Quality Over Volume: Modeling Centralization of Gastric Cancer Resections in Italy

BACKGROUND: The correlation between hospital volume and postoperative outcomes has led to the centralization of complex procedures in several countries. However, the results reported in relation to gastric cancer (GC) are contradictory. This study aimed to analyze GC surgical volumes and 30-day postoperative mortality in Italy and to provide a simulation for modeling centralization of GC resections based on district case volumes. METHODS: A national registry was used to identify all GC resections, record mortality rates, and track the national in-border GC resection health travel. Hospitals were grouped according to caseload. Centralization of all GC procedures performed within the same district was modeled. The outcome measures were a minimal volume of 25 GC resections/year and the 30-day postoperative mortality. RESULTS: In 2018, 5,873 GC resections were performed in 498 Italian hospitals (mean resections per hospital per year: 11.8); the postoperative mortality rate (5.51%) was tracked from 2016–2018. GC resection health travel ranged from 2% to 50.5%, with a significant (P<0.001) difference between northern and central/southern Italy. The mean mortality rate was 7.7% in hospitals performing one to 3 GC resections per year, compared with 4.7% in those with >17 GC resections/year (P≤0.01). Most Italian districts achieved 25 procedures/year after centralization; however, 66.3% of GC cases in southern Italy vs. 42.2% in central and 52.7% in the northern regions (P<0.001) required reallocation. CONCLUSION: Postoperative mortality after GC resection correlated with hospital volume. Despite health travel, most Italian districts can reach a high-volume threshold, but discrepancies in mortality rates are alarming. Trial Registration RESEARCH REGISTRY IDENTIFIER: researchregistry6869