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Editorial: All for one, one for all: is centralisation the way to go?

The need to centralise complex surgical procedures in large centres remains at the core of many health policy discussions. Much of the debate is focussed on three main aspects: (i) outcomes, (ii) costs and (iii) accessibility. Gray et al. [1] recently noted that increasing centralisation may be unnecessary for invasive procedures such as nephrectomy and cystectomy. Specifically, they noted almost no difference in outcomes of high‐volume centralised centres and those with lower throughput. Their findings go against most of the current literature on the volume–outcomes relationship, which generally reports a correlation between a hospital’s volume of procedures and improved healthcare outcomes. One could ask what factors specific to their analysis could explain the different observations. For one, the healthcare system in the UK may (and likely) operate in ways different from other European and USA‐based healthcare systems, from which most of the current data are derived. Healthcare in the UK may already be organised in such a way that further centralisation may not improve outcomes, which the authors allude to in their conclusions. Differences in methodology may explain their findings, e.g. their use of multilevel modelling, testing specific incremental volume cutoffs, etc. Outcome selection may play a role as well; length of stay and re‐admissions may vary more according to organisational factors rather than individual surgeon expertise.

Regardless of their findings, we would argue that there are other tangible benefits to centralisation, which extend well beyond ‘better outcomes’. For instance, the management of the modern oncological, and urological, patient is critically dependent on a multidisciplinary team. The inherent multidisciplinary nature of large centres facilitates patients receiving their entire course of treatment at the same place. This enhances the continuity and efficiency of care, both of which are undoubtedly hampered in small peripheral centres that ultimately depend on referrals to larger facilities for advanced care for the most complex patients.

This ties into yet another major advantage of centralised centres, which is the ease of access to research. For instance, our affiliated cancer centre runs >1100 active clinical trials, 42 of which pertain to advanced urological diseases. Such trials provide access to otherwise unavailable therapies and enhance the production, diffusion, and application of knowledge.

In touting the many benefits of centralisation, one would imagine it comes at a significant cost. While this may have been true in the past, recent data comparing the higher‐volume teaching hospitals to lower‐volume non‐teaching centres suggest that centralisation actually decreases the 30‐day hospital costs and have similar costs at 90 days compared with non‐teaching hospitals [2]. Similar trends were also seen with radical cystectomies [3] and prostatectomies [4], showing that with the major urological procedures, centralisation is cost‐effective with at least the same outcomes as compared to peripheral centres.

A common objection to centralisation is that it forces many patients to travel long distances and that this in turn could introduce or worsen discrepancies in accessibility to care. If true, this would have profound social and economic consequences for disadvantaged groups, as well as particularly fragile patients. Many centralised centres have developed approaches to ease the burdens of travelling from afar and, if patients can make the journey, the data suggest a survival advantage over those who are treated at peripheral centres. To this end, Vetterlein et al. [5] stratified >700 000 patients by risk class and demonstrated an overall survival benefit in those with all stages of prostate cancer. In the not‐too‐distant future, patient follow‐up can be shifted almost entirely to telemedicine, which can further alleviate travel burdens.

Our aim is not to promote a system of oncological care based solely at centralised hubs. However, to suggest that all care should be distributed equally across all centres seems unrealistic and may have devastating consequences, particularly for those with advanced disease. We strongly advocate the treatment of complex disease at high‐volume, centralised centres and suggest better use of an impartial classification of what constitutes a ‘complex’ disease. Therefore, one answer to this problem is broadly represented by the redistribution of the different surgical procedures amongst the hospitals.

by Daniele Modonutti, Venkat M. Ramakrishnan and Quoc‐Dien Trinh

 

References

  1. Gray WKDay JBriggs TWHarrison SUnderstanding volume‐outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme. BJU Int 2020125234– 43
  2. Burke LGKhullar DZheng JFrakt ABOrav EJJha AKComparison of costs of care for medicare patients hospitalized in teaching and nonteaching hospitals. JAMA Netw Open 20192: e195229
  3. Leow JJReese STrinh QD et al. Impact of surgeon volume on the morbidity and costs of radical cystectomy in the USA: a contemporary population‐based analysis. BJU Int 2015115713– 21
  4. Gershman BMeier SKJeffery MM et al. Redefining and contextualizing the hospital volume‐outcome relationship for robot‐assisted radical prostatectomy: implications for centralization of care. J Urol 201719892– 9
  5. Vetterlein MWLöppenberg BKarabon P et al. Impact of travel distance to the treatment facility on overall mortality in US patients with prostate cancer. Cancer 20171233241– 52

 

 

 

