New Marketplace
New Risk, New Business Models

Moving Prostatectomies to a High-Volume Center

Case Study · October 24, 2015

For patients with prostate cancer, concentrating radical prostatectomies at a high-volume hospital in the Netherlands reduced surgical complications, improved patient outcomes, and increased patient satisfaction. Initial logistical obstacles to migrating patients from a low-volume to a high-volume center for robotic surgery were overcome by fostering a sense of shared commitment to optimal patient care.

Key Takeaways

  1. For certain treatments, achieving the best possible patient outcomes may require regionalization of care.

  2. A sense of shared commitment to optimal care and a relationship of trust are absolute musts for a successful collaboration.

  3. Sharing expensive robot technology reduces the fixed costs per operation.

  4. Concentrating a complex procedure at a high-volume center increases the exposure and experience of surgeons and supporting staff. The competitive feedback sharpens their skill with the operative technique, allows for knowledge-sharing, and improves surgical outcomes.

The Challenge

Ample research has shown that for complex surgical procedures, patients have better outcomes at high-volume centers, thanks to the greater experience of the surgical team and supporting staff. In the Netherlands, a center that performs prostatectomies is now expected to do at least 30 procedures per year — a number that is likely to increase to 50 per year.

Santeon is a network of six non-academic teaching hospitals in the Netherlands. In 2012, the Santeon facility in Eindhoven (Catharina Hospital) lacked comprehensive robot-surgery facilities and was doing a relatively low volume of 40 prostatectomies. Investing in robotic surgery solely for the urology practice would not have been financially feasible at this low-volume center, despite increasing population demand for robotic radical prostatectomies.

The Plan

The low-volume Eindhoven hospital found an ideal and willing Santeon partner, Canisius Wilhelmina Hospital, which had high-end robotics facilities and did more than 150 prostatectomies per year — but was located 40 miles away in Nijmegen. The high-volume center in Nijmegen saw some advantages in further increasing its volume of robotic prostatectomies through this partnership. For instance, changes in operative technique could be evaluated more rapidly, and the per-prostatectomy fixed costs of the surgical robot would decrease. For its part, the low-volume center was willing to accept some loss of income to achieve better outcomes for its patients.

As part of the Santeon-wide Care for Outcome project, launched in 2013, researchers retrospectively studied important clinical parameters and patient-reported outcome measures for 5019 prostate-cancer patients, 1154 of whom (23%) had undergone a radical prostatectomy from 2008 to 2012. The positive surgical margin rate was found to be significantly lower at two high-volume Santeon hospitals (including the high-volume center in Nijmegen) than at the relatively low-volume center in Eindhoven (35–41% vs. 53%), as was the incidence of residual tumor at three months after prostatectomy (9% vs. 18 %).

Given these findings, radical-prostatectomy procedures were, in April 2013, relocated from the low-volume center in Eindhoven to the high-volume center in Nijmegen.

The Execution

A single urologist from the low-volume center was trained, certified, and integrated into the high-volume center’s robotics team. Therefore, the patients from the low-volume center could undergo robot-assisted radical prostatectomy by a urologist from their home hospital, but at an experienced high-volume center. The urologist from the low-volume center initially resisted traveling to the new location, but he gradually warmed to the idea so that he could optimize care for his patients. Health insurers applauded the initiative, and the insurance companies contracted with the low-volume center for prostate-cancer care through 2015 (with an option to renew).

Initially, the extra prostatectomies placed pressure on operating room availability at the high-volume center, and additional personnel had to be trained in robot assistance — both of which frustrated other surgical specialists. However, the other specialties eventually accepted the change because they recognized that this initiative might serve as a model for concentrating other procedures, such as esophageal surgery, at one center to achieve higher volume and better outcomes for patients.

To lessen their travel time, prostatectomy patients from the low-volume center were allowed to make a preoperative one-stop visit at the high-volume center, where they underwent intake (for anesthesiology and surgery) and received information about the procedure. The two hospitals’ outpatient and nursing departments mapped clear patient-routing protocols, with intense ongoing communication between the staff of the two centers. The board of directors and the medical staff from both hospitals unanimously supported this major logistical change.

