Association of Hospital Flagship System Affiliation on Surgical Outcomes Following Complex Cancer Surgery
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Background: We evaluated variations in patient outcomes and financial expenditures following complex cancer surgery across flagship hospitals and their affiliates. Methods: Using Medicare 100% Standard Analytic Files (2018–2021), we identified patients undergoing resection of lung, esophageal, gastric, hepatopancreatobiliary, or colorectal cancer. Flagship hospitals were defined as the highest-volume major teaching hospital within a system in each region. Propensity score matching was performed to create a 1:1 matched cohort to assess the association between flagship systems, hospitals, affiliates, and outcomes. Results: Among 110,670 patients, 55,335 treated within a flagship hospital system (median age, 73 years [IQR, 69–79]; including 29,381 [53.1%] women) were matched with 55,335 patients who were not (median age, 73 years [IQR, 69–79]; including 29,274 [52.9%] women) across 35 regions. Patients at flagship system hospitals had lower 30-day mortality rates than matched controls (4.23% vs 4.88%; difference, −0.65% [95% CI, −0.89% to −0.40%]; P<.001). Mortality was also lower at flagship hospitals (2.76% vs 3.82%; difference, −1.06% [95% CI, −1.62% to −0.50%]) and flagship affiliates (4.46% vs 4.79%; difference, −0.32% [95% CI, −0.58 to −0.07]) compared with controls (both P<.001). However, patients who underwent cancer surgery at flagship hospital systems had higher expenditures ($21,011 vs $20,016; difference, +$995 [95% CI, $797 to $1,193]; P<.001). Conclusions: Flagship hospitals are the primary drivers of decreased postoperative mortality following complex oncologic surgical procedures performed within their systems, although expenditures were higher compared with unaffiliated hospitals.
Submitted May 17, 2024; final revision received November 21, 2024; accepted for publication December 9, 2024.
Author contributions: Conception: All authors. Design: All authors. Analysis: Munir, Woldesenbet. Writing—original draft: Khan, Dillhoff, Tsai, Pawlik. Writing—review & editing: All authors.
Data availability statement: The data for this study were obtained from the Medicare Standard Analytic Files. There are restrictions to the availability of this data, which is used under license for this study. Data can be accessed with permission from the Centers for Medicare & Medicaid Services.
Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.
Supplementary material: Supplementary material associated with this article is available online at https://doi.org/10.6004/jnccn.2024.7096. The supplementary material has been supplied by the author(s) and appears in its originally submitted form. It has not been edited or vetted by JNCCN. All contents and opinions are solely those of the author. Any comments or questions related to the supplementary materials should be directed to the corresponding author.
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