Keywords
regionalization - centralization - access to care - colorectal surgery - rural surgery
The dominant trend in U.S. health care today is hospital consolidation into ever-expanding
hospital networks. How this changing landscape will impact cancer outcomes remains
to be seen. These emerging hospital networks present a unique opportunity for broader
regionalization of cancer care. For example, there is potential to enhance care coordination,
reduce fragmentation, and optimize the site of care for best surgical and oncologic
outcomes. In this narrative review, we seek to define key concepts informing regionalization
and potential strategies, such as centralization, as they relate to colon cancer.
We explore the advantages and disadvantages of centralizing colon cancer care within
the context of contemporary scientific evidence. Finally, we describe other strategies
that may be employed to balance quality, access, and patient-centered approaches to
optimizing colon cancer care delivery across regional hospital networks.
What Is Regionalization?
Regionalization of health care involves organizing networks of structures, resources,
and practitioners to serve a defined geographic area. The goal is to provide cost-effective,
high-quality care to all individuals within this area. Countries such as England,
Canada, and Brazil have established nationwide regionalized health care systems.[1] In contrast, regionalization in the United States has been limited due to the fee-for-service
market-based system. Examples of regionalized health care systems in the United States
have been limited to acute care for conditions such as trauma, burn, stroke, and acute
coronary syndrome, and for neonates requiring intensive care.[2] Unlike the comprehensive national systems in other countries that have established
structures to coordinate care delivery, the current U.S. regionalized systems rely
on interhospital agreements for standards of care, data collection, and resource coordination.[2]
Over the past two decades, U.S. hospitals have increasingly merged into multihospital
networks, offering a critical opportunity for further regionalization within existing
health care structures. Hospital consolidation (represented by mergers and acquisitions)
has primarily been driven by economic factors, rather than clinical motivations,[3]
[4] for example, increasing bargaining power to negotiate with payers and boosting referrals
from broader catchment areas to increase revenue.[5]
[6] Costs are also reduced through shared infrastructure (e.g., billing) and by shifting
patients toward facilities with excess capacity. Further, by having a diverse portfolio
of hospitals, hospital networks are buffered against shifting policy landscapes.[7]
[8] Although marketed as improving care quality, the impact of hospital consolidation
on patient outcomes has been inconsistent.[9]
[10]
[11] For example, disease-specific outcomes, including colon cancer, vary widely among
hospitals within a single system.[11]
[12]
[13]
[14]
Many regional models use a hub-and-spoke design, with a central hub (often an academic
medical center) and smaller spoke hospitals (typically community hospitals). This
model often leverages centralization to concentrate expertise, resources, and patients at the hub hospital where more
complex care is delivered.[1] Centralization should be distinguished from regionalization: centralization represents
one strategy that may be employed by health networks to deliver regionalized care.
In contrast, regionalization may encompass any combination of many potential strategies
to coordinate care for patients living within the captured region. Centralization
is beneficial for complex or rare conditions. For colon cancer, which is the third
most common cancer affecting 1 in 24 U.S. adults, the question becomes whether centralization
remains advantageous or whether other regionalization strategies may provide greater
benefit.
The “Good” of Centralization for Colon Cancer Surgery
The “Good” of Centralization for Colon Cancer Surgery
By leveraging the volume–outcome relationship, centralization of complex cancer surgery
has been shown to reduce perioperative mortality and improve long-term outcomes for
complex cancers such as rectal, esophageal, and pancreatic cancer. Hospital ranking
bodies like The Leapfrog Group have established volume standards for hospitals performing
high-risk cancer operations (e.g., proctectomy, esophagectomy, and pancreatectomy),
but no benchmarks exist for common operations like segmental colectomy for colon cancer.
Studies indicate that stage-for-stage colon cancer survival is higher at high-ranking
cancer hospitals as compared with their brand-sharing affiliates.[12]
[13]
[14] However, most colon cancer surgeries are currently performed at lower-volume spoke
hospitals.[12]
[15] Thus, centralizing colon cancer surgery may offer several advantages, including
better perioperative outcomes, improved coordination of multidisciplinary care, and
more efficient use of resources ([Fig. 1]).
