Cost-Volume Relationship in Rectal Cancer Resection Across the United States

BackgroundWhile greater institutional experience with high-risk rectal cancer operations has previously been associated with improved clinical outcomes, the impact on costs remains unclear. The present work aimed to characterize the relationship between hospital proctectomy volume and hospitalization costs.MethodsThe 2016-2021 Nationwide Readmissions Database was queried to identify all adults undergoing elective rectal cancer resection. Multivariable linear regression was used to model hospitalization costs, with inclusion of hospital volume as restricted cubic splines. The volume corresponding to the inflection point (60 cases) was used to categorize hospitals as high-volume (HVH) or low-volume (LVH). Association of HVH status with adverse events, resource use, and readmission was assessed.ResultsAn estimated 123,231 patients underwent rectal cancer resection, with median cost of $24,700. Although only 22.1% of hospitals were defined as HVH, 65.3% of patients were treated at these centers. Compared to LVH, patients at HVH were more commonly privately insured and had neoadjuvant chemoradiation and robotic operations. After adjustment, HVH was associated with lower odds of complications (AOR 0.91, P = 0.001) and non-home discharge (AOR 0.86, P < 0.001), while mortality and 30-day readmission were comparable. Furthermore, HVH was associated with a -$1800 decrement in costs (P < 0.001) and a -0.6-day decrease in length of stay (P < 0.001). Of note, the disparity in costs between HVH and LVH persisted over time.DiscussionIncreasing institutional volume of rectal cancer resection was associated with reduced hospitalization costs. Further cost mitigation strategies to streamline care pathways at low-volume centers are warranted to improve the value of rectal surgical care.