Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study.
Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study.
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DOI：
10.1016/s1470-2045(17)30572-7
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发表时间：
2017-11
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影响因子：
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通讯作者：
van der Meulen J
中科院分区：
文献类型：
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作者：
Aggarwal A;Lewis D;Mason M;Purushotham A;Sullivan R;van der Meulen J
关于患者选择和医院竞争政策在外科癌症服务中的作用，缺乏证据。此前的证据表明，患者准备绕过最近的癌症中心，在更远的中心接受更符合他们需求的手术。在这项以人群为基础的全国性研究中，我们以前列腺癌手术为模型，调查了患者流动性和医院竞争对英国国家医疗服务体系(NHS)服务配置和技术采用的影响。我们根据居住地和治疗地点绘制了2010年1月1日至2014年12月31日期间在英国接受根治性前列腺切除术的所有患者的地图。对于每个根治性前列腺切除术中心，我们分析了医院竞争的影响(使用空间竞争指数[SCI]衡量，分数为0表示最弱的竞争，1表示最强的竞争)，以及在2010年初成为一个已建立的机器人前列腺癌根治术中心对患者净收益或损失的影响(在一个中心接受治疗的患者数量与基于其居住地的预期数量之间的差额)，以及关闭其根治性前列腺切除术服务的可能性。2010年1月1日至2014年12月31日，19名 256患者在英国一家国民保健服务提供商接受了根治性前列腺切除术。在研究开始时开放的65个根治性前列腺切除术中心中，23个(35%)在2010-14年间患者净增长具有统计学意义。这23个中心中有10个(40%)是已建立的机器人中心。在研究期间，65个中心中有37个(57%)患者大量净流失，其中两个(5%)是机器人中心，10个(27%)关闭了根治性前列腺切除术服务。关闭的根治性前列腺切除术中心更可能位于竞争较强的地区(最高SCI四分位数[0.87-0.92]；p=0.0081)，而不是竞争较弱的地区。没有机器人手术中心关闭，无论患者的净损失有多大。进行机器人手术的中心数量从2010年初65个中心中的12个(18%)增加到2014年底开放的55个中心中的39个(71%)。除了提倡集中化和要求进行最低手术次数的政策外，竞争因素还导致了在没有证据表明结果优越的情况下对机器人手术设备的大规模投资，并导致了癌症外科部门的关闭。如果没有高质量的绩效和结果指标来指导患者的选择，这些政策可能会威胁到卫生服务提供公平和负担得起的癌症护理的能力。国家健康研究所。
There is a scarcity of evidence about the role of patient choice and hospital competition policies on surgical cancer services. Previous evidence has shown that patients are prepared to bypass their nearest cancer centre to receive surgery at more distant centres that better meet their needs. In this national, population-based study we investigated the effect of patient mobility and hospital competition on service configuration and technology adoption in the National Health Service (NHS) in England, using prostate cancer surgery as a model. We mapped all patients in England who underwent radical prostatectomy between Jan 1, 2010, and Dec 31, 2014, according to place of residence and treatment location. For each radical prostatectomy centre we analysed the effect of hospital competition (measured by use of a spatial competition index [SCI], with a score of 0 indicating weakest competition and 1 indicating strongest competition) and the effect of being an established robotic radical prostatectomy centre at the start of 2010 on net gains or losses of patients (difference between number of patients treated in a centre and number expected based on their residence), and the likelihood of closing their radical prostatectomy service. Between Jan 1, 2010, and Dec 31, 2014, 19 256 patients underwent radical prostatectomy at an NHS provider in England. Of the 65 radical prostatectomy centres open at the start of the study period, 23 (35%) had a statistically significant net gain of patients during 2010–14. Ten (40%) of these 23 were established robotic centres. 37 (57%) of the 65 centres had a significant net loss of patients, of which two (5%) were established robotic centres and ten (27%) closed their radical prostatectomy service during the study period. Radical prostatectomy centres that closed were more likely to be located in areas with stronger competition (highest SCI quartile [0·87–0·92]; p=0·0081) than in areas with weaker competition. No robotic surgery centre closed irrespective of the size of net losses of patients. The number of centres performing robotic surgery increased from 12 (18%) of the 65 centres at the beginning of 2010 to 39 (71%) of 55 centres open at the end of 2014. Competitive factors, in addition to policies advocating centralisation and the requirement to do minimum numbers of surgical procedures, have contributed to large-scale investment in equipment for robotic surgery without evidence of superior outcomes and contributed to the closure of cancer surgery units. If quality performance and outcome indicators are not available to guide patient choice, these policies could threaten health services' ability to deliver equitable and affordable cancer care. National Institute for Health Research.