Fig. 1 Goods and bads of centralizing colon cancer care to a hub hospital. For many cancer
types, benchmarking organizations suggest that operative resection should only be
performed in a high-volume hospital. In the era of regionalized health care via hospital
networks, there are both advantages (goods) and disadvantages (bads) to centralizing
colon cancer care, given the surgical volume and complication profile.
Improved perioperative outcomes. High-volume hospitals may achieve better surgical outcomes by honing operative techniques,
decision-making, and perioperative care. For example, centralizing ovarian cancer
treatment in France increased complete tumor resection by 15 percentage points. Notably,
the largest relative benefit was in the decision-making to pursue neoadjuvant therapy
rather than a surgery-first approach.[16] Similarly, higher surgical volumes correlate with lower failure-to-rescue rates
after postoperative complications, suggesting that high-volume hospitals may have
more resources to recognize and address postoperative complications than low-volume
counterparts.[17] Notably, these findings have been modest and inconsistent for colon cancer operations.[18]
[19]
[20]
Enhanced multidisciplinary care coordination. Effective colon cancer care requires coordination among multiple specialists, including
surgeons, oncologists, radiologists, pathologists, and others. As readers can anecdotally
attest, centralizing care facilitates this coordination as it is easier to coordinate
complex care among co-located specialists with efficient communication streams via
shared electronic health records (EHRs). For colon cancer, this may mean that biopsy
specimens can undergo pathologic review on-site, appropriate testing (e.g., mismatch
repair protein status) can be performed immediately, and unnecessary time is not spent
requesting or re-reviewing external imaging. Despite these anecdotal experiences,
it remains unclear whether care in a cancer center decreases (or in fact increases)
the time to treatment.
Concentrated resources for cost efficiency. Centralization can theoretically reduce costs through site specialization, by concentrating
costly technology and expertise in one location, rather than paying the costs to supply
these for every hospital.[21] Thus, efficient care delivery should, theoretically, cost less. However, centralization
can also create monopolized markets, which has been shown to increase the cost of
care.[22] Additionally, these increased costs may shift to patients who must travel to centralized
locations.[21]
The “Bad” of Centralization for Colon Cancer Surgery
The “Bad” of Centralization for Colon Cancer Surgery
Despite the potential benefits, contemporary evidence supporting centralization for
colon cancer operations has been mixed.[22]
[23]
[24]
[25] For example, no association has been found between the degree of centralization
within existing hospital networks and morbidity, mortality, or readmission rates after
colectomy for colon cancer.[23] Further, centralization assumes patients can and will travel for care and that high-volume
hospitals have the capacity to accommodate care for the additional patients to be
transferred in a timely manner. Addressing these challenges is critical to ensure
regionalization strategies deliver on their intent without violating patient preference,
exacerbating inequities, or delaying care ([Fig. 1]).
Patient preference and barriers to travel. Policies misaligned with patient preferences will be less effective. For example,
only about half of surveyed patients were willing to travel hours for care at a high-volume
center, even when presented with higher long-term survival rates. Prior studies have
corroborated these findings reporting nearly 1 in 10 patients who would choose a local
hospital with higher surgical mortality rates.[26]
[27] Barriers such as travel or accommodations may be addressable, but comorbid health
conditions and other nonmitigatable factors also play a role.[26] A balanced assessment including the patient perspectives of centralized colon cancer
care is necessary to guide organizational strategy among regionalized hospital networks.
Exacerbating inequities. Centralization may worsen existing inequities if some patients can travel for care,
while others cannot due to limited transportation, financial resources, social support,
or other barriers. Lower-income or nonwhite race patients are less likely to travel
for surgery at a specialty cancer center.[28] Further, specialized centers, often in urban or suburban areas, limit access for
rural patients. When patients receive their colon cancer operation far from home,
the geographic separation can also complicate postoperative coordination between the
specialized center and outpatient providers, leading to disruptions or delays in care,
thereby perpetuating inequities even among those able to travel.
