van der Schors Wouter, Kemp Ron, van Hoeve Jolanda, Tjan-Heijnen Vivianne, Maduro John, Vrancken Peeters Marie-Jeanne, Siesling Sabine, Varkevisser Marco
Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
BMJ Open. 2022 Apr 26;12(4):e057301. doi: 10.1136/bmjopen-2021-057301.
For oncological care, there is a clear tendency towards centralisation and collaboration aimed at improving patient outcomes. However, in market-based healthcare systems, this trend is related to the potential trade-off between hospital volume and hospital competition. We analyse the association between hospital volume, competition from neighbouring hospitals and outcomes for patients who underwent surgery for invasive breast cancer (IBC).
Surgical margins, 90 days re-excision, overall survival.
DESIGN, SETTING, PARTICIPANTS: In this population-based study, we use data from the Netherlands Cancer Registry. Our study sample consists of 136 958 patients who underwent surgery for IBC between 2004 and 2014 in the Netherlands.
Our findings show that treatment types as well as patient and tumour characteristics explain most of the variation in all outcomes. After adjusting for confounding variables and intrahospital correlation in multivariate logistic regressions, hospital volume and competition from neighbouring hospitals did not show significant associations with surgical margins and re-excision rates. For patients who underwent surgery in hospitals annually performing 250 surgeries or more, multilevel Cox proportional hazard models show that survival was somewhat higher (HR 0.94). Survival in hospitals with four or more (potential) competitors within 30 km was slightly higher (HR 0.97). However, this effect did not hold after changing this proxy for hospital competition.
Based on the selection of patient outcomes, hospital volume and regional competition appear to play only a limited role in the explanation of variation in IBC outcomes across Dutch hospitals. Further research into hospital variation for high-volume tumours like the one studied here is recommended to (i) use consistently measured quality indicators that better reflect multidisciplinary clinical practice and patient and provider decision-making, (ii) include more sophisticated measures for hospital competition and (iii) assess the entire process of care within the hospital, as well as care provided by other providers in cancer networks.
在肿瘤护理方面，存在明显的集中化和协作趋势，旨在改善患者预后。然而，在以市场为基础的医疗体系中，这一趋势与医院规模和医院竞争之间的潜在权衡有关。我们分析了医院规模、来自邻近医院的竞争与接受浸润性乳腺癌（IBC）手术患者的预后之间的关联。
手术切缘、90天再次切除率、总生存率。
设计、设置、参与者：在这项基于人群的研究中，我们使用了荷兰癌症登记处的数据。我们的研究样本包括2004年至2014年在荷兰接受IBC手术的136958名患者。
我们的研究结果表明，治疗类型以及患者和肿瘤特征解释了所有结局中大部分的差异。在多变量逻辑回归中对混杂变量和医院内相关性进行调整后，医院规模和来自邻近医院的竞争与手术切缘和再次切除率没有显著关联。对于每年进行250例或更多手术的医院中接受手术的患者，多水平Cox比例风险模型显示生存率略高（风险比0.94）。在30公里范围内有四个或更多（潜在）竞争对手的医院中，生存率略高（风险比0.97）。然而，在改变这种医院竞争的替代指标后，这种效应并不成立。
基于对患者结局的选择，医院规模和区域竞争在解释荷兰各医院IBC结局差异方面似乎仅起有限作用。建议对像本文所研究的这种高容量肿瘤的医院差异进行进一步研究，以（i）使用能更好反映多学科临床实践以及患者和医疗服务提供者决策的一致测量的质量指标，（ii）纳入更复杂的医院竞争测量方法，以及（iii）评估医院内部的整个护理过程，以及癌症网络中其他医疗服务提供者提供的护理。
