Equitable Solutions Are Needed for Patients Who Seek Treatment for Thyroid Cancer at Ultra-Low-Volume Hospitals

Disparities in access to high-volume surgeons or high-volume hospitals are recognized factors associated with higher mortality, longer length of stay, and higher complication rates after thyroidectomy ^{1 –3} and lateral neck dissection ⁴ for thyroid cancer. In this issue, Huston-Paterson et al. reported their retrospective review of 52,599 thyroid surgery patients operated on for thyroid cancer in California between 1999 and 2017. ⁵ They evaluated the association between hospital volume of thyroid operations and outcomes, including complications, reoperation, use of radioactive iodine (RAI), and mortality.

They hypothesized that unequal access to high-volume hospitals might contribute to the observed disparities in surgical outcomes for thyroid cancer patients. They found that thyroid surgery at an ultra-low-volume hospital (0–5 cases/year) was associated with a higher risk of adverse outcomes compared with low-, moderate-, and high-volume centers. Specifically, these patients were at higher risk for reoperation and had a lower rate of receiving guideline-concordant RAI therapy.

The authors build upon previous findings and link thyroid surgery at an ultra-low-volume center with other social determinants of health. They divided California centers into four tiers based on the annual volume of thyroid surgery: high volume (>50 cases/year), moderate volume (26–50 cases/year), low volume (6–25 cases/year), and ultra-low volume (0–5 cases/year). During the study period, 12% of thyroid operations were performed at ultra-low-volume hospitals annually with no significant variation from year to year. Ultra-low-volume centers were found to care for more women, Hispanics, Asian and Pacific Islanders, and Native Americans.

Patients receiving care at ultra-low-volume centers were more likely to reside in census tracts with average lower income, years of education, and employment. Also, ultra-low-volume hospitals cared for a higher percentage of patients with lower socioeconomic status, and those uninsured and covered by Medicaid/Medicare. The index operation was more likely to be a limited thyroid resection. Accordingly, patients from ultra-low-volume centers had a higher rate of reoperation for recurrent disease than those from hospitals with >5 cases/year. Finally, the authors connected thyroidectomy at ultra-low-volume centers with higher rates for complications (specifically, higher rates of wound and airway complications) than those at moderate-volume centers.

It has been recognized for decades that worse outcomes are associated with thyroidectomy performed by low-volume surgeons and that race and ethnicity are predictors of being operated on by low-volume surgeons. ⁶ Furthermore, surgical complications, particularly hypoparathyroidism, are associated with worse quality of life ^{7 –10} and higher costs. Compounding the problem, costs have been shown to be higher for racial and ethnic minorities treated in low-volume hospitals. ^1,6 Note that in this study, only ultra-low-volume centers had significantly higher rates of adverse outcomes. Outcomes at other centers were similar. This suggests that efforts should be focused on those ultra-low-volume centers.

One factor the authors did not examine was the cost of care at each hospital tier. Higher surgical complications have been shown to be associated with higher costs of care, greater resource utilization and longer length of stay across multiple surgical procedures. ¹¹ Given that complication rates were higher in the ultra-low-volume setting, it stands to reason that if evaluated in this study, the authors might have found that costs were higher as well. Financially marginalized patients are less likely to receive the care they need, and higher rates of reoperation and complications impact these patients the most. These findings suggest that there may be a greater risk of financial toxicity for surgical patients in ultra-low-volume settings and a greater cost imposed on these hospitals; these issues should be explored.

Another vital patient-centric factor the authors discuss briefly is the significant benefit to patients who avoid long travel distances for surgical care. ¹² Although regionalization of care has been proposed as a possible solution, patient preference to seek care closer to home is a major equity issue that should be respected. For the past 18 years, there have been nearly 200 closures of hospitals located in rural and underserved communities in the United States, and this crisis has been associated with a loss of access to cancer treatment, specifically surgical services. ¹³

The need for extensive travel increases the patients' and families' burden, reduces the likelihood of receiving timely surgery and other guideline-concordant care, and leads to postoperative care fragmentation. Steering patients away from ultra-low-volume centers would actually exacerbate the access issues of already marginalized populations. A more equitable solution would be to help these ultra-low-volume centers improve the quality of care delivered.

There are several possible solutions to explore for improving outcomes at ultra-low-volume hospitals without regionalizing care away from the population the hospital serves. As the authors suggested, partial coverage models employing well-trained specialists should be considered. Quality improvement initiatives at ultra-low-volume centers could be employed to improve the delivery of high-quality cancer treatment. Telemedicine could be leveraged to a greater extent, especially when transportation and time are barriers. Mobile health clinics may be employed, as they have been shown to provide an important link between the hospital and resource-limited communities. ¹⁴

Value-based payment models are controversial but might be explored. Ultra-low-volume hospitals might also gain cost and quality advantages by aligning with larger health care networks or systems that would allow them to tap into the well-known value of interdisciplinary cancer care. An example of such a functioning comprehensive cancer control program is British Columbia Cancer (BC Cancer), which is a Canadian province-wide cancer care system publicly funded and available to patients for cancer care and to specialist physicians for tumor-board reviews and subspecialist treatment suggestions. Finally, the need to update the training of specialist providers to equip them to provide care in more underserved and resource-limited settings is apparent.

It is vital that health system data are interpreted with the intention to improve patient care; not just to highlight existing disparities. Challenges to providing high-quality equitable surgical care in rural and other resource-limited areas are not new. To meet these challenges, innovative approaches are needed that also deliver equitable solutions.