Effect of centralization on complex surgical care: A population-based case study of radical cystectomy
Keywords:bladder cancer, cystectomy, quality, Volume, Centralization, Outcomes
Introduction: We sought to determine whether non-mandated or passive centralization of radical cystectomy (RC) to higher-volume centers leads to enhanced processes of care and outcomes.
Methods: This is a population-based, retrospective, cohort study that used the Ontario Cancer Registry (OCR) to identify all incident patients who underwent RC from 1994‒2013. Electronic records of treatment were linked to OCR; pathology records were obtained for all cases and reviewed by a team of trained data abstractors. The primary objective was to describe annual provider RC volumes. Secondary objectives included investigating process and outcome measures.
Results: For the 5574 patients identified, the mean annual surgeon volume and hospital volume of RC from 1994–2008 was 4.5 (95% confidence interval [CI] 4.4–4.7) and 12.2 (95% CI 11.8– 12.5), respectively. From 2009‒2013, these volumes significantly increased to 6.8 (95% CI 6.5–7. 1) and 16.4 (95% CI 15.8–16.9). Process variables improved over time, including the use of neoadjuvant chemotherapy. Over the study period, there was a substantial improvement in cancer-specific survival (CSS): hazard ratio (HR) 0.60 (95% CI 0.53‒0.67) for 2009‒2013. During the most recent era, there was still evidence of a provider volume effect on both process measures and CSS.
Conclusions: There has been recent passive centralization of RC to higher-volume providers in the province of Ontario, with measurable improvements in processes of quality care. Although centralization was also associated with improvement in CSS, in the most recent era, there continues to be low-volume providers with a residual volume-outcome effect.
How to Cite
You, the Author(s), assign your copyright in and to the Article to the Canadian Urological Association. This means that you may not, without the prior written permission of the CUA:
- Post the Article on any Web site
- Translate or authorize a translation of the Article
- Copy or otherwise reproduce the Article, in any format, beyond what is permitted under Canadian copyright law, or authorize others to do so
- Copy or otherwise reproduce portions of the Article, including tables and figures, beyond what is permitted under Canadian copyright law, or authorize others to do so.
The CUA encourages use for non-commercial educational purposes and will not unreasonably deny any such permission request.
You retain your moral rights in and to the Article. This means that the CUA may not assert its copyright in such a way that would negatively reflect on your reputation or your right to be associated with the Article.
The CUA also requires you to warrant the following:
- That you are the Author(s) and sole owner(s), that the Article is original and unpublished and that you have not previously assigned copyright or granted a licence to any other third party;
- That all individuals who have made a substantive contribution to the article are acknowledged;
- That the Article does not infringe any proprietary right of any third party and that you have received the permissions necessary to include the work of others in the Article; and
- That the Article does not libel or violate the privacy rights of any third party.