Video: Centralisation of RC for bladder cancer in England

Centralisation of radical cystectomies for bladder cancer in England, a decade on from the ‘Improving Outcomes Guidance’: the case for super centralisation

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Abstract

Objective

To analyse the impact of centralisation of radical cystectomy (RC) provision for bladder cancer in England, on postoperative mortality, length of stay (LoS), complications and re-intervention rates, from implementation of centralisation from 2003 until 2014. In 2002, UK policymakers introduced the ‘Improving Outcomes Guidance’ (IOG) for urological cancers after a global cancer surgery commission identified substantial shortcomings in provision of care of RCs. One key recommendation was centralisation of RCs to high-output centres. No study has yet robustly analysed the changes since the introduction of the IOG, to assess a national healthcare system that has mature data on such institutional transformation.

Patients and Methods

RCs performed for bladder cancer in England between 2003/2004 and 2013/2014 were analysed from Hospital Episode Statistics (HES) data. Outcomes including 30-day, 90-day, and 1-year all-cause postoperative mortality; median LoS; complication and re-intervention rates, were calculated. Multivariable statistical analysis was undertaken to describe the relationship between each surgeon and the providers’ annual case volume and mortality.

Results

In all, 15 292 RCs were identified. The percentage of RCs performed in discordance with the IOG guidelines reduced from 65% to 12.4%, corresponding with an improvement in 30-day mortality from 2.7% to 1.5% (P = 0.024). Procedures adhering to the IOG guidelines had better 30-day mortality (2.1% vs 2.9%; P = 0.003) than those that did not, and better 1-year mortality (21.5% vs 25.6%; P < 0.001), LoS (14 vs 16 days; P < 0.001), and re- intervention rates (30.0% vs 33.6%; P < 0.001). Each single extra surgery per centre reduced the odds of death at 30 days by 1.5% (odds ratio [OR] 0.985, 95% confidence interval [CI] 0.977–0.992) and 1% at 1 year (OR 0.990, 95% CI 0.988–0.993), and significantly reduced rates of re-intervention.

Conclusion

Centralisation has been implemented across England since the publication of the IOG guidelines in 2002. The improved outcomes shown, including that a single extra procedure per year per centre can significantly reduce mortality and re-intervention, may serve to offer healthcare planners an evidence base to propose new guidance for further optimisation of surgical provision, and hope for other healthcare systems that such widespread institutional change is achievable and positive.

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Editorial: Examining the role of centralisation of radical cystectomy for bladder cancer

Despite the high risk of postoperative complications and/or death, radical cystectomy (RC) is currently considered as the standard of care for patients with muscle-invasive bladder cancer (MIBC) without clinical evidence of metastases at initial diagnosis. As an alternative, trimodality bladder-sparing therapy with a potentially more favourable toxicity profile has been developed over recent decades, but definitive surgery may provide better cancer control outcomes, especially in fit individuals. Consequently, efforts have been made recently to improve RC quality by introducing new concepts in the perioperative management of patients with MIBC. For example, the implementation of robot-assisted techniques and enhanced recovery protocols may help to reduce surgical stress and facilitate discharge after early rehabilitation. Nonetheless, such valuable interventions are more likely to be delivered at expert centres in MIBC management.

Interestingly, given that surgical experience mostly comes from surgical volume, numerous studies suggest that there is an inverse relationship between hospital as well as surgeon volume and morbidities for major surgeries including RC. Specifically, a recent meta-analysis showed that high-volume hospitals (odds ratio [OR] 0.55, 95% CI: 0.44–0.69; P < 0.001) and surgeons (OR 0.58, 95% CI: 0.46–0.73; P < 0.001) were significantly associated with a lower risk of death after RC [1]. As a result, centralisation of RC at high-output centres has been advocated worldwide to optimise perioperative management of patients with MIBC and improve short-term outcomes.

