Spontaneous regionalization of esophageal cancer surgery: an analysis of the National Cancer Database

Background: Esophagectomy patients are up to three times more likely to die after surgery when cared for at low-volume hospitals (LVHs). Increased awareness by patients and clinicians of the hazards of esophagectomy at LVHs, may inspire a “spontaneous regionalization” away from LVHs, yet the extent to which this has taken place is unclear. Methods: Retrospective analysis of patients undergoing esophagectomy for esophageal cancer in the National Cancer Database (NCDB) across two eras: 2004–2006 (Era 1) and 2010–2012 (Era 2). Primary outcomes included the proportion of patients at high-volume hospitals (HVHs) (≥13/year per Leapfrog Group), adjusted, and unadjusted 90-day mortality. Results: The NCDB captured 5,968 esophagectomy patients in Era 1 and 5,580 in Era 2, a 6.5% decrease (P vs . 663, P=0.014), yet the proportion of patients treated at LVHs declined slightly between eras (73% vs . 70%, P Conclusions: Spontaneous regionalization of esophageal cancer surgery has not occurred on a large scale, yet for high-risk patients, the hazards of being cared for at LVHs have dissipated. Further study is needed to optimize alignment of esophagectomy patients and hospitals.