Access to accredited hospitals improves cancer care outcomes for vulnerable patients

Vulnerable patients facing social, environmental, and economic disadvantages often experience worse cancer outcomes than other groups. Some of these disparities may be reduced by increasing access to hospitals accredited by the American College of Surgeons (ACS) Commission on Cancer (CoC), according to a study published in the Journal of the American College of Surgeons (JACS).

The study found that highly vulnerable patients treated at CoC-accredited hospitals, as measured by the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), were more likely to receive care that adhered to national treatment guidelines and were 9% less likely to die than patients treated at non-CoC-accredited hospitals during the study period. These results may be due to CoC-accreditation requirements for treatment guideline adherence, community engagement, and addressing barriers to care, the study authors said.

All ACS Quality programs are rooted in evidence-based standards of care. These study findings validate that adhering to national guidelines, such as those of the Commission on Cancer, make an important difference in the care and outcomes of our patients."

Clifford Y. Ko, MD, MS, MSHS, FACS, study coauthor and Director of the ACS Division of Research and Optimal Patient Care

Key study findings

• Patients with high social vulnerability treated at CoC-accredited hospitals had a 9% reduction in mortality rate compared to those treated at non-CoC-accredited hospitals during the study period.
• Patients treated at CoC-accredited hospitals had a 79% higher likelihood of receiving guideline-concordant care (GCC) compared to those treated at non-CoC-accredited hospitals.
• Patients in the highest SVI quartile had 21% decreased potential of receiving GCC overall.

This retrospective observational study identified 124,950 patients with stage I-III colon cancer (102,399 patients) or stage II-III rectal cancer (22,551 patients) between 2018 and 2020 from the National Program of Cancer Registries Database. Vulnerability was measured using the SVI, which was developed by the CDC and ranks the relative vulnerability of every U.S. census tract or county based on 16 social factors on a composite scale ranging from 0 to 100, with 0 indicating the least vulnerable population and 100 indicating the most vulnerable population.

"Highly vulnerable patients are at an increased risk for late cancer stage at diagnosis, treatment delays, and non-receipt of guideline-concordant care," said lead author Kelley Chan, MD, MS, a Clinical Scholar in Residence at the ACS Cancer Programs and also a general surgery resident at Loyola University Medical Center. "For example, colorectal cancer survival has been demonstrated to be 30% lower in more deprived neighborhoods."

Despite the overall decline in the incidence and mortality of colon and rectal cancer, which is likely due to the increase in screening colonoscopies, this rate of decline has not been shared equally, she said. For example, incidence rates are higher in Black patients than in non-Hispanic White patients.

The study found that patients treated at CoC-accredited hospitals had 79% higher likelihood of receiving GCC than those treated at non-CoC-accredited hospitals. Patients in the highest SVI quartile had a 21% decreased chance of receiving GCC but were more likely to receive GCC at a CoC-accredited hospital than at a non-CoC-accredited hospital. The JACS study found that the probability of receiving GCC declined as SVI rose; this decline, however, was faster among patients at non-CoC-accredited hospitals than those at CoC-accredited hospitals, she said.

CoC hospitals must address barriers to care

High SVI patients may be more likely to receive GCC at CoC-accredited hospitals because those hospitals benchmark data and have accreditation requirements to address barriers to care, Dr. Chan said. Research has shown that programs that track adherence to evidence-based quality measures and benchmark their performance with other CoC-accredited hospitals are more likely to have better coordination of multidisciplinary care and better outcomes than hospitals that do not track and benchmark data, she said. The CoC also provides resources to assess community needs and requires accredited hospitals to partner with community organizations to address challenges related to social determinants of health.

"CoC requirements for conducting quality improvement projects and leveraging community partnerships may have contributed to improved outcomes in underserved communities," Dr. Chan said. "We have heard from hospitals how these initiatives have improved care."

An example of an ACS Cancer Programs national quality improvement collaborative is Breaking Barriers, which has assisted programs in addressing barriers for patients missing three or more radiation therapy appointments, she said. Other initiatives include offering community cancer prevention and screening events, improving access to care, screening for psychosocial distress, and supporting survivorship, according to Dr. Chan.

While patients overall had increased odds of receiving guideline-concordant care at CoC-accredited hospitals compared to non-CoC-accredited hospitals, disparities were also noted when comparing patients with low and high vulnerability at CoC-accredited hospitals, which shows that more work needs to be done to address the influence of social determinants on cancer treatment and outcomes, Dr. Chan said.

"These findings are encouraging and demonstrate that Commission on Cancer accreditation increases compliance with guideline-based care and improves outcomes for cancer patients. This work shows our impact of what we're trying to achieve with our efforts at the Commission on Cancer," said Ronald J. Weigel, MD, PhD, MBA, FACS, a study coauthor and Medical Director for ACS Cancer Programs. "However, our work is not done. To expand the reach of the Commission on Cancer to underserved populations, we are developing a Rural CoC program to improve the care of those in our society who lack access to cancer care."

Dr. Chan also recently published a JAMA Network Open study that found that Black patients with colon cancer who were treated at CoC-accredited hospitals were more likely to receive GCC and have lower mortality risk than Black patients treated at non-CoC-accredited hospitals.

"We decided to build upon the JAMA Network Open study by using a vulnerability index that includes other social determinants of health including socioeconomic status, household characteristics, housing type, and transportation," she said.

Increasing access to CoC-accredited hospitals can reduce disparities in cancer care, either by making it easier for patients to get to those hospitals or by increasing the number of CoC-accredited hospitals, said Dr. Chan. Notably, there are ongoing efforts to support CoC-accreditation in underserved areas such as rural areas, according to Dr. Chan.

Coauthors are Bryan E. Palis, MA; Joseph H. Cotler, PhD; Lauren M. Janczewski, MD, MS; and David J. Bentram, MD, MS.