Early results after regionalization of thoracic surgical practice in a single-payer system

Regionalization of the practice of thoracic surgery into designated centers was carried out in Ontario to manage volume, improve outcomes, and facilitate comprehensive care. This article describes the process used by Cancer Care Ontario (CCO) to regionalize thoracic surgery practice and reports early results.

A thoracic surgery standard was created by CCO, specifying criteria for level I (tertiary) and level II (secondary) thoracic surgery centers based on current volumes and projected population growth and referral patterns, and then implemented the standard using various incentives and disincentives.

Before regionalization (2004), 46 hospitals performed thoracic surgical procedures compared with 13 level I and 2 level II centers in 2010. From 2007 to 2011, a mean $8.4 million was distributed annually to designated centers to fund a mean 625 additional thoracic operations annually. By 2009 to 2010, the number of esophagectomies performed at designated centers increased from 212 to 285 (89% being performed in designated centers). Correspondingly, the number of lung resections increased from 1,396 to 1,858 (94% being performed in designated centers). Median wait time for lung cancer resection did not change. Regionalization achieved a significant reduction in 30-day mortality after pneumonectomy (10.9%-5.6%; p = 0.03) but no change for esophagectomy (5.9%-5.8%; p = 0. 96) or lobectomy (2.2%-1.9%; p = 0. 37).

Regionalization was challenging but feasible and was associated with reduced 30-day mortality after pneumonectomy. More data are required to evaluate other short- and long-term outcome measures to further validate benefits from regionalization.