ORIGINAL ARTICLE – HEALTHCARE POLICY AND OUTCOMES Do Hospital Attributes Predict Guideline-Recommended Gastric Cancer Care in the United States? Vikas Dudeja, MD 1 , Greer Gay, PhD 2 , Elizabeth B. Habermann, MPH 1 , Todd. M. Tuttle, MD 1 , Jennifer F. Tseng, MD 3 , Barry W. Feig, MD 4 , and Waddah B. Al-Refaie, MD 1 1 Division of Surgical Oncology, Department of Surgery, Univ. of Minnesota and Minneapolis VAMC, Minneapolis, MN; 2 National Cancer Data Base, American College of Surgeons, Commission on Cancer, Chicago, IL; 3 Division of Surgical Oncology and Endocrinology, University of Massachusetts Medical School, Worcester, MA; 4 Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX ABSTRACT Background. Hospital attributes have been shown to impact short- and long-term outcomes after cancer surgery. However, the effect of hospital attributes on processes of cancer care in terms of delivery of guideline recommended care has not been evaluated. We examined the impact of hospital attributes (volume and type) on guideline-recom- mended care in patients treated for gastric cancer. Methods. We identified patients who were surgically trea- ted for gastric cancer at Commission on Cancer (CoC) hospitals from 2001 to 2006. Patient, tumor, and treatment factors were compared separately by hospital volume and type. Multivariable analyses were used to evaluate the impact of hospital attributes on delivery of guideline rec- ommended gastric cancer care: adequate lymphadenectomy (C15 lymph nodes), and adjuvant multimodality therapy (for AJCC Ib–IVM0), controlling for covariates. Results. More than 1,490 CoC hospitals performed 37,124 gastrectomies. High-volume and teaching CoC hospitals were more likely to treat younger patients, non-whites, patients with lower AJCC stage, and to perform adequate lymphadenectomy than low-volume and community CoC hospitals (p B 0.001). Hospital volume and type, however, were not associated with receipt of adjuvant multimodality therapy. These associations persisted in our multivariable analyses to show that CoC hospital attributes were asso- ciated with adequate lymphadenectomy, but marginally predictive of receipt of adjuvant multimodality therapy. Conclusions. The strong association between CoC hospi- tal volume or type and guideline-recommended care diminishes after gastric cancer surgery. Variations in referral, insurance, and documentation patterns are poten- tial explanations for these findings. These results highlight some limitations of using hospital attributes as a sole pre- dictor of optimal cancer care. The impact of hospital attributes on surgical outcomes has been extensively evaluated to show that high hospital vol- ume is associated with favorable short- and long-term survival after cancer surgery. 1–5 High-volume centers also have been associated with optimal oncologic metrics and survival, that is receipt of oncologic surgery at high-volume centers has been associated with an increased likelihood of margin-negative resection and adequate nodal evaluation across several solid malignant tumor sites, thus contributing to an improved overall survival. 6–10 Indeed, these relation- ships have encouraged efforts to regionalize cancer care in the United States to high-volume centers. 11 Even though the incidence of gastric cancer in the United States is on the decline, it remains the second- highest cause of cancer-related mortality in the world. 12 As such, several lines of investigations have demonstrated the survival benefit of adequate nodal evaluation (15 and more lymph nodes) and adjuvant therapy for resectable gastric cancer, AJCC stage IB-IVM0 in the treatment of gastric cancer. 13–15 These recommendations have become guide- lines for clinicians to treat their patients with gastric cancer outside clinical trials. 14,16 Nevertheless, optimal gastric cancer care requires a multidisciplinary approach that is perhaps influenced by the attributes of its treating facility. To date, the effects of hospital attributes on processes of Ó Society of Surgical Oncology 2011 First Received: 29 January 2011; Published Online: 12 August 2011 W. B. Al-Refaie, MD e-mail: alref003@umn.edu Ann Surg Oncol (2012) 19:365–372 DOI 10.1245/s10434-011-1973-z