Disparities in quality of care for colon cancer between hospitals in the Netherlands

https://doi.org/10.1016/j.ejso.2010.05.026Get rights and content

Abstract

Background

Aim of this study was to describe treatment patterns and outcome according to region, and according to hospital types and volumes among patients with colon cancer in the Netherlands.

Methods

All patients with invasive colon carcinoma diagnosed in the period 2001–2006 were selected from the Netherlands Cancer Registry. Logistic regression analyses were performed to examine the influence of relevant factors on the odds of having adequate lymph node evaluation, receiving adjuvant chemotherapy and postoperative mortality. Relative survival analysis was used to estimate relative excess risk of dying according to hospital type and volume.

Results

In total, 39 907 patients were selected. Patients diagnosed in a university hospital had a higher odds (OR 2.47; 95% CI 2.19–2.78) and patients diagnosed in a hospital with >100 colon carcinoma diagnoses annually had a lower odds (OR 0.70; 95% CI 0.64–0.77) of having ≥10 lymph nodes evaluated. The odds of receiving adjuvant chemotherapy was lower in patients diagnosed in teaching hospitals (OR 0.85; 95% CI 0.73–0.98) and university hospitals (OR 0.56; 95% CI 0.45–0.70) compared to patients diagnosed in non-teaching hospitals. Funnel plots showed large variation in these two outcome measures between individual hospitals. No differences in postoperative mortality were found between hospital types or volumes. Patients diagnosed in university hospitals and patients diagnosed in hospitals with >50 diagnoses of colon carcinoma per year had a better survival.

Conclusions

Variation in treatment and outcome of patients with colon cancer in the Netherlands was revealed, with differences between hospital types and volumes. However, variation seemed mainly based on the level of the individual hospital.

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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