CURE

SUMMER / 2013

Check Please: Choosing the Best Hospital for Your Cancer Surgery

Doing hospital homework can pay off.

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For nine months before Tom Murphy was rolled into the operating room for removal of a suspicious nodule on his lung, the 58-year-old management consultant vetted available surgical resources. His research involved surfing hospital websites, studying rankings and becoming involved with online cancer forums.

Because Murphy was a former smoker with other risk factors (including exposure to Agent Orange and radon gas), he had been undergoing computed tomography scans since his mid-50s. The suspicious nodule was identified by a scan in early 2010.

During subsequent months, as Murphy returned for additional scans that pointed to (but didn’t confirm) cancer, he realized that surgery was increasingly likely. That's when he began researching hospitals where he could receive the best surgical outcome with minimal post-surgical complications. His research focused on high-profile facilities, such as The Johns Hopkins Hospital in Baltimore, MD Anderson Cancer Center in Houston and Moffitt Cancer Center in Tampa, Fla., as well as hospitals closer to his home in central Maryland.

The investigation became a part-time job, one that wouldn’t have been feasible if he hadn’t been self-employed, he says.

"It was kind of like a shotgun [approach]," Murphy says. "Some of the sites I hit were helpful, and some weren't. I would have loved to have gone to a site that I felt gave me objective assessments."

A Work in Progress

While many healthcare professionals benefit from insider knowledge of high-quality facilities and providers, patients facing cancer surgery have relatively few resources beyond marketing materials and their doctor’s recommendation.

"It's always bothered me—how does the average cancer patient find the right place to go?" asks Daniel McKellar, a clinical professor of surgery at Wright State University in Dayton, Ohio. "There needs to be more available data."

Providing public access to treatment outcomes in an accurate and understandable way is improving, but it’s a work in progress, according to McKellar.

How does the average cancer patient find the right place to go?  There needs to be more available data.

—Daniel McKellar

In recent years, federal officials began publishing some hospital readmission and infection rates, as well as other treatment barometers, on Medicare's Hospital Compare website (medicare.gov/hospitalcompare). The bulk of the findings, particularly for outcomes like death rates, are restricted to heart-related issues and pneumonia. But some of the information is more relevant to cancer patients, such as post-surgical infections and the frequency with which surgical procedures are being followed, such as removing a patient's urinary catheter within two days after surgery.

The data "are all worth something," says Peter B. Bach, an epidemiologist who directs the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center in New York City. "I think the mistake would be to assume that they tell you a great deal about the quality of care in that hospital."

Where surgical data isn't available, patients should ask very specific questions to gain a better sense of a facility's expertise, says John Sweeney, chief of the division of general and gastrointestinal surgery at Emory University School of Medicine in Atlanta. He recommends patients ask about the number of similar procedures the surgeon has performed, as well as how many similar procedures have been done at that particular facility. Also of interest, the hospital's readmission rate and the hospital’s complication rates. "Those are fair things to ask," Sweeney says.

Details in the Data

Unlike Murphy, many patients who have just received a cancer diagnosis aren't likely to launch cross-country searches, preferring instead to get their treatment close to home and to follow the recommendation of a trusted doctor, McKellar says.

But those who want to dig further can become quickly flummoxed. A writer in suburban Philadelphia recently posted her frustration about a family member’s possible stomach cancer diagnosis and treatment options on an online forum. "It's not like you can Google 'best cancer hospital' and expect to get unbiased results," she wrote, asking for strategies to locate the best facility for treating stomach cancer.

When Tom Murphy learned he would have surgery to treat his lung cancer, he began researching hospitals where he could receive the best care. Photo by Colby Ware.

One good way to start is by searching for a hospital that's accredited by an external organization, such as the National Cancer Institute, says John Birkmeyer, who teaches surgery and directs the Center for Healthcare Outcomes and Policy at the University of Michigan in Ann Arbor, Mich. The Commission on Cancer, created by the American College of Surgeons, also has an accreditation process. The more than 1,500 accredited cancer facilities make up 30 percent of all U.S. hospitals but care for about 70 percent of cancer patients, according to McKellar, who chairs the commission.

External or independent hospital rankings can also provide partial insight into a facility, reflecting some insider perspective, Birkmeyer says.

He points out that about a third of the total scores calculated by U.S. News & World Report incorporate rankings by physicians and an additional third is based on Medicare's mortality data. The remaining 30 percent incorporate the use of technology, the level of nurse staffing and other elements associated with improved care, with 5 percent of the scores given to patient safety scores. "There’s no doubt that if you had no other information at your disposal, picking a hospital that was on the U.S. News Honor Roll would be much better than picking one that wasn't," Birkmeyer says.

