Colon cancer requires interdisciplinary care with quality of initial surgical treatment being a major prognostic factor. Implementation of quality standards based on structural and procedural indicators in routine care via certification (Germany) or accreditation (USA) is an established quality assurance method. However, evidence on effects is scarce. We undertook a population-based cohort study to investigate the effectiveness of colon cancer care in certified vs non-certified hospitals.
Materials and methods
We utilized data of a large statutory health insurance including in- and outpatient data from 2005 to 2015 of >2 million individuals from Saxony, Germany. Case definitions were based on diagnosis, medical procedures and prescriptions. Patients treated in certified hospitals (CH) were compared to patients treated in non-certified hospitals (NCH) using logistic and Cox regression models adjusting for relevant confounders concerning overall survival (OS), disease-specific survival (DSS), 30-day mortality, recurrence, complications and second resections within 6 months after first resection (SR).
Overall, 6186 patients with incident colon cancer undergoing surgery were identified (mean age 74.1 ± 11.0 years, 51.1% male) with 2120 (34.3%) patients treated in a CH. Confounder-adjusted regression models indicated positive effects in CH on OS (HR = 0.90, 95%CI: 0.83–0.97), DSS (HR = 0.71, 95%CI: 0.57–0.88), 30-day mortality (OR = 0.69, 95%CI: 0.55–0.87) and SR (OR = 0.51, 95%CI: 0.30–0.87). These results remained stable after adjustment for hospital volume. 30-day mortality in 2014 was 41% lower in CH (7.4%) compared to NCH (12.6%).
This study indicates that the implementation and assurance of evidence-based quality standards has substantial positive effects on various patient-relevant outcomes in colon cancer care.
Abbreviations:AIC (Akaike information criterion), ATC (Anatomical Therapeutic Chemical code), CH (Certified hospital), DGAV (“Deutsche Gesellschaft für Allgemein-und Viszeralchirurgie” (German Society for General and Visceral surgery)), DKG (“Deutsche Krebsgesellschaft” (German Cancer Society)), DSS (Disease-specific survival), EBM (“Einheitlicher Bewertungsmaβstab” (Uniform Value Scale)), HR (Hazard Ratio), NCH (Non-certified hospital), OPS (“Operationen-und Prozedurenschlüssel” (German modification of the International Classification of Procedures in Medicine)), OR (Odds Ratio), OS (Overall survival), PZN (pharmaceutical registration numbers), SR (second resections within 6 months after first resection), UICC (Union international contre le cancer), 95%CI (95% confidence intervals)
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Published online: May 17, 2018
Accepted: May 9, 2018
© 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.