Associations of centralization with health care quality for gastric cancer patients receiving gastrectomy in China

OBJECTIVE: Limited evidence is available regarding the associations of centralization with gastric cancer patients’ quality of care in high surgical volume settings. The current study aimed to explore the effects of hospital volume and the Herfindahl-Hirschman index (HHI) on in-hospital mortality, total cost, and length of stay for Chinese gastrectomy patients in a nationwide database. METHODS: We extracted data on gastrectomy for gastric cancer from the Hospital Quality Monitoring System Database between 2013 and 2018. Hospital volume was divided into 4 quartiles: low (1−83 cases per year), medium (84−238 cases), high (239−579 cases), and very high (580−1,193 cases). The HHI was divided into 3 categories: highly concentrated (>2,500), moderately concentrated (1,500−2,500), and unconcentrated (<1,500). We used mixed-effects models to analyze the data while accounting for data clustering. RESULTS: We analyzed 125,683 patients in 515 institutions. In the multivariable analyses, hospital volume was significantly associated with in-hospital mortality [medium vs. low: odds ratio (OR)=0.61, 95% confidence interval (95% CI)=0.43−0.84, P=0.003; high: OR=0.57, 95% CI=0.38−0.87, P=0.009; and very high: OR=0.33, 95% CI=0.18−0.61, P<0.001) and length of stay (highvs. low: β=−0.036, 95% CI=−0.071−−0.002, P=0.039) but not with total cost. Hospitals located in unconcentrated provinces had higher in-hospital mortality (OR=1.52, 95% CI=1.03−2.26, P=0.036) and longer lengths of stay (β=0.024, 95% CI=0.001−0.047, P=0.041) than hospitals located in highly concentrated provinces. CONCLUSIONS: Centralization of gastrectomy, measured by hospital volume and the HHI, was associated with decreased in-hospital mortality and shortened length of stay without increasing total cost. These results support the strategy of centralizing gastrectomy in high-volume settings.