Centralisation of radical cystectomies for bladder cancer in England, a decade on from the ‘Improving Outcomes Guidance’: The case for super centralisation

Mehran Afshar, Henry Goodfellow, Francesca Jackson-spence, Felicity Evison, John Parkin, Richard Bryan, Helen Parsons, Nicholas James, Prashant Patel

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Objective To analyse the impact of centralisation of radical cystectomy provision for bladder cancer in England, on post-operative mortality, length of stay, complications and re-intervention rate, from implementation of centralisation from 2002, 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 radical cystectomies. One key recommendation was centralisation of cystectomies to high output centres. No study has yet robustly analysed the changes since IOG, to assess a national healthcare system which has mature data on such institutional transformation. Methods Radical Cystectomies 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 one-year all-cause post-operative mortality, median length of stay, complications and re-interventions were calculated. Multivariable statistical analysis was undertaken to describe the relationship between each surgeon and the providers’ annual case volume and mortality. Results 15,292 cystectomies were identified. Percentage of cystectomies performed in discordance with IOG reduced from 65.0% to 12.4%, corresponding with improvement in 30-day mortality from 2.7% to 1.5% (p=0.0235). Procedures adhering to IOG had superior 30-day mortality (2.9% vs. 2.1%; p=0.0029) to those which did not, and superior one-year mortality (25.6% vs. 21.5%; p<0.001), length of stay (16 vs. 14days P<0.001) and re- intervention rates (33.6% vs. 30.0%; p<0.001). Each single extra surgery per centre reduced odds of death at 30 days by 1.5% (OR-0.985; 95%CI (0.977, 0.992) and 1% at one 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 publication of the IOG 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.
Original languageEnglish
Pages (from-to)217-224
Number of pages8
JournalBJU international
Issue number2
Early online date8 Jun 2017
Publication statusPublished - Feb 2018


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