Grand Rounds

Are Ovarian Cancer Outcomes Better at High Volume Centers?

PURPOSE:

When assessing ovarian cancer survival, both hospital and physician procedural volume are associated with improved outcomes
Following recommended guidelines is also associated with improved outcomes
The purpose of this study by Wright et al. (Obstetrics & Gynecology, 2017) was to determine the relative importance of hospital volume compared to complying with standards and guidelines

Retrospective cohort study using the National Cancer Database
Invasive epithelial ovarian cancer diagnosed from 2004 to 2013
Annualized hospital volume based total number of patients divided by the years in which a given hospital treated at least one patient
Volume definitions (annual)
- High-volume hospital: 20 cases or greater
- High- to intermediate-volume hospital: 9.01–19.9 cases
- Intermediate-volume hospital: 5.01–9 cases
- Intermediate-low hospital: 2.01–5 cases
- Low-volume hospital: ≤ 2 cases
Primary outcome of the analysis was overall survival at 2 and 5 years

100,725 patients treated at 1,268 hospitals were identified
Compliance with the composite, overall quality metric was noted in 64.2% (SD 24.5%) of low-volume centers and increased with each volume category to 82.2% (SD 7.7%) at the highest volume hospitals
Two-year adjusted survival rose sequentially from 64.4% (95% CI 62.5–66.4%) at low-volume hospitals to 77.4% (95% CI 77.0–77.8%) at high-volume hospitals (P<.001)
Two-year adjusted survival rose sequentially from 66.5% (95% CI 65.5–67.5%) at low-quality hospitals to 77.3% (95% CI 76.8–77.7%) at high-quality hospitals (P<.001)
Similar findings (survival increased with volume and adherence to standards) were observed for 5-year rates
When controlling for each hospital volume category, survival increased with increasing quality
- Adjusted 2-year survival was 61.4% (95% CI 58.4–64.5%) at hospitals with the lowest adherence to quality metrics and rose to 65.8% (95% CI 61.2–70.8%) at the hospitals with highest adherence to the quality metrics (P<.001)
- Lower volume hospitals with higher quality scores still had survival that was lower than higher volume hospitals

Best outcomes were still seen at high-volume hospitals and therefore referral to these centers for ovarian cancer care is reasonable
However, for practical reasons, low-volume hospitals may still serve an important role and targeting quality improvement and adherence to standards may improve outcomes

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