Association of Quality and Technology With Patient Mobility for Colorectal Cancer Surgery

Is Centralisation of Cancer Services Associated With Under-Treatment of Patients With High-Risk Prostate Cancer?-A National Population-Based Study

BACKGROUND

Centralising prostate cancer surgical and radiotherapy services, requires some patients to travel longer to access treatment, but its impact on actual treatment utilisation and outcomes is unknown.

METHODS

Using national cancer registry records linked to administrative hospital data, we identified all patients with high risk and locally advanced prostate cancer diagnosed between 1 April 2019 and 31 March 2020 in the English National Health Service (n = 15,971). Estimated travel times from the patient residential areas to the nearest hospital providing surgery or radiotherapy were estimated for journeys by car and by public transport. Multivariable logistic regression was used to model relationships between travel time and receipt of care with adjustment for patient characteristics.

RESULTS

10,693 (67%) men received radical surgery or radiotherapy (RT) within 12 months of diagnosis. Average travel time to the nearest hospital providing prostatectomy or RT was 23.2 min by private car and 58.2 min by public transport. We found no association between travel time, either by car or public transport and the likelihood of receiving curative treatment. Patients living in the most socially deprived areas, those aged over 70, those with two or more comorbidities, and those of black ethnic origin, were less likely to receive curative treatment (p& =& 0.001 for all associations).

CONCLUSIONS

The current configuration of national prostate cancer services is not associated with the likelihood of receiving curative treatment. Further increases in capacity will unlikely improve utilisation rates beyond addressing sociodemographic barriers.

Hospital Factors Influencing the Mobility of Patients for Systemic Therapies in Breast and Bowel Cancer in the Metastatic Setting: A National Population-based Evaluation

AIMS

This national study investigated hospital quality and patient factors associated with treatment location for systemic anticancer treatment (SACT) in patients with metastatic cancers.

MATERIALS AND METHODS

Using linked administrative datasets from the English NHS, we identified all patients diagnosed with metastatic breast and bowel cancer between 1 January 2016 and 31 December 2018, who subsequently received SACT within 4 months from diagnosis. The extent to which patients bypassed their nearest hospital was investigated using a geographic information system (ArcGIS). Conditional logistic regression models were used to estimate the impact of travel time, hospital quality and patient characteristics on where patients underwent SACT.

RESULTS

541 of 2,364 women (22.9%) diagnosed with metastatic breast cancer, and 2,809 of 10,050 (28.0%) patients diagnosed with metastatic bowel cancer bypassed their nearest hospital providing SACT. There was a strong preference for receiving treatment at hospitals near where patients lived (p < 0.001). However, patients who were younger (p = 0.043 for breast cancer; p < 0.001 for bowel cancer) or from rural areas (p = 0.001 for breast cancer; p < 0.001 for bowel cancer) were more likely to travel to more distant hospitals. Patients diagnosed with rectal cancer were more likely to travel further for SACT than patients with colon cancer (p = 0.002). Patients were more likely to travel to comprehensive cancer centres (p = 0.019 for bowel cancer) and designated Experimental Cancer Medicine Centres (ECMCs) although the latter association was not significant. Patients were less likely to receive SACT in hospitals with the highest readmission rates (p = 0.046 for bowel cancer).

CONCLUSION

Patients with metastatic cancer receiving primary SACT are prepared to travel to alternative more distant hospitals for treatment with a preference for larger comprehensive centres providing multimodal care or hospitals which offer early phase cancer clinical trials.

NHS cancer services and systems-ten pressure points a UK cancer control plan needs to address

In this Policy Review we discuss ten key pressure points in the NHS in the delivery of cancer care services that need to be urgently addressed by a comprehensive national cancer control plan. These pressure points cover areas such as increasing workforce capacity and its productivity, delivering effective cancer survivorship services, addressing variation in quality, fixing the reimbursement system for cancer care, and balancing of the cancer research agenda. These areas have been selected based on their relative importance to ensuring sustainable cancer services, persistence as key issues in the NHS, and their impact on delivering better and more equitable and affordable patient outcomes. Many of these pressure points are not acknowledged explicitly in any current discourse. The evidence we provide points to their impact on the ability to deliver world class cancer care, but also to their amenability to affordable solutions if given the relevant prioritisation and investment. The current narrative needs to move away from a technocentric approach to improving care, to one focused on understanding the complexity of cancer services and the wider health system to drive improvements in survival, quality of life, and experience for patients.

Comparative analysis of the short and medium-term efficacy of the Da Vinci robot versus laparoscopic total mesangectomy for rectal cancer

BACKGROUND

The Da Vinci robot-assisted surgery technique has been widely used in laparoscopic mesangectomy for rectal cancer. However, the short-term efficacy of these procedures compared to traditional laparoscopic surgery remains controversial. The purpose of this study was to compare and analyze the short- and medium-term efficacy of Da Vinci robot and laparoscopic surgery in total mesangectomy (TME) for rectal cancer, so as to provide guidance and reference for clinical practice.

AIM

To investigate the safety and long-term efficacy of robotic and laparoscopic total mesorectal resection for the treatment of rectal cancer.

