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.

译文

目的:分析从2003年至2014年实施中央集权化对英国膀胱癌的根治性膀胱切除术(RC)的集中化对术后死亡率,住院时间(LoS),并发症和再干预率的影响。2002年,英国的一项政策制定者在全球癌症外科委员会发现了在提供RC护理方面存在的重大缺陷后,针对泌尿系统癌症引入了“改善结果指南”(IOG)。一项重要建议是将区域合作中心集中到高产出中心。自从引入IOG以来,还没有研究有力地分析这些变化,以评估拥有有关此类机构转型的成熟数据的国家医疗保健系统。
病人与方法:根据《医院病情统计》(HES)数据分析了2003/2004年至2013/2014年在英格兰进行的膀胱癌RCs。结果包括30天,90天和1年的全因术后死亡率;中位数视距;计算并发症发生率和再干预率。进行多变量统计分析以描述每个外科医生与提供者的年度病例数量和死亡率之间的关系。
结果:总共鉴定出15 292个RC。与IOG指南不符的RC的百分比从65%降低到12.4%,对应的30天死亡率从2.7%降低到1.5%(P = 0.024)。遵循IOG指南的程序的LoS较好,其30天死亡率(2.1%比2.9%; P = 0.003)和没有更好的1年死亡率(21.5%比25.6%; P <0.001),LoS(14) vs 16天; P <0.001)和再干预率(30.0%vs 33.6%; P <0.001)。每个中心的每一次额外手术都会使30天时的死亡几率降低1.5%(赔率[OR] 0.985,95%置信区间[CI] 0.977-0.992)和1%时1%(OR 0.990,95%CI 0.988) -0.993),并显着降低了再次干预率。
结论:自从2002年IOG指南发布以来,英格兰就开始实行集中化措施。结果有所改善,包括每个中心每年增加一次额外程序可以显着降低死亡率和再次干预,这可能为医疗保健计划者提供证据以此为基础,为进一步优化外科手术提供新的指导,并希望其他医疗保健系统能够实现这种广泛的机构变革,并带来积极的影响。

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