In this issue of the BJUI, Afshar et al. [2] eloquently show that such a healthcare policy can be effective at the population level. The authors impressively collected perioperative information on >15 000 RC patients from the Hospital Episode Statistics (HES) dataset in England, where the ‘Improving Outcomes Guidance’ (IOG) programme recommends since 2002 that RC should be performed by surgeons operating at least five cases per year at centres carrying out ≥50 procedures per year. Interestingly, they found that the proportion of RC performed in discordance with IOG guidelines decreased from 60.7% in 2003 to 12.4% in 2013. This resulted in a significant improvement in the overall 30-day crude mortality rate, with a reduction from 2.7% to 1.5% over the 11-year period (P = 0.02). After adjusting for available confounding, RC patients in the non-IOG-compliant group were more likely to die at 30 days (OR 1.41, 95% CI: 1.13–1.76) or 1 year (OR 1.31, 95% CI: 1.21–1.43) as compared to those in the IOG-compliant group. When analysing the incremental effect of hospital volume, each extra RC per year reduced the risk of death at 30 days and 1 year by 1.5% (OR 0.985, 95% CI: 0.977–0.992) and 1% (OR 0.990, 95% CI: 0.988–0.993), respectively. Although there was no significant difference in the odds of postoperative complications between the two groups (OR 0.96, 95% CI: 0.88–1.04), the risk of re-intervention was higher in the non-IOG-compliant group (OR 1.20, 95% CI: 1.12–1.30). It is noteworthy that, as observed for the risk of death, each extra RC decreased the risk of re-intervention (OR 0.99, 95% CI: 0.991–0.995). In conclusion, the findings by Afshar et al. [2] suggest that urologists have embraced centralisation of care for RC patients in England and this is likely to have positively affected the short-term outcomes.

Although, as acknowledged by the authors, many limitations related to the administrative nature of the HES dataset (e.g. missing data or coding errors) may have influenced the aforementioned results, other reports from the USA are consistent with this study. Specifically, it has been estimated that up to 40% of the decline in 30-day mortality after RC from 2000 to 2008 was attributable to centralisation of care [3]. In addition, other RC quality criteria, such as adequate pelvic lymph node dissection at the time of surgery, have improved after similar centralisation in the Netherlands between 2006 and 2012 [4]. As such, centralisation of RC offers many undisputable advantages, but given that travel distance to the treating facility may represent an important barrier for patients with MIBC seeking surgical care, concerns have been raised with regards to potential drawbacks, including increased time to definitive surgery. However, a recent report from the USA showed that, although centralisation of RC has led to a decrease overall access to the treating facilities, the process simultaneously improved access to high-volume centres [5]. It is noteworthy that hospital volume standards for centralisation of RC should not be set too high to avoid unreasonable travel burdens on patients with MIBC [6].

To summarise, centralisation of care is arguably the best way to go, to continue improving quality of RC and its associated short-term outcomes in the near future. Despite inherent limitations, virtually all available evidence, including the study by Afshar et al. [2], converge toward the general concept that RC patients should be managed by experienced urologists operating at expert centres with trained surgical teams.

Thomas Seisen 
Department of Urology, Pitie Salpetriere Hospital, Assistance Publique des Hopitaux de Paris, Paris Sorbonne University, Paris, France

 

Read the full article

 

References

 

 

2 Afshar M, Goodfellow H, Jackson-Spence F et al. Centralisation of radical cystectomies for bladder cancer in England, a decade on from the ‘Improving Outcomes Guidance: the case for super centralisation. BJU Int 2018; 121: 21724 166

 

 3 Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011; 364: 212837

 

4 Hermans TJ, Fransen van de Putte EE, Fossion LM et al. Variations in
pelvic lymph node dissection in invasive bladder cancer: a Dutch

 

nationwide population-based study during centralization of care. Urol
Oncol 2016;34:532. e7532.e12

 

5 Casey MF, Wisnivesky J, Le VH et al. The relationship between centralization of care and geographic barriers to cystectomy for bladder cancer. Bladder Cancer 2016; 2: 31927

 

6 Birkmeyer JD, Siewers AE, Marth NJ, Goodman DC. Regionalization of high-risk surgery and implications for patient travel times. JAMA 2003; 290: 27038

 

Article of the Week: Centralisation of RC for bladder cancer in England

Every Week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video discussing the paper.

If you only have time to read one article this week, it should be this one.

Centralisation of radical cystectomies for bladder cancer in England, a decade on from the ‘Improving Outcomes Guidance’: the case for super centralisation

Mehran Afshar*, Henry Goodfellow, Francesca Jackson-Spence, Felicity Evison§John Parkin§, Richard T. Bryan, Helen Parsons, Nicholas D. James§‡ and Prashant Patel§

 

*St Georges Hospital NHS Trust, London, UK, The Royal Free London NHS Trust, London, UK, University of Birmingham, Birmingham, UK, §University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK, and Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
Read the full article

Abstract

Objective

To analyse the impact of centralisation of radical cystectomy (RC) provision for bladder cancer in England, on postoperative mortality, length of stay (LoS), complications and re-intervention rates, from implementation of centralisation from 2003 until 2014. In 2002, UK policymakers introduced the ‘Improving Outcomes Guidance’ (IOG) for urological cancers after a global cancer surgery commission identified substantial shortcomings in provision of care of RCs. One key recommendation was centralisation of RCs to high-output centres. No study has yet robustly analysed the changes since the introduction of the IOG, to assess a national healthcare system that has mature data on such institutional transformation.

