SAN FRANCISCO, CA USA (UroToday.com) - Centralization of bladder cancer care in the United Kingdom was implemented in 2001.
The National Institute of Clinical Effectiveness in the UK recommends providers perform a cumulative total of at least 50 radical cystectomies (RC) or prostatectomies per year, while surgeons must perform ≥ 5 RC per year with 30-day mortality rates of 3.5% or less. Dr. Prashant Patel (London, UK) and colleagues attempted to characterize the effect of bladder cancer-care centralization on outcomes. The authors used the Health Episode Statistic database to examine outcomes for 14 693 patients treated with RC throughout England over the past 11 years (since institution of centralization).
Prior to the institution of NICE recommendations, 85.5% and 70.9% of providers and surgeons, respectively, were performing less than the recommended standard number of cases. A decade later, 50% of providers and 42% of surgeons continue to perform less than the recommended standard. Overall, centralization of RC care in the UK has resulted in 87.5% of RC being performed in compliance with NICE regulations. Implementation of NICE regulations resulted in reduction of the 30-day mortality rate from 3.7% to 2.4%. When stratified by provider/surgeon volume, there was no difference in age, sex, or deprivation scores amongst the bands for providers/surgeons. However, high volume providers and surgeons operated on patients with higher comorbidity scores but still achieved shorter hospital LOS. No difference in complications was seen when care was stratified by volume, but re-intervention rates were higher amongst low-volume surgeons. Mortality (early and overall) was lower among high volume-providers and surgeons (median OS by provider 3.4 vs 4.4 years; by surgeon 4.7 vs 5.8 years).
In conclusion, centralization of RC care in the UK has led to < 1% of RCs being performed by low-volume surgeons and at low-volume centers. Compliant centers appear to have better outcomes, with shorter lengths of stay and lower re-intervention rates, at high- vs low-volume centers. These data demonstrate promising potential targets to improve perioperative outcomes following RC.
Highlights of a presentation by Prashant Patel at the 2014 Genitourinary Cancers Symposium - January 30 - February 1, 2014 - San Francisco Marriott Marquis - San Francisco, California USA