6 April 2022

Growing push for surgical volume standards

Cancer Clinical Gastrointestinal cancer

Introducing surgical-volume standards for complex procedures could not only increase patient safety and success rates, but also save the health system money – so why are they virtually non-existent in Australia? 

The idea behind high-volume centres is a relatively simple one: the more of a specific type of surgery a specific surgeon or hospital does, the better at it the surgeon or hospital will become. 

Therefore, mandating that certain surgeries be performed only at a handful of centres should theoretically lead to better patient outcomes.  

So far, so good.  

In countries with a small landmass and centralised healthcare system, such as the United Kingdom, this can be executed with some ease. 

But because Australia has a large rural population, and its hospital systems are largely separated by states and territories – not to mention the parallel private hospital system – the logistics of high-volume centres are more complex.  

“This has been an issue that Australia has never really wanted to address at the national level – I think people have just thought it was too hard,” Professor David Watson told Oncology Republic.  

Professor Watson, an Adelaide-based oncologist specialising in oesophageal and upper gastrointestinal surgery, also said that some states have started to address volume standards independently.  

“Queensland has actually addressed this as a state system and has pushed towards procedures being done in a limited number of centres, partly driven by Dr [Jayant] Patel, because a significant number of the patients [who died as a result of his surgeries] had oesophagectomies,” Professor Watson said. 

There have also been natural moves toward higher-volume centres – Professor Watson said most Northern Territory patients who required an oesophagectomy flew down to Adelaide or out to Brisbane for the procedure.  

“In South Australia, I can say from experience that, several years ago, this sort of surgery was done in three public hospitals and four private hospitals,” he said. 

“It’s now basically being done in two public hospitals – but that’s by evolution rather than revolution.” 

This is countered by the fact that because Australia’s population is so dispersed, it’s almost impossible for any single hospital to become a high-volume centre by international standards.  

International standards themselves are somewhat hazy, but the most recent set of targets, in 2015, specify that the minimum number of oesophagus cancer surgeries a hospital must perform to be considered a high- volume centre is 20 a year.  

By that standard, there would be very few Australian hospitals that qualify as high volume – only two would do more than 26 a year, Professor Watson said. 

“We’re dealing with about 600 oesophagectomy procedures in Australia every 12 months, and we’ve got the population of the Netherlands spread over a continent that’s the same size as the United States,” he told OR.  

If Australia were to move towards high-volume care more formally, Professor Watson said, it would be important to take a holistic view of the treating team.  

A recent editorial in the Journal of Clinical Oncology that accompanied an analysis of patient outcomes from German high-volume centres argued that risk-standardised mortality rates were a better metric to assess hospital performance.  

“Strikingly, the risk-standardised mortality-rates-based centralisation model was also associated with lower median travel times for patients – even lower than observed travel times – which is an often-cited barrier to centralised surgical care,” the authors wrote.  

“These findings question the notion of volume-based case minimums as a metric of surgical quality for complex cancer operations.” 

One potential issue with high-volume centres that Professor Watson felt may be behind some of the inconsistencies was the discrepancy between whole-of-hospital volume and individual-surgeon volume.  

“The evidence is probably stronger for hospital volume, rather than surgeon volume, being what counts,” he said.  

“The reason for that is, and this is one of the problems that we saw locally, … is that you can have a higher-volume surgeon who’s operating in three or four different hospitals and doing one or two of these cases a year in each of those hospitals.  

“As a result, the anaesthetist might be experienced and the surgeon might be experienced – but if the nursing staff are not experienced, then you’ve got a potential problem.” 
 
Whatever the issues, Professor Watson said it would probably take time for high-volume centres to become a priority for health departments.  

“When the priority is ambulance ramping and emergency departments, [high-volume centres] never quite get to the top of the pile,” he said.  

Journal of Clinical Oncology 2022, online 24 January