Centers offering specialist cancer surgery are investing in unproven technologies in a bid to attract more patients and avoid the threat of closure, concludes an analysis that highlights recent changes in the provision of radical prostatectomy for prostate cancer in the United Kingdom.
The study of more than 19,000 men treated over 4 years in the UK National Health Service (NHS) revealed that surgical centers that gained patients, typically from outside their local area, were eight times more likely to offer robotic surgery vs none of the centers that closed.
The research, which was published online in Lancet Oncology on October 3, was lead by Ajay Aggarwal, MD, from the Department of Health Services Research and Policy at the London School of Hygiene & Tropical Medicine, London, United Kingdom.
“Even within publicly-funded systems like the NHS, competition policies have stimulated a form of centralisation through ‘natural selection’, as centres invest in unproven new technologies to protect their status, instead of services being regionally planned and coordinated,” Dr Aggarwal commented in a statement.
“Similar patterns have been observed in other healthcare markets such as the United States,” he added.
“Rapid adoption of high technology therapies is not unique to prostate cancer, and further research should look at other types of cancer where new types of treatment are increasingly available as well,” he suggested.
Increased Patient Choice
A major tool for driving improvements in the quality of healthcare in recent years has been to give patients the choice over their healthcare provider, a move that has been accompanied by the centralization of specialist cancer services.
In the United Kingdom, this was expected to lead to patients being treated at their nearest hospital, following standard referral patterns, despite care being free at the point of access and patients having the right to choose any hospital that meets their needs.
However, a previous study by the team revealed that around one third of men who underwent radical prostatectomy for prostate cancer were not treated in their nearest hospital and that the younger, fitter, and more affluent men were more likely to travel.
The researchers therefore conducted a population-based analysis of patient choice and hospital competition, obtaining individual patient-level data from the National Cancer Registration and Analysis Service for all men diagnosed with prostate cancer who underwent radical prostatectomy in the UK NHS between 2010 and 2014.
These were linked at the patient level to the Hospital Episode Statistics database of all NHS hospitals in England, from which the changes in the configuration of prostate cancer surgical units and in the availability of robotic surgery during the study was examined.
The team also determined each patient’s residence. Patients using their nearest center were defined as “core users,” and those who did not were defined as “bypassers.”
The researchers calculated, for each surgical center, the number of patients who had surgery elsewhere, despite it being their local hospital (“leavers”), and the number who had surgery there, although it was not their local center (“arrivers”).
Finally, the spatial competition index (SCI) was calculated for each center to measure the degree of external competition, in terms of the demand for services and the availability of alternative hospitals.
The team identified 19,518 men who underwent radical prostatectomy for prostate cancer between 2010 and 2014, of whom 19,256 were included in the analysis.
Of the 65 surgical centers open in 2010, 23 (35%) gained patients and 37 (57%) lost patients during the study period, with five centers experiencing no net changes. Ten (27%) of the centers with a net loss closed down during the study period.
In some cases, units performed 400 to 500 more procedures than they would have done had they operated only on local men, while some of those that lost patients performed 200 fewer procedures than expected.
Centers with a net gain of patients were more likely to be established robotic centers than those with a net loss, at 43% vs 5% (P = .0043).
The largest net gains and losses of patients were seen in the most competitive areas.
Moreover, established robotic centers were more likely to be located in the highest quartile of SCI scores, at 7 (41%) of the 17 centers in the highest quartile vs 5 (10%) of the 48 centers in the other quartiles (P = .0050).
Center closures were also more common in hospitals in the highest quartile of SCI scores than in centers in the other quartiles, at 6 (35%) vs 4 (8%) (P = .0081).
The team found large-scale adoption of robotic surgery during the study period, increasing from 12 (18%) of 65 centers in 2010 to 39 (71%) of 55 centers in 2014.
The trend increased after the study period, reaching 42 (86%) of 49 centers in 2017.
The researchers write: “Both the closures and the rapid and widespread adoption of robotic surgery have been unforeseen, effectively rendering commissioning guidelines — published only in 2015 and recommending phased introduction of robotics for prostate cancer surgery within the NHS — obsolete.”
Dr Aggarwal commented: “NHS choice and competition policy [are] based on the principle that patients will travel to centres they think will provide the best service.”
“Closures were never intended to result from this, but the large number of patients deciding to receive treatment elsewhere meant some centres faced the risk of closures as they were no longer performing a sufficient number of procedures to sustain their service.”
He continued: “However, since there are no publicly available indicators to help patients judge the quality of prostate cancer surgery, patients have to make their choices based on other factors.”
“In this case, it appears that patients use the availability of robotic prostatectomy as an indicator of high quality care, despite a lack of evidence of its superiority compared with open surgery.”
The study was funded by the National Institute for Health Research. Dr Aggarwal is funded by a Doctoral Research Fellowship from the National Institute for Health Research. Coauthor Dr van der Meulen is partly supported by the NHS National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North Thames at Bart’ s Health NHS Trust. Dr van der Meulen reports grants from Healthcare Quality Improvement Partnership during the conduct of the study. The other authors have disclosed no relevant financial relationships.
Lancet Oncol. Published online October 3, 2017. Abstract
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