Afshar Mehran, Goodfellow Henry, Jackson-Spence Francesca, Evison Felicity, Parkin John, Bryan Richard T, Parsons Helen, James Nicholas D, Patel Prashant
St George's Hospital NHS Trust, London, UK.
The Royal Free London NHS Trust, London, UK.
BJU Int. 2018 Feb;121(2):217-224. doi: 10.1111/bju.13929. Epub 2017 Jul 10.
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.
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.
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.
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.
分析2003年至2014年在英格兰将膀胱癌根治性膀胱切除术（RC）的实施集中化，对术后死亡率、住院时间（LoS）、并发症及再次干预率的影响。2002年，在全球癌症手术委员会确定RC护理存在重大缺陷后，英国政策制定者出台了针对泌尿系统癌症的“改善预后指南”（IOG）。一项关键建议是将RC集中到高产量中心。尚无研究对IOG出台后的变化进行有力分析，以评估一个拥有此类机构转型成熟数据的国家医疗体系。
从医院事件统计（HES）数据中分析2003/2004年至2013/2014年在英格兰为膀胱癌实施的RC。计算包括30天、90天和1年全因术后死亡率、中位LoS、并发症及再次干预率等结局指标。进行多变量统计分析以描述每位外科医生与医疗机构年病例量及死亡率之间的关系。
共识别出15292例RC。不符合IOG指南实施的RC比例从65%降至12.4%，相应地30天死亡率从2.7%降至1.5%（P = 0.024）。遵循IOG指南的手术30天死亡率（2.1%对2.9%；P = 0.003）低于未遵循的手术，1年死亡率（21.5%对25.6%；P < 0.001）、LoS（14天对16天；P < 0.001）及再次干预率（30.0%对33.6%；P < 0.001）也更低。每个中心每年每多做一台手术，30天死亡几率降低1.5%（比值比[OR] 0.985，95%置信区间[CI] 0.9 – 0.992），1年时降低1%（OR 0.990，95% CI 0.988 - 0.993），并显著降低再次干预率。
自2002年IOG指南发布以来，英格兰已全面实施集中化。所显示的改善结局，包括每个中心每年多做一台手术可显著降低死亡率和再次干预率，可为医疗规划者提供证据基础，以提出进一步优化手术实施的新指南，并为其他医疗体系带来希望，即这种广泛的机构变革是可实现且积极的。