METHODS

The clinicopathologic data of 240 patients who underwent TME for rectal cancer in the Anorectal Department of People's Hospital of Xinjiang Uygur Autonomous Region from August 2018 to March 2023 were retrospectively analyzed. Among them, 112 patients underwent laparoscopic TME (L-TME) group, and 128 patients underwent robotic TME (R-TME) group. The intraoperative, postoperative, and follow-up conditions of the two groups were compared.

RESULTS

The conversion rate of the L-TME group was greater than that of the R-TME group (5.4% vs 0.8%, χ 2 = 4.417, P = 0.036). The complication rate of the L-TME group was greater than that of the R-TME group (32.1% vs 17.2%, χ 2 = 7.290, P = 0.007). The percentage of positive annular margins in the L-TME group was greater than that in the R-TME group (7.1% vs 1.6%, χ 2 = 4.658, P = 0.031). The 3-year disease-free survival (DFS) rate and overall survival (OS) rate of the L-TME group were lower than those of the R-TME group (74.1% vs 85.2%, χ 2 = 4.962, P = 0.026; 81.3% vs 91.4%, χ 2 = 5.494, P = 0.019); in patients with American Joint Committee on Cancer stage III DFS rate and OS rate in the L-TME group were significantly lower than those in the R-TME group (52.5% vs 76.1%, χ 2 = 5.799, P = 0.016; 65.0% vs 84.8%, χ 2 = 4.787, P = 0.029).

CONCLUSION

Compared with the L-TME group, the R-TME group had a better tumor prognosis and was more favorable for patients with rectal cancer, especially for patients with stage III rectal cancer.

Association of travel time, patient characteristics, and hospital quality with patient mobility for breast cancer surgery: A national population-based study

BACKGROUND

This national study investigated hospital quality and patient factors associated with treatment location for breast cancer surgery.

METHODS

By using linked administrative data sets from the English National Health Service, the authors identified all women diagnosed between January 2, 2016, and December 31, 2018, who underwent breast-conserving surgery (BCS) or a mastectomy with or without immediate breast reconstruction. The extent to which patients bypassed their nearest hospital was investigated using a geographic information system (ArcGIS). Conditional logistic regressions were used to estimate the impact of travel time, hospital quality, and patient characteristics.

RESULTS

22,622 Of 69,153 patients undergoing BCS, 22,622 (32.7%) bypassed their nearest hospital; and, of 23,536 patients undergoing mastectomy, 7179 (30.5%) bypassed their nearest hospital. Women who were younger, without comorbidities, or from rural areas were more likely to travel to more distant hospitals (p < .05). Patients undergoing BCS (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.36-2.50) or mastectomy (OR, 1.52; 95% CI, 1.14-2.02) were more likely to be treated at specialist breast reconstruction centers despite not undergoing the procedure. Patients receiving mastectomy and immediate breast reconstruction were more likely to travel to hospitals employing surgeons who had a media reputation (OR, 2.41; 95% CI, 1.28-4.52). Patients undergoing BCS were less likely to travel to hospitals with shorter surgical waiting times (OR, 0.65; 95% CI, 0.46-0.92). The authors did not observe a significant impact for research activity, hospital quality rating, breast re-excision rates, or the status as a multidisciplinary cancer center.

CONCLUSIONS

Patient choice policies may drive inequalities in the health care system without improving patient outcomes.

Quality indicators in surgical oncology: systematic review of measures used to compare quality across hospitals

BACKGROUND

Measurement and reporting of quality indicators at the hospital level has been shown to improve outcomes and support patient choice. Although there are many studies validating individual quality indicators, there has been no systematic approach to understanding what quality indicators exist for surgical oncology and no standardization for their use. The aim of this study was to review quality indicators used to assess variation in quality in surgical oncology care across hospitals or regions. It also sought to describe the aims of these studies and what, if any, feedback was offered to the analysed groups.

METHODS

A literature search was performed to identify studies published between 1 January 2000 and 23 October 2023 that applied surgical quality indicators to detect variation in cancer care at the hospital or regional level.

RESULTS

A total of 89 studies assessed 91 unique quality indicators that fell into the following Donabedian domains: process indicators (58; 64%); outcome indicators (26; 29%); structure indicators (6; 7%); and structure and outcome indicators (1; 1%). Purposes of evaluating variation included: identifying outliers (43; 48%); comparing centres with a benchmark (14; 16%); and supplying evidence of practice variation (29; 33%). Only 23 studies (26%) reported providing the results of their analyses back to those supplying data.

CONCLUSION

Comparisons of quality in surgical oncology within and among hospitals and regions have been undertaken in high-income countries. Quality indicators tended to be process measures and reporting focused on identifying outlying hospitals. Few studies offered feedback to data suppliers.

