Association of Hospital Flagship System Affiliation on Surgical Outcomes Following Complex Cancer Surgery

We evaluated variations in patient outcomes and financial expenditures following complex cancer surgery across flagship hospitals and their affiliates.

Using Medicare 100% Standard Analytic Files (2018-2021), we identified patients undergoing resection of lung, esophageal, gastric, hepatopancreatobiliary, or colorectal cancer. Flagship hospitals were defined as the highest-volume major teaching hospital within a system in each region. Propensity score matching was performed to create a 1:1 matched cohort to assess the association between flagship systems, hospitals, affiliates, and outcomes.

Among 110,670 patients, 55,335 treated within a flagship hospital system (median age, 73 years [IQR, 69-79]; including 29,381 [53.1%] women) were matched with 55,335 patients who were not (median age, 73 years [IQR, 69-79]; including 29,274 [52.9%] women) across 35 regions. Patients at flagship system hospitals had lower 30-day mortality rates than matched controls (4.23% vs 4.88%; difference, -0.65% [95% CI, -0.89% to -0.40%]; P<.001). Mortality was also lower at flagship hospitals (2.76% vs 3.82%; difference, -1.06% [95% CI, -1.62% to -0.50%]) and flagship affiliates (4.46% vs 4.79%; difference, -0.32% [95% CI, -0.58 to -0.07]) compared with controls (both P<.001). However, patients who underwent cancer surgery at flagship hospital systems had higher expenditures ($21,011 vs $20,016; difference, +$995 [95% CI, $797 to $1,193]; P<.001).

Flagship hospitals are the primary drivers of decreased postoperative mortality following complex oncologic surgical procedures performed within their systems, although expenditures were higher compared with unaffiliated hospitals.