Disparities in quality of care for colon cancer between hospitals in the Netherlands☆
Introduction
Ever since the Institute of Medicine reviewed variations in the quality of cancer care in their 1999 report,1 there is an ongoing debate on this issue, not only in the United States, but also in European countries. Especially, the differences in surgical outcome of patients treated in high- and low-volume hospitals and between specialized and non-specialized providers, have been studied extensively.2, 3, 4 Most of these studies focus on adverse outcomes like complications and postoperative mortality; few describe differences in the proportion of patients getting optimal treatment for their cancer.
In the Netherlands, colon cancer is one of the most frequent cancers with more than 7500 new diagnoses in 2007.5 It is also one of the most frequent causes of cancer death with more than 3800 deaths in 2007.6 According to the current Dutch guideline, the primary treatment for colon cancer is surgery, while adjuvant chemotherapy should be considered for patients with lymph node metastasis. Therefore, adequate lymph node evaluation is important in patients with colon cancer7, 8, 9; 10 or more lymph nodes should be evaluated for accepting N0 status.10 However, regional population-based studies in the Netherlands showed large variation on the level of lymph nodes evaluated by pathologists and in the proportion of patients receiving adjuvant chemotherapy.11, 12
Currently, colon cancer patients are treated in every hospital in the Netherlands. These patients are treated in different settings: university, teaching and non-teaching hospitals; high- and low-volume hospitals, situated in urbanized or more rural regions. It is unknown, to what extent these structural differences between hospitals lead to differences in patterns of care and outcome. A number of studies demonstrated better patient outcomes in teaching versus non-teaching hospitals.13, 14, 15 Others found lower mortality with increasing hospital or surgeon volume.16, 17 However, studies on mortality among patients with colon cancer showed conflicting results: some demonstrated an association between mortality and hospital volume or teaching status, while others did not.18, 19, 20, 21, 22, 23, 24
Aim of this study was to describe variation in staging, treatment patterns and outcome according to region and, according to type and volume of individual hospitals among patients with colon cancer in the Netherlands.
Section snippets
Netherlands Cancer Registry
In the Netherlands, all newly diagnosed malignancies are registered in the nationwide population-based Netherlands Cancer Registry (NCR). The automated pathological archive (PALGA) and the haematology departments are the main sources of notification. The National Registry of Hospital Discharge Diagnosis is an additional source, which accounts for up to 8% of new cases.25 Data are collected from the medical records by specially trained registrars and are coded according to a nationally used
Results
In the period 2001–2006, 39 907 patients were newly diagnosed with colon carcinoma in the Netherlands, with an annual increase from 6016 in 2001 to 7360 in 2006. The male/female ratio was 1:1 and 40% of the patients were aged 75 years or older. Most frequent were stage II tumours (35%). Stage was unknown for 3% of the patients. Six percent of the patients were diagnosed in a university hospital and half of the patients were diagnosed in a hospital with 50–100 diagnoses per year (Table 1).
Discussion
In this nationwide population-based study, analyzing Netherlands Cancer Registry data of 39 907 patients with colon carcinoma diagnosed in the period 2001–2006, considerable variation in treatment patterns and outcome was identified. The proportion of patients receiving optimal postoperative staging with adequate lymph node evaluation and accurate treatment for their cancer increased considerably over time, but differed widely between individual hospitals.
Being diagnosed in a hospital with a
Conflict of interest statement
None declared.
Funding
This article is published in a supplement sponsored by a grant from the Dutch Cancer Society. The Dutch Cancer Society did not influence the article in any way.
Acknowledgements
The authors thank the registration teams of the Comprehensive Cancer Centres for the collection of data for the Netherlands Cancer Registry and the investigators of the Netherlands Cancer Registry involved in the analyses of quality of cancer care.
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Study performed by the ‘Quality of cancer care’ taskforce of the Signalling Committee Cancer of the Dutch Cancer Society (the committees full report is available on www.kwfkankerbestrijding.nl).