Quality indicators for evaluating cancer care in low-income and middle-income country settings: a multinational modified Delphi study

This Policy Review sourced opinions from experts in cancer care across low-income and middle-income countries (LMICs) to build consensus around high-priority measures of care quality. A comprehensive list of quality indicators in medical, radiation, and surgical oncology was identified from systematic literature reviews. A modified Delphi study consisting of three 90-min workshops and two international electronic surveys integrating a global range of key clinical, policy, and research leaders was used to derive consensus on cancer quality indicators that would be both feasible to collect and were high priority for cancer care systems in LMICs. Workshop participants narrowed the list of 216 quality indicators from the literature review to 34 for inclusion in the subsequent surveys. Experts' responses to the surveys showed consensus around nine high-priority quality indicators for measuring the quality of hospital-based cancer care in LMICs. These quality indicators focus on important processes of care delivery from accurate diagnosis (eg, histologic diagnosis via biopsy and TNM staging) to adequate, timely, and appropriate treatment (eg, completion of radiotherapy and appropriate surgical intervention). The core indicators selected could be used to implement systems of feedback and quality improvement.

Managing the cancer backlog: a national population-based study of patient mobility, waiting times and 'spare capacity' for cancer surgery

Background

Waiting times for cancer treatments continue to increase in many countries. In this study we estimated potential 'spare surgical capacity' in the English NHS and identified regions more likely to have spare capacity based on patterns of patient mobility (the extent to which patients receive surgery at hospitals other than their nearest).

Methods

We identified patients who had an elective breast or colorectal cancer surgical resection between January 2016 and December 2018. We estimated each hospital's 'maximum surgical capacity' as the maximum 6-month moving average of its surgical volume. 'Spare surgical capacity' was estimated as the difference between maximum surgical capacity and observed surgical volume. We assessed the association between spare surgical capacity and whether a hospital performed more or fewer procedures than expected due to patient mobility as well as the association between spare surgical capacity and whether or not waiting times targets for treatment were likely to be met.

Findings

100,585 and 49,445 patients underwent breast and colorectal cancer surgery respectively. 67 of 166 hospitals (40.4%) providing breast cancer surgery and 82 of 163 hospitals (50.3%) providing colorectal cancer surgery used less than 80% of their maximum surgical capacity. Hospitals with a 'net loss' of patients to hospitals further away had more potential spare capacity than hospitals with a 'net gain' of patients (p < 0.001 for breast and p = 0.01 for colorectal cancer). At the national level, we projected an annual potential spare capacity of 8389 breast cancer and 4262 colorectal cancer surgical procedures, approximately 25% of the volumes actually performed.

Interpretation

Spare surgical capacity potentially exists in the present configuration of hospitals providing cancer surgery and requires regional allocation for efficient utilisation.

Funding

National Institute for Health Research.

Comparison of Simulated Outcomes of Colorectal Cancer Surgery at the Highest-Performing vs Chosen Local Hospitals

IMPORTANCE

Variation in outcomes across hospitals adversely affects surgical patients. The use of high-quality hospitals varies by population, which may contribute to surgical disparities.

OBJECTIVE

To simulate the implications of data-driven hospital selection for social welfare among patients who underwent colorectal cancer surgery.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation used the hospital inpatient file from the Florida Agency for Health Care Administration. Surgical outcomes of patients who were treated between January 1, 2016, and December 31, 2018 (training cohort), were used to estimate hospital performance. Costs and benefits of care at alternative hospitals were assessed in patients who were treated between January 1, 2019, and December 31, 2019 (testing cohort). The cohorts comprised patients 18 years or older who underwent elective colorectal resection for benign or malignant neoplasms. Data were analyzed from March to October 2022.

EXPOSURES

Using hierarchical logistic regression, we estimated the implications of hospital selection for in-hospital mortality risk in patients in the training cohort. These estimates were applied to patients in the testing cohort using bayesian simulations to compare outcomes at each patient's highest-performing and chosen local hospitals. Analyses were stratified by race and ethnicity to evaluate the potential implications for equity.

MAIN OUTCOMES AND MEASURES

The primary outcome was the mean patient-level change in social welfare, a composite measure balancing the value of reduced mortality with associated costs of care at higher-performing hospitals.

RESULTS

A total of 21 098 patients (mean [SD] age, 67.3 [12.0] years; 10 782 males [51.1%]; 2232 Black [10.6%] and 18 866 White [89.4%] individuals) who were treated at 178 hospitals were included. A higher-quality local hospital was identified for 3057 of 5000 patients (61.1%) in the testing cohort. Selecting the highest-performing hospital was associated with a 26.5% (95% CI, 24.5%-29.0%) relative reduction and 0.24% (95% CI, 0.23%-0.25%) absolute reduction in mortality risk. A mean amount of $1953 (95% CI, $1744-$2162) was gained in social welfare per patient treated. Simulated reassignment to a higher-quality local hospital was associated with a 23.5% (95% CI, 19.3%-32.9%) relative reduction and 0.26% (95% CI, 0.21%-0.30%) absolute reduction in mortality risk for Black patients, with $2427 (95% CI, $1697-$3158) gained in social welfare.

CONCLUSIONS AND RELEVANCE

In this economic evaluation, using procedure-specific hospital performance as the primary factor in the selection of a local hospital for colorectal cancer surgery was associated with improved outcomes for both patients and society. Surgical outcomes data can be used to transform care and guide policy in colorectal cancer.