Physician Linkage to High-Volume Hospitals Key to Expanding Colorectal Cancer Surgery Access and Reducing Disparities of Care.

Physician Linkage to High-Volume Hospitals Key to Expanding Colorectal Cancer Surgery Access and Reducing Disparities of Care.

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This article was written by Waddah B. Al-Refaie, MD, David Stein, MD, and James McDermott, medical student at UCLA.


A new study by MedStar Health Research Institute found that patients are more likely to have colorectal cancer surgery at high-volume hospitals if their primary care clinician or specialist has linkages—referral relationships—with surgeons at these locations. High-volumes are often associated with better outcomes for patients and such linkages can thus reduce disparities.


Primary care clinicians are the gateway to cancer care. Their connections to specialists and surgeons at high-volume hospitals determine where they refer patients for advanced oncologic care. Research shows that patients strongly rely on their primary care clinician’s guidance when making health care decisions.


Primary care clinicians without strong specialist linkages at high-volume hospitals might refer patients to centers with which they’re more familiar or that are closer to home. Unfortunately, inconsistent access to experienced, high-quality surgical care can lead to preventable health disparities that compound existing barriers to healthcare.


Our researchers used Maryland’s Health Services Cost Review Commission to examine physician linkages in 6,909 patients across 52 hospitals who had colon or rectal cancer surgery from 2013-2018.


A linkage was defined as nine or more shared patients between two clinicians in different specialties. Two linkages were examined:


  • Primary care clinician to specialist (gastroenterologist or medical oncologist)
  • Specialist to surgeon (general or colorectal)

The researchers found that every additional linkage between primary care clinicians and specialists connected to high-volume hospitals increased the likelihood of patients having colorectal cancer surgery at those locations by up to 14%. Further, each additional linkage between referring specialists and surgeons at high-volume hospitals increased patients choosing these hospitals for cancer surgeries up to 25%.


High-volume hospitals offer the full range of cancer treatment and support services for complex conditions. Surgeons at these centers have performed thousands of cancer procedures—as with any other skill, the more surgeries performed, the more skilled the surgeons and the entire care team become.


Surgeries performed at high-volume hospitals are associated with better patient outcomes, especially for complicated procedures such as colorectal cancer surgery.


Our findings suggest that improving linkages between community-based primary care clinicians, private practice specialists, and surgeons at high-volume hospitals is an important step in providing equitable surgical care for all patients.


This work was supported in part by a Cancer Center Support Grant Developmental Funds Award from the Georgetown Lombardi Comprehensive Cancer Center, The Lee Folger Foundation, Surgical Oncology/Surgical Outcomes Disparities fund, and The John S. Dillon Endowed Chair in Surgical Oncology.


Collaboration Among Cancer Experts.

Specialists and primary care clinicians rely heavily on reputation, past experiences, and professional relationships when making referrals. Cancer surgeons and hospitals must work together to foster good working relationships with referring physicians in all communities.


Building and strengthening these linkages can increase the likelihood of referrals to high-volume, successful outcome centers when advanced cancer care is needed. At a high-volume center, patients benefit from surgical expertise and access to advanced support for underlying or emergent medical needs.


However, barriers persist in insurance coverage, regionalization of care, and other obstacles beyond a patient’s control. Clinicians collectively have the strength of voice to advocate for our patients—working with policymakers, we can influence and potentially begin to expand access for patients in areas without strong existing linkages.


Increasing Community and Patient Engagement.

Engaging and educating community members about cancer care options can empower them if they need to make care decisions in the future. This outreach must start with the high-volume hospital care teams.


MedStar Health is taking steps to improve these relationships and reduce linkage-associated health care disparities in our community. Our efforts include:


  • Conducting colon cancer prevention programs, such as providing free at-home screening kits for colorectal cancer 
  • Using electronic medical records that prompt primary care clinicians to remind patients about preventive cancer screenings 
  • Working with insurance companies to expand coverage
  • Asking how patients heard about us so we can make access easier

When it comes to choosing the best cancer treatment and doctor, it’s important to understand your diagnosis and get a second opinion. Cancer doesn’t discriminate. Everyone should have equitable and timely access to the full range of advanced treatment options—the onus is on clinicians and policymakers to collaboratively reduce barriers and expand access.


McDermott, James BSa,b; Wang, Haijun MSb,c; DeLia, Derek PhDc,d; Sweeney, Matthew MSb; Bayasi, Mohammed MD, FACSd; Unger, Keith MDd; Stein, David E. MDe; Al-Refaie, Waddah B. MD, FACSb,c,d Impact of Clinician Linkage on Unequal Access to High-Volume Hospitals for Colorectal Cancer Surgery, Journal of the American


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