The Impact of Centralised Services on Metric Reflecting High-quality Performance: Outcomes from 1110 Consecutive Radical Cystectomies at a Single Centre

Abstract

Background: The 2002 National Institute for Health and Care Excellence guidance on centralisation of radical cystectomy (RC) coincided with changes in practice: use of neoadjuvant chemotherapy (NAC) and pelvic lymph node dissection (PLND), and RC for high-risk non–muscle-invasive bladder cancer (HR-NMIBC). Objective: To report the outcomes of RC at a single centre and to compare trends in survival with respect to centralisation and change in RC practice. Design, setting, and participants: Data were collected retrospectively between 1 January 1994 and 31 December 2016. Patients with urothelial cell carcinoma (UCC) were selected. Outcomes from 1994 to 2007 (before centralisation, era 1) were compared with those from 2008 to 2016 (after centralisation, era 2). Outcome measurements and statistical analysis: The primary outcome was disease-specific mortality. Secondary outcomes were survival and use of NAC and PLND. Results and limitations: Overall, 1100 RCs (era 1, 316; era 2, 794) were performed for UCC. Median (interquartile range [IQR]) follow-up was 28.5 (11.9–57.4) mo. RC for NMIBC was 36.2% versus 51.3% (p < 0.001), NAC use was 2.2% versus 31.6% (p < 0.001), and PLND use was 59.7% versus 76.4% (p < 0.001) in era 1 versus era 2. The 30-d (1.6% [era 1] vs 0.8% [era 2], p = 0.21) and 90-d (4.1% vs 2.6%, p = 0.2) mortality rates did not differ with respect to RC year. Five-year disease-specific survival (DSS) was 56.0% in era 1 versus 79.0% in era 2 (p < 0.001). RC for patients aged ≥75 yr was 13.9% versus 28.1% (p < 0.001) and 30-d mortality in this group was 4.5% versus 0% (p = 0.001) in era 1 versus era 2. The study is limited by its retrospective design. Conclusions: Centralisation was associated with higher rates of NAC and PLND use, and increased RC performed for older patients and patients with HR-NMIBC. DSS was higher and RC appeared to be safer for older patients (fewer postoperative mortalities) after centralisation. Patient summary: We looked at outcomes from bladder removal for bladder cancer. Survival outcomes improved following centralisation of services. Surgery appeared to be safer for older patients, as there were fewer postoperative mortalities after centralisation. Centralisation of radical cystectomy (RC) services was associated with higher rates of neoadjuvant chemotherapy and pelvic lymph node dissection use, and increased usage of RC for older patients with high-risk non–muscle-invasive bladder cancer. Survival outcomes from RC were superior after centralisation and safer for older patients undergoing RC (fewer postoperative mortalities).