Postoperative outpatient visits at the low-volume center were planned preoperatively, with discharge summaries and pathology reports sent by electronic mail. Referring partners (general practitioners) in the low-volume center’s region were thoroughly informed, and both hospitals created patient-information brochures. Agreements with incontinence and oncology nurses were aligned, contracts between the two hospitals were drawn up, and all other legal issues were resolved in advance. The high-volume center’s urologists oversaw postoperative care, given that urologists based at the low-volume center could not.

The Metrics

Forty to fifty radical prostatectomies were moved to the high-volume center. Serious surgical complications (Clavien score >2) declined at both centers: from 8% in 2013 to 0% in the second and third quarters of 2015. The rate of positive surgical margins also declined significantly at the low-volume center (from 51% to 24%) and even at the high-volume center (from 40% to 22%). Data on incontinence and erectile dysfunction for 2013 and 2014 have been gathered, but full results are not yet available.

Cohorts from both hospitals, not just the cohort originally from the low-volume center, benefited from this collaboration, possibly because of the more-intensive preoperative workup. Specifically, the staging MRI of the prostate (important for surgical planning) and the histological biopsy results were double-checked, and operative strategies were (if necessary) adjusted in close cooperation between the two centers. Each urologist also received individual feedback on surgical results, compared with his or her colleagues, on a quarterly basis.

***

This joint effort between two large teaching hospitals in the Santeon network is a unique event for radical-prostatectomy procedures in the Netherlands. We found that prostate-cancer patients, urologists, and provider organizations all benefit from this type of collaboration. The ongoing effort will also facilitate our evaluation of patient-reported outcome measures and clinical parameters in Santeon’s Care for Outcome program, putting us closer to our long-term goals of creating a national Santeon Prostate Center and comparing results with those from centers in other countries.

 

We thank Christine Cramer for the valuable analyses of the results.

This case study originally appeared in NEJM Catalyst on December 16, 2015.

New Call for Submissions ­to NEJM Catalyst

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From New Marketplace
New Risk, New Business Models

Opportunities for Private-Sector Entrepreneurship in Health Care Transformation

Two veterans of public service say that government can do only so much — which creates attractive business opportunities for entrepreneurs.

New Risk, New Business Models

Moving Past the EHR Interoperability Blame Game

Why can't EHRs talk to one another? We never created the right incentives, but we pretend that we did.

New Risk, New Business Models

Emerging from EHR Purgatory — Moving from Process to Outcomes

What's the effect of the mode of physician payment when it comes to EHRs?

New Risk, New Business Models

Reframing Analytics: Transforming Insights into Action

Centralizing clinical data for an integrated delivery system revealed a surprising lesson: sometimes predictive analytics are not enough.

New Risk, New Business Models

Infographic: The Effects of Health Insurance on Health and Survival

There is strong evidence that expansions in health coverage have increased people’s use of health care across multiple domains of well-being and reduced deaths overall.

New Risk, New Business Models

Provider Rating Systems Can and Should Be Better

Which is better: to pretend we know little when in fact we know much, or to pretend we know much when in fact we know little?

New Risk, New Business Models

The Committed Perspective — Policy Principles for Regional Health Plans

When we say “committed,” we mean “in it for the long haul.”

New Risk, New Business Models

What U.S. Hospitals Can Still Learn from India’s Private Heart Hospitals

Cost-cutting lessons are clear, so what stands in our way?

New Risk, New Business Models

Good Riddance to Big Insurance Mergers

If there is any silver lining, it’s that other insurers might learn from blocked mergers and devote more energy to growing by offering superior value, rather than by swallowing rivals.

New Risk, New Business Models

Massachusetts Hospitals Seek to Get Larger to Shrink Costs

Beth Israel Deaconess Medical Center, Lahey Health, and New England Baptist Hospital propose to merge to gain market heft. What will be the impact on costs in one of the nation’s most expensive health care markets?

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Value Based Care

115 Articles

Survey Snapshot: “Culture Is What You…

Commentary from NEJM Catalyst Insights Council members on the leadership skills needed for next-generation health…

Opportunities for Private-Sector Entrepreneurship in Health…

Two veterans of public service say that government can do only so much — which…

Rules of Business = Rules of…

The same rules of business apply for health care when it comes to new market…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now