1. The Relationship of Surgeon and Hospital Volume with Long-Term Survival For Women with Breast Cancer Patrick J. Roohan New York State Department of Health June 28, 2005 Work conducted under a grant from the New York Community Trust

2. Volume/Outcomes Studies Began in 1979, with work conducted by Harold Luft on the relationship between surgeon volume and mortality Ethan Halm et al. 2002, published “Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature”

3. 1998 New York State Breast Cancer Surgery Study Used linked cancer registry data and inpatient hospital data Comprised of 47,890 women diagnosed with breast cancer between 1984-1989 Analyzed the effect of hospital volume on 5 year survival

4. Breast Cancer Surgery Volume Outcome Studies Other studies include: Sainsbury, 1995 – surgeon effect Morrow, 2000 – hospital effect Skinner, 2003 – surgeon and hospital effect Harcourt, 2003 – no volume effect Mikeljevic, 2003 – surgeon effect

5. Study Objectives To update 1998 study with more current information Include analysis of both surgeon and hospital volume Include outpatient hospital surgery cases

6. Methods All cancer registry cases with a diagnosis of breast cancer from 1995- 1998 were matched to both inpatient and outpatient breast cancer surgeries Due to limitations in the outpatient data, only the years 1997-1998 were used in the inpatient/outpatient analysis

7. Methods Two studies emerged: A five-year survival analysis of inpatient breast surgeries for the years 1995-1998 A three-year survival analysis of outpatient and inpatient breast surgeries for the years 1997-1998

8. Methods Survival is risk-adjusted by the following factors: Demographic factors (Age, Race/Ethnicity, Type of Insurance, Socioeconomic Status) Clinical factors (Type of Surgery, Excision of Axillary Nodes or not, Comorbidity Index, Stage of Cancer) Volume factors (Annual Surgeon Volume, Annual Hospital Volume)

9. Breast Cancer Survival by Surgeon Volume Inpatient Data 1995-1998

10. Breast Cancer Survival by Surgeon Volume Inpatient/Outpatient Data 1997-1998

11. Discussion Similar to 5 of the 6 other studies presented, both the inpatient study and combined outpatient/inpatient studies show a volume effect on survival In both studies surgeon volume is related to long term survival, hospital volume is not

12. Discussion Why do we see this effect when in- hospital mortality is negligible for breast cancer surgery? “Practice makes perfect” High volume surgeons more likely to work in larger, more comprehensive facilities Surgical skill (Skinner, 2003)

13. Strengths of the Study All hospitals in NY included in the study Large samples -- 25,000 and 17,000 Effects of demographic factors and clinical factors are all consistent with confirmed previously known relationships Outpatient data included in the 3 year survival study

14. Limitations SPARCS outpatient data is incomplete Cancer Registry does not capture chemotherapy or radiation information Cancer Registry death information is complete only through 2001

15. Conclusions / Next Steps There is a need to: Continue to investigate the effect of volume on survival Improve data accuracy and timeliness Women with breast cancer should: Discuss treatment options with their physician Inquire about their expertise in breast surgery Consult with consumer organizations that can assist women in decision making