Division of Abdominal Transplantation, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
Division of Surgical Oncology, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
Department of Medicine, Baylor College of Medicine, Houston, TX.
VA HSR &D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX.
Department of Abdominal Transplantation, Lahey Hospital & Medical Clinic, Boston, MA.
Department of Surgery, University of Pittsburgh and VA Pittsburgh Healthcare System, Pittsburgh, PA.
BACKGROUND AND RATIONALE:
Multidisciplinary hepatocellular carcinoma (HCC) treatment is associated with optimal outcomes. There is little data analyzing the impact of treating hospitals' therapeutic offerings on survival. We performed a retrospective cohort study of patients aged 18-70 years with HCC in the National Cancer Database (2004-2012). Hospitals were categorized based on the level of treatment offered (Type I-non-surgical; Type II-ablation; Type III-resection; Type IV-transplant). Associations between overall risk of death and hospital type were evaluated with multivariable Cox shared frailty modeling.
Among 50,381 patients, 65% received care in Type IV hospitals, 26% in Type III, 3% in Type II, and 6% in Type I. Overall 5-year survival across modalities was highest at Type IV hospitals (untreated: Type IV - 13.1% versus Type I-5.7%, Type II-7.0%, Type III-7.4% [log-rank, p<0.001]; chemotherapy and/or radiation: Type IV-18.1% versus Type I-3.6%, Type II-4.6%, Type III-7.7% [log-rank, p<0.001]; ablation: Type IV-33.3%; versus Type II-13.6%, Type III-23.6%, [log-rank, p<0.001]; resection: Type IV-48.4% versus Type III-39.1%, [log-rank, p<0.001]). Risk of death demonstrated a dose-response relationship with the hospital type-Type I (ref); Type II (Hazard Ratio [HR] 0.81, 95% Confidence Interval [0.73-0.90]); Type III (HR 0.67 [0.62-0.72]); Type IV hospitals (HR 0.43 [0.39-0.47]).
Although care at hospitals offering the full complement of HCC treatments is associated with decreased risk of death, one-third of patients are not treated at these hospitals. These data can inform the value of health policy initiatives regarding regionalization of HCC care.