Patients and Methods

RCs performed for bladder cancer in England between 2003/2004 and 2013/2014 were analysed from Hospital Episode Statistics (HES) data. Outcomes including 30-day, 90-day, and 1-year all-cause postoperative mortality; median LoS; complication and re-intervention rates, were calculated. Multivariable statistical analysis was undertaken to describe the relationship between each surgeon and the providers’ annual case volume and mortality.

Results

In all, 15 292 RCs were identified. The percentage of RCs performed in discordance with the IOG guidelines reduced from 65% to 12.4%, corresponding with an improvement in 30-day mortality from 2.7% to 1.5% (P = 0.024). Procedures adhering to the IOG guidelines had better 30-day mortality (2.1% vs 2.9%; P = 0.003) than those that did not, and better 1-year mortality (21.5% vs 25.6%; P < 0.001), LoS (14 vs 16 days; P < 0.001), and re- intervention rates (30.0% vs 33.6%; P < 0.001). Each single extra surgery per centre reduced the odds of death at 30 days by 1.5% (odds ratio [OR] 0.985, 95% confidence interval [CI] 0.977–0.992) and 1% at 1 year (OR 0.990, 95% CI 0.988–0.993), and significantly reduced rates of re-intervention.

Conclusion

Centralisation has been implemented across England since the publication of the IOG guidelines in 2002. The improved outcomes shown, including that a single extra procedure per year per centre can significantly reduce mortality and re-intervention, may serve to offer healthcare planners an evidence base to propose new guidance for further optimisation of surgical provision, and hope for other healthcare systems that such widespread institutional change is achievable and positive.

Read more articles of the week

 

Article of the Week: Centralized histopathological review in penile cancer. Should this be the global standard?

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Should centralized histopathological review in penile cancer be the global standard?

Vincent Tang, Laurence Clarke, Zara Gall, Jonathan H. Shanks, Daisuke, Nonaka, Nigel J. Parr, P. Anthony Elliott, Noel W. Clarke, Vijay Ramani, Maurice W. Lau and Vijay K. Sangar

The Christie NHS Foundation Trust, Manchester and the *Royal Bolton NHS Foundation Trust, Bolton, UK

Read the full article
OBJECTIVE
  • To assess the role of centralized pathological review in penile cancer management.
MATERIALS AND METHODS
  • Newly diagnosed squamous cell carcinomas (SCC) of the penis, including squamous cell carcinoma in situ (CIS), from biopsy specimens were referred from 15 centres to the regional supra-network multidisciplinary team (Sn-MDT) between 1 January 2008 and 30 March 2011.
  • Biopsy histology reports and slides from the respective referring hospitals were reviewed by the Sn-MDT pathologists.
  • The biopsy specimens’ histological type, grade and stage reported by the Sn-MDT pathologist were compared with those given in the referring hospital pathology report, as well as with definitive surgery histology.
  • Any changes in histological diagnosis were sub-divided into critical changes (i.e. those that could alter management) and non-critical changes (i.e. those that would not affect management).
RESULTS
  • A total of 155 cases of squamous cell carcinoma or CIS of the penis were referred from 15 different centres in North-West England.
  • After review by the Sn-MDT, the histological diagnosis was changed in 31% of cases and this difference was statistically significant. A total of 60.4% of the changes were deemed to be critical changes that resulted in a significant change in management.
  • When comparing the biopsy histology reported by the Sn-MDT with the final histology from the definitive surgical specimens, a good correlation was generally found.
CONCLUSIONS
  • In the present study a significant proportion of penile cancer histology reports were revised after review by the Sn-MDT. Many of these changes altered patient management.
  • The present study shows that accurate pathological diagnosis plays a crucial role in determining the correct treatment and maximizing the potential for good clinical outcomes in penile cancer.
  • In the case of histopathology, centralization has increased exposure to penile cancer and thereby increased diagnostic accuracy, and should therefore be considered the ‘gold standard’.
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Editorial: A call for the international adoption of penile specialist networks

The recent article by Tang et al. [1] from the Christie Hospital in Manchester raises an interesting question. The urological cancer plan for England and Wales specifies that review of the pathology of prostate and high-risk superficial bladder cancer should take place as part of the referral process for these cases to specialist pelvic cancer teams, but the penile pathway does not indicate that this is necessary [2]. The Royal College of Pathologists [3] also specifies the need for expert review and/or double reporting in other rare cancers and dysplasias, but does not yet specify this for penile cancers.

