Variation in rates of breast cancer surgery: A national analysis based on French Hospital Episode Statistics

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Abstract

Aims

Minimum volume thresholds were introduced in France in 2008 to improve the quality of cancer care. We investigated whether/how the quality of treatment decisions in breast cancer surgery had evolved before and after this policy was implemented.

Methods

We used Hospital Episode Statistics for all women having undergone breast conserving surgery (BCS) or mastectomy in France in 2005 and 2012. Three surgical procedures considered as better treatment options were analyzed: BCS, immediate breast reconstruction (IBR) and sentinel lymph node biopsy (SLNB). We studied the mean rates and variation according to the hospital profile and volume.

Results

Between 2005 and 2012, the volume of breast cancer surgery increased by 11% whereas one third of the hospitals no longer performed this type of surgery. In 2012, the mean rate of BCS was 74% and similar in all hospitals whatever the volume. Conversely, IBR and SLNB rates were much higher in cancer centers (CC) and regional teaching hospitals (RTH) [IBR: 19% and 14% versus 8% on average; SLNB: 61% and 47% versus 39% on average]; the greater the hospital volume, the higher the IBR and SLNB rates (p < 0.0001). Overall, whatever the surgical procedure considered, inter-hospital variation in rates declined substantially in CC and RTH.

Conclusions

We identified considerable variation in IBR and SLNB rates between French hospitals. Although more complex and less standardized than BCS, most clinical guidelines recommended these procedures. This apparent heterogeneity suggests unequal access to high-quality procedures for women with breast cancer.

Introduction

In 2012, approximately 50 000 women were diagnosed with breast cancer in France and most of them underwent surgery. Through early detection and improved treatments, breast conserving surgery (BCS) is possible for most primary tumors [Clough et al.,1 Stang et al.2]. The surgical management of breast cancer comprises several steps: the initial excision, lymph node exploration and breast reconstruction. Several studies have shown that variations in practice between hospitals are not only driven by patient characteristics which suggests heterogeneity in the quality of care across institutions [Greenberg et al.,3 Jeevan et al.,4 Van Steenbergen et al.,5 Zhong et al.6]. Furthermore, a growing body of evidence shows that breast cancer surgery outcomes are better in high-volume hospitals [Guller at al.,7 Roohan et al.8].

In 2008, the Ministry of Health and the French Cancer Institute introduced minimum activity thresholds for cancer-related procedures to improve the quality of care. A volume threshold for breast cancer surgery was set at a minimum of 30 surgical procedures per year. So far, no studies have assessed the impact of this policy on the quality of care.

The aim of this study was to examine whether the threshold policy affected the quality of surgical treatment decisions for patients diagnosed with early breast cancer in French hospitals. We studied how the rates of appropriate surgical procedures (considered as quality of care benchmarks) evolved between 2005 and 2012.

Section snippets

Data source

We used patient-level data from the French Hospital Episode Statistics Database (Programme de Medicalisation des Systemes d’Information) for 2005 and 2012. This administrative database used for activity-based payment contains all hospital stays in all acute care hospitals. The information available for each stay comprises: patient age, sex, primary and secondary diagnosis (ICD-10 codes), procedures (French classification procedure codes) and diagnosis-related group (DRG) codes. Another

Results

In 2012, 63 414 patients underwent breast cancer surgery in 526 hospitals versus 57 156 patients in 804 hospitals in 2005 (Table 1). Between 2005 and 2012, the volume of breast cancer surgery increased by 11% whereas one third of the hospitals had stopped performing this type of surgery. In 2012, 62 250 patients underwent a mastectomy or BCS versus 54 904 in 2005. Among these patients, 46 088 underwent BCS in 2012 versus 40 138 in 2005 (Table 1). The number of patients who underwent both BCS

Discussion

In this nationwide study, we showed that the implementation of minimum activity thresholds was followed by a decrease in the number of hospitals performing breast cancer surgery and by an increase in the rates of “good practice” for breast cancer surgery. The introduction of a minimum volume threshold set at 30 interventions per year and per hospital appears to be relatively low compared to international standards. In fact, according to guidelines on breast cancer surgery issued by the European

Role of the funding source

This research study was supported by the French Institute for Public Health Research (IRESP) on the occasion of a call for proposals launched in 2012 alongside the Plan Cancer 2009–2013. The funding source had no role in study design, data analysis, data interpretation, or manuscript writing.

Conflict of interest

None.

Acknowledgments

This research study was supported by the French Institute for Public Health Research (IRESP) on the occasion of a call for proposals launched in 2012 alongside the Plan Cancer 2009–2013. We would like to thank Lorna Saint Ange for editing.

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