Surviving ovarian cancer: Is there an association between hospital volume and quality of care?

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:

1. patients prefer to receive local care and are often unwilling to or cannot travel
2. regionalization can worsen inequalities in access to care and may adversely affect low-volume hospitals
3. 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

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