Penile cancers are rare, with 600 new cases diagnosed in the UK per year. They are almost invariably squamous cell carcinomas, which also occur at other sites including the lung, upper aerodigestive tract and skin. This may lead some pathologists to assume that they are similar and do not need second opinion or review; however, the subtypes of squamous cell carcinoma that occur on the penis are not common elsewhere, include basaloid, warty and verrucous carcinomas [4], and are not always recognized by general pathologists. The anatomy of the penis is challenging and the identification of invasion of urethra, corpus spongiosum and corpus cavernosum is important in accurate staging. Penile cancers have their own TNM system. TNM7, published in 2010 [5], recognises the importance of grading and different stage groups on prognosis.

Our own experience at St George’s Hospital in South London mirrors that of the Christie Hospital in North West England. Our practice from the outset of the establishment of our supra-regional penile centre was to review outside pathology in the setting of our specialist multidisciplinary meeting to devise a management plan for each patient. We also found that our reviewed cases were more likely to be under-graded and that staging was frequently inaccurate if it was attempted at all. Our original audit was presented at the BAUS annual meeting in 2005. We repeated the audit in 2008 after the publication of the Royal College of Pathologists guidelines on the reporting of penile cancer and found no improvement (unpublished data).

An average urological pathologist in a non-specialist centre in the UK will only see 1–3 cases of penile cancer per year and will have little opportunity or incentive to gain expertise in this area. Although second opinion services through the supra-networks are freely available, these are not always sought, perhaps because of time pressures and the mistaken impression that penile cancers are like those of other sites. There is also a lack of awareness of new entities, for example, differentiated penile intraepithelial neoplasia (PeIN) and subtypes of undifferentiated PeIN. There has been a recent change in nomenclature, whereby all morphological types of squamous carcinoma in situ and dysplasias are now classified within PeIN [6].

The supra-network of penile centres in the UK has allowed a small group of pathologists to gain expertise in the reporting of penile cancer in a specialist clinical setting, and has produced a group of pathologists with a special interest in this type of tumour, all of whom are seeing at least 25 new cases per year. Many centres are seeing more, with our own centre managing 126 new cases in 2012.

In 2008 we formed a UK-wide group of specialist penile pathologists (the Hobnobs) which meets annually to exchange both clinical and research information and to discuss individual cases. Members of this group are currently updating the Royal College of Pathologists penile guidelines [3]. These will advise central review, but we recognize we are writing them mainly for specialist pathologists to ensure consistent and high-quality assessment of penile cancer to inform the penile cancer team.

In the UK, expert pathological review of penile cancer is already the norm for the penile supra-networks, but it would be difficult to make this the global standard for several reasons. Sub-specialization in penile cancer management is not widely practised outside Britain and there are few specialist high-volume centres, with some notable exceptions in Europe and the USA. Without clinical sub-specialization it is difficult for pathologists to develop an interest and sufficient expertise to offer an expert second opinion because the numbers seen by any individual pathologist will be too small.

The UK penile supra-network system works well and has led to a group of pathologists developing an interest in this area simply because they are seeing a large number of such cases and working with dedicated clinical teams. Penile supra-networks should be adopted worldwide. Following this, a group of expert and experienced pathologists will ultimately be developed, who can offer a central review and expert second opinion service, as has happened over the last 10 years in the UK.

Read the full article

Catherine M. Corbishley
Department of Cellular Pathology, St George’s Healthcare NHS
Trust, London, UK

References

1. Tang V, Clarke L, Gall Z et al. Should centralised histopathological review in penile cancer be the global standard? BJU Int 2014;114: 340–343

2. Manual for Cancer services. Urology measures Version 2.1. NHS National Cancer Peer Review Programme 2011 and Evidence guide for Urology Supraregional Penile MDT NHS National Cancer Peer Review Programme 2010.

3. Royal College of Pathologists. Cancer Datasets and Tissue Pathways. Available at: https://www.rcpath.org/publications-media/publications/datasets.

4. Epstein JI, Cubilla AL, Humphrey PA. Tumours of the Prostate Gland, Seminal Vesicles, Penis and Scrotum. American Registry of Pathology, Washington DC published in collaboration with the Armed Forces Institute of Pathology, 2011, 405–612

5. Gospodarowicz MK (section editor, Genitourinary Tumours). TNM classification of malignant tumours (7th edition) penis. In Edge SB,Byrd DR, Compton CC Fritz AG, Greene FL, Trotti A eds, AJCC Cancer Staging Manual, 7th edn. New York: Springer, 2010:447–455

6. Velazquez EF, Chaux A, Cubilla AL. Histologic classification of penile intraepithelial neoplasia. Semin Diagn Pathol 2012; 29: 96–102

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