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.
For certain treatments, achieving the best possible patient outcomes may require regionalization of care.
A sense of shared commitment to optimal care and a relationship of trust are absolute musts for a successful collaboration.
Sharing expensive robot technology reduces the fixed costs per operation.
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.
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 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.
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.
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.