Is It Time to Centralize High-risk Cancer Care in the United States? Comparison of Outcomes of Esophagectomy Between England and the United States

Objective: To determine the difference in in-hospital mortality and length of hospital stay (LOS) after esophagectomy between the United States and England. Background: Since 2001, complex procedures such as esophagectomy have been centralized in England, but in the United States no formal plan for centralization exists. Methods: Patients who underwent esophagectomy for cancer between 2005 and 2010 were identified from the Nationwide Inpatient Sample (United States) and the Hospital Episodes Statistics (England). In-hospital mortality and LOS were compared. Results: There were 7433 esophagectomies performed in 66 English hospitals and 5858 resections in 775 US hospitals; median number of resections per center per year was 17.5 in England and 2 in the United States. In-hospital mortality was greater in US hospitals (5.50% vs 4.20%, P=0.001). In multiple regression analysis, predictors of mortality included patient age, comorbidities, hospital volume, and surgery performed in the United States [odds ratio (OR) = 1.20 (1.02-1.41), P = 0.03]. Median LOS was greater in the English hospitals (15 vs 12 days, P < 0.001). However, when subset analysis was done on high-volume centers in both health systems, mortality was significantly better in US hospitals (2.10% vs 3.50%, P = 0.02). LOS was also seen to decrease in the US high-volume centers but not in England. Conclusions: The findings from this international comparison suggest that centralization of high-risk cancer surgery to centers of excellence with a high procedural volume translates into an improved clinical outcome. These findings should be factored into discussions regarding future service configuration of major cancer surgery in the United States.