In Medicare's Hospital Compare, some of the first efforts are being made to publish death rates and hospital readmissions for a short list of conditions, such as heart failure, heart attack and pneumonia. It's still unclear whether publishing those numbers will spur improvement. One study published last year in the journal Health Affairs found little to no post-publication change in death rates for heart failures or the other two reportable conditions. 

Sweeney says, however, that for individual patients, readmission data is highly relevant. Take someone who's grappled first with a scary cancer diagnosis and then weathers a related surgery. "You think you’re just getting over that hurdle, and you get discharged from the hospital, and then you have to come back 10 days later," he says.

Even without surgery-related data, hospital readmission figures can be illuminating, particularly if there are notable trends. Sweeney co-authored a 2012 study, published in the Journal of the American College of Surgeons, which found that gastrointestinal problems and surgical infections accounted for half of all patient readmissions within 30 days after discharge.

Sweeney advises patients to check several years of readmission figures rather than a single year's snapshot. "The important thing is, are they moving the dial?" he asks. "If they're not getting better, I would be worried about that. That means that the institution doesn’t have the organizational structure to deal with the problem."

Asking the Right Questions

When examining any comparative hospital information, patients should verify that the data have been risk-adjusted, to reflect the severity of the cases treated there, Sweeney says. Otherwise, a cancer facility could stack up more poorly, simply because it operates on more complex cases and patients who are more ill.

Still, Birkmeyer points out that, in some cases, a single number can provide a quick, albeit incomplete, window into surgical expertise. He has published a series of studies that show—in the absence of other outcomes data—the number of surgeries performed can be linked to better patient results.

As a general rule, patients should look for both the higher-volume hospital as well as the higher-volume surgeon for the specific procedure in question at a facility, Birkmeyer says. Research shows that the benefits are greatest, including postoperative mortality rates for complex surgeries, such as those for the esophagus, liver and the pancreas, he says.

To a lesser extent, surgical volume also matters for other cancers, such as of the bladder and stomach. And for some other cancers, such as colon, the study results are more mixed and less conclusive, he says.

Regardless, the question is one worth asking, Birkmeyer says. "How readily patients are likely to get that information is probably going to vary widely," he says, adding: "If hospitals or surgeons are unable or unwilling to share that information—that should serve as a red flag."

If hospitals or surgeons are unwilling or unable to share that information—that should serve as a red flag.

—John Birkmeyer

Neither should surgical experience be assumed. A study published in 2009 in The Journal of Urology found that 26.9 percent of surgeons had performed just one radical prostatectomy in the year studied, and about two-thirds had performed five or fewer. Thus, they weren't operating frequently enough to acquire the cumulative expertise needed to achieve the best results in terms of cancer control, according to the researchers.

A more recent analysis, involving more than 13,000 women with ovarian cancer in California, found that 16.4 percent of operations were performed by surgeons classified as high volume, with 10 or more cases annually. Those surgeons were significantly more likely to follow National Comprehensive Cancer Network treatment guidelines than low-volume surgeons—47.6 percent versus 34.5 percent—according to the findings, which were presented in March at the annual meeting of the Society of Gynecologic Oncology. Patients who received treatment complying with guidelines were more likely to live at least five years.

Informal Feedback

Comparing notes with others in the same situation can also be helpful. While Murphy conducted his research, he ended up on online cancer forums, where he obtained a lot of in-the-trenches information. "People talk about their experiences, what they chose, what they opted for and where they [went]," says Danielle Leach, director of partnerships at Inspire.com, a company that builds and manages online communities, which Murphy checked out. "They'll say, 'I went to Johns Hopkins, or I went to MD Anderson, and this is what they are telling me that I need to do.'"

This "pseudo crowdsourcing," as Bach dubs it, makes the Sloan-Kettering physician a bit edgy. It works "reasonably well," he says. But just as with travel or restaurant sites, such forums can highlight the extremes, he adds. "You tend to voice your opinions when they're strongly felt. You end up with a non-average look into things."

Murphy, who eventually settled on The Johns Hopkins Hospital, asked the surgeon how many minimally invasive procedures he had performed and about the hospital's expertise.

Murphy has been cancer-free since his 1.3 centimeter cancerous tumor was removed in September 2010.

"I remember telling myself before I went under [anesthesia] that I was in good hands," he recalls. "I was at peace with God. My family was taken care of. And there was nothing I could do to make the outcome of this any better than it was."

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