The Financial Argument for Centralization of Care for Esophagectomy

To determine if spending is lower at high-volume esophagectomy centers.

There is growing enthusiasm for centralization of care for operations with strong volume-outcome relationships, such as esophagectomy. While justifications for centralization of care have traditionally relied on clinical outcomes, little is known about whether spending also differs at hospitals with varying levels of experience performing esophagectomy.

We queried Medicare claims data for fee-for-service Medicare beneficiaries undergoing esophagectomy from 2011 to 2021. Centers were categorized as high-volume (≥20 cases/year) or low-volume (<20 cases/year), a threshold backed by a large body of evidence and patient safety organizations. We used generalized linear models, adjusting for patient demographics and comorbidities, to estimate price-standardized episode payments for low- and high-volume centers.

We identified 26,676 beneficiaries who underwent esophagectomy at 30 high-volume centers (7044 beneficiaries, 26.4%) and 1731 low-volume centers (19,632 beneficiaries, 73.6%) during the study period. Adjusted 90-day total episode spending was $62,305 [95% confidence interval: $61,239-$63,372] per beneficiary for high-volume centers; spending was 6.1% higher ($3781) at low-volume centers (total episode spending $66,087, 95% confidence interval: $65,362-$66,812), representing excess annual spending of $7.1 million. Index hospitalization, post-acute care, and readmission spending were also higher at low-volume centers. Low-volume centers had significantly higher rates of 90-day mortality and complications and longer length of stay.

Compared to high-volume esophagectomy centers, Medicare spends more per episode at low-volume centers, possibly driven by readmissions and post-acute care utilization. Restricting esophagectomy to high-volume centers may both achieve safety and reduce spending.