Inadequate capacity and care delays. If high-volume hospitals fail to expand their capacity to meet the increased demand,
centralization may delay colon cancer care. Specialty clinics, diagnostic testing,
operating room time, and bed availability at academic hubs are often at capacity.
Increasing patient volumes may result in longer wait times for appointments, diagnostic
tests, and operations. Thus, larger hub hospitals may struggle to balance the resources
required for routine cases with those needing more complex expertise and resources
or emergent cases that are more suited at the tertiary center.
Strategies to Optimize Regional Care Delivery and Clinical Integration for Colon Cancer
Strategies to Optimize Regional Care Delivery and Clinical Integration for Colon Cancer
Colon cancer is common, with well-established guidelines and varying clinical complexity.
Beyond centralization, other regional strategies can aim to deliver “the right care
in the right place at the right time.” These strategies outlined in the following
section include integrating service line delivery, optimizing the site of care, and
disseminating expertise and resources ([Fig. 2]).
Fig. 2 Potential alternative strategies to centralization for regionalized colon cancer
care. Uniform centralization may not be advantageous for common disease types such
as colon cancer. Instead, opportunities include integrated service line delivery for
coordinated care across sites, optimization of site of care through selective centralization
of patients, and dissemination of expertise via technology-enabling services. These
approaches may balance equity, access, and patient preference while ensuring high-quality
care across regional hospital networks.
Integration of service line care delivery. Regional care for colon cancer can benefit from integrating clinical service lines,
where care is standardized across sites, information is freely shared, and quality
is continuously assessed. Federal mandates support EHR interoperability of medical
records between sites across a hospital network, promoting care coordination with
robust communication among geographically dispersed providers. EHR integration facilitates
the sharing of diagnostic findings and may eliminate redundant workups across care
transitions. Further, EHR integration can allow for the implementation of standardized
best practices through EHR-based interventions and continuous quality monitoring to
identify areas for improvement.
Site of care optimization. Site of care optimization refers to aligning patient needs and disease complexity
with the capacity and resources of each facility. Some patients may be over-triaged
to specialized centers with more expertise than they require, while others may be
under-triaged to facilities lacking the necessary experience. For example, a young
healthy patient with a localized mid-sigmoid neoplasm can be treated safely at a smaller
spoke hospital, preserving capacity at the hub. Conversely, an older patient with
cardiac disease on systemic anticoagulation with right-sided colon cancer invading
the duodenum could undergo local staging workup but should have perioperative planning
and surgery at the hub hospital where multidisciplinary surgical specialists work
together routinely to achieve the best oncologic outcome. Unlike centralization, this
approach keeps most patients local. Like centralization, barriers remain for patients
requiring travel to the hub hospital; however, because the number of patients is limited,
this approach may allow for greater allocation of resources toward supporting their
travel.
Dissemination of clinical expertise. Sharing expertise across sites can elevate the level of care across the hospital
network.[29] Telehealth, which grew significantly during the COVID-19 pandemic, can facilitate
initial consultations and routine postoperative follow-ups for patients who underwent
surgery at hub hospitals. Beyond patient-to-provider communication, telehealth may
also enhance provider-to-provider communication via virtual teleconsultation. For
example, the Extension for Community Healthcare Outcomes (ECHO) Model (Project ECHO),
supported by Congress in 2016, allows disease-specific consultants to regularly discuss
patient cases with rural primary care teams. Multidisciplinary tumor boards can also
integrate expert opinions across various sites to enhance knowledge sharing, decision-making,
and site of care selection for complex cases. These strategies bridge expertise gaps
at sites of care with greater capacity, provide evidence-based strategies to treat
complex care at more locations, and reduce costs and travel burdens for patients.
Conclusion
The U.S. health care landscape is rapidly evolving toward regionalized hospital networks,
creating an opportunity for these networks to fulfill their clinical potential. While
centralization is an effective strategy for many complex cancers, its costs may outweigh
the benefits for colon cancer due to the higher volume and variation in complexity.
However, strategies like service line integration, centralization of select patients,
and dissemination of expertise through technology can help mitigate fragmentation
in cancer care. These approaches are crucial for improving the quality, access, and
equity of colon cancer care delivery.
