Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Department of Clinical Oncology, Guy's and St Thomas' National Health Service Trust, London, United Kingdom.
Cancer. 2019 Jun 1;125(11):1898-1907. doi: 10.1002/cncr.31987. Epub 2019 Feb 1.
Policies that encourage patient choice and hospital competition have been introduced across several countries with the purpose of improving the quality of health care services. The objective of the current national cohort study was to analyze the correlation between choice and competition on outcomes after cancer surgery using prostate cancer as a case study.
The analyses included all men who underwent prostate cancer surgery in the United Kingdom between 2008 and 2011 (n = 12,925). Multilevel logistic regression was used to assess the effect of a radical prostatectomy center being located in a competitive environment (based on the number of centers within a threshold distance) and being a successful competitor (based on the ability to attract patients from other hospitals) on 3 patient-level outcomes: postoperative length of hospital stay >3 days, 30-day emergency readmissions, and 2-year urinary complications.
With adjustment for patient characteristics, men who underwent surgery in centers located in a stronger competitive environment were less likely to have a 30-day emergency readmission, irrespective of the type or volume of procedures performed at each center (odds ratio, 0.46; 95% confidence interval, 0.36-0.60; P = .005). Men who received treatment at centers that were successful competitors were less likely to have a length of hospital stay >3 days (odds ratio, 0.49; 95% confidence interval, 0.25-0.94; P = .02).
The current results suggest for the first time that hospital competition improves short-term outcomes after prostate cancer surgery. Further evaluation of the potential role of patient choice and hospital competition is required to inform health service design in contrast to the role of top-down-driven approaches, which have focused on centralization of services.
鼓励患者选择和医院竞争的政策已在多个国家推出，目的是提高医疗服务质量。本项全国队列研究旨在以前列腺癌为案例研究，分析癌症手术后选择与竞争对结果的相关性。
本分析纳入了 2008 年至 2011 年期间在英国接受前列腺癌手术的所有男性（n=12925）。采用多水平逻辑回归评估了根治性前列腺切除术中心处于竞争环境（基于阈值距离内的中心数量）和作为成功竞争者（基于吸引其他医院患者的能力）对 3 个患者水平结局的影响：术后住院时间＞3 天、30 天内急诊再入院和 2 年尿失禁。
在调整了患者特征后，无论每个中心进行的手术类型或数量如何，在竞争环境更强的中心接受手术的男性 30 天内急诊再入院的可能性较低（比值比，0.46；95%置信区间，0.36-0.60；P=.005）。在成功竞争的中心接受治疗的男性，住院时间＞3 天的可能性较低（比值比，0.49；95%置信区间，0.25-0.94；P=0.02）。
目前的结果首次表明，医院竞争可改善前列腺癌手术后的短期结局。需要进一步评估患者选择和医院竞争的潜在作用，以告知卫生服务设计，而不是关注服务集中化的自上而下驱动方法。
