R.
        • Zinner M.J.
        • et al.
        Esophagectomy outcomes at low-volume hospitals: the association between systems characteristics and mortality.
        Ann Surg. 2011; 253: 912-917
        • Wakeam E.
        • Hevelone N.D.
        • Maine R.
        • Swain J.
        • Lipsitz S.A.
        • Finlayson S.R.
        • et al.
        Failure to rescue in safety-net hospitals: availability of hospital resources and differences in performance.
        JAMA Surg. 2014; 149: 229-235
        • McCrum M.L.
        • Lipsitz S.R.
        • Berry W.R.
        • Jha A.K.
        • Gawande A.A.
        Beyond volume: does hospital complexity matter?: an analysis of inpatient surgical mortality in the United States.
        Med Care. 2014; 52: 235-242
        • Urbach D.R.
        Pledging to eliminate low-volume surgery.
        N Engl J Med. 2015; 373: 1388-1390
        • Bartunek J.M.
        • Murninghan J.K.
        The nominal group technique: expanding the basic procedure and underlying assumptions.
        Group Organ Manage. 1984; 9: 417-432
        • Mack M.
        Balancing optimal outcomes with access to care: it can be done!.
        JACC Cardiovasc Interv. 2015; 8: 1952-1953
        • Billingsley K.G.
        • Morris A.M.
        • Dominitz J.A.
        • Matthews B.
        • Dobie S.
        • Barlow W.
        • et al.
        Surgeon and hospital characteristics as predictors of major adverse outcomes following colon cancer surgery: understanding the volume-outcome relationship.
        Arch Surg. 2007; 142: 23-31
        • Johnston M.J.
        • Arora S.
        • King D.
        • Bouras G.
        • Almoudaris A.M.
        • Davis R.
        • et al.
        A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery.
        Surgery. 2015; 157: 752-763
        • Joseph B.
        • Morton J.M.
        • Hernandez-Boussard T.
        • Rubinfeld I.
        • Faraj C.
        • Velanovich V.
        Relationship between hospital volume, system clinical resources, and mortality in pancreatic resection.
        J Am Coll Surg. 2009; 208: 520-527
        • Jha A.K.
        Back to the future: volume as a quality metric.
        JAMA. 2015; 314: 214-215
        • Birkmeyer J.D.
        • Finlayson E.V.
        • Birkmeyer C.M.
        Volume standards for high-risk surgical procedures: potential benefits of the leapfrog initiative.
        Surgery. 2001; 130: 415-422
        • Finlayson S.R.
        • Birkmeyer J.D.
        • Tosteson A.N.
        • Nease Jr., R.F.
        Patient preferences for location of care: implications for regionalization.
        Med Care. 1999; : 204-209
        • Livingston E.H.
        • Burchell I.
        Reduced access to care resulting from centers of excellence initiatives in bariatric surgery.
        Arch Surg. 2010; 145: 993-997
        • Chhabra K.R.
        • Dimick J.B.
        Hospital networks and value-based payment: fertile ground for regionalizing high-risk surgery.
        JAMA. 2015; 314: 1335-1336
        • Schrag D.
        • Panageas K.S.
        • Riedel E.
        • Cramer L.D.
        • Guillem J.G.
        • Bach P.B.
        • et al.
        Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection.
        Ann Surg. 2002; 236: 583-592
        • Simunovic M.
        • To T.
        • Baxter N.
        • Balshem A.
        • Ross E.
        • Cohen Z.
        • et al.
        Hospital procedure volume and teaching status do not influence treatment and outcome measures of rectal cancer surgery in a large general population.
        J Gastrointest Surg. 2000; 4: 324-330
        • Grimes D.A.
        Epidemiologic research with administrative databases: red herrings, false alarms and pseudo-epidemics.
        Hum Reprod. 2015; 30: 1749-1752
        • Haut E.R.
        • Pronovost P.J.
        • Schneider E.B.
        Limitations of administrative databases.
        JAMA. 2012; 307: 2589-2590