Men with prostate cancer patients may choose where to have surgery based on the availability of new technology over what they know about the quality of the hospital itself, a British study finds.
The hospital’s reputation and its doctors also influence the decision-making process, concludes the report, “Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study,” which appeared The Lancet Oncology.
“It appears that patients use the availability of robotic prostatectomy as an indicator of high quality care, despite a lack of evidence of its superiority compared with open surgery,” Ajay Aggarwal, the study’s lead author, said in a press release. “NHS [National Health Service] hospitals are investing millions of pounds into new and sometimes unproven technologies which have a direct impact on the type of care patients receive.”
The authors’ assessment is that competition among hospitals — in addition to policies promoting centralization and the requirement to do minimum numbers of surgical procedures — have consequently increased investment in equipment for robotic surgery, even without any evidence of superior outcomes.
But if men don’t have access to quality performance and outcome indicators, such policies could threaten the ability of hospitals to deliver equitable and affordable healthcare, said researchers.
The study looked at more than 19,000 men who had their prostates removed through the NHS between 2010 and 2014. The team recorded where these patients lived and where they had surgery. With the aid of previous work, researchers found that one-third of men who had a radical prostatectomy traveled beyond their nearest prostate cancer surgery center and often across regional boundaries. These men were usually younger, fitter and wealthier.
In 2010, the NHS had 65 centers open; of these, 23 saw an increase in the number of patients. Ten of these 23 centers offered robot-assisted surgery, and 37 of the 65 initial centers saw a decrease in the number of patients. Of these 37, only two offered robot-assisted surgery at the start of 2010 and 10 had to close their radical prostatectomy service.
No center offering robot-assisted surgery closed during the study period. However, the number of centers offering robot-assisted surgery more than tripled during this period, from 12 to 39.
“NHS choice and competition policy is based on the principle that patients will travel to centers they think will provide the best service,” Aggarwal added. “Closures were never intended to result from this, but the large number of patients deciding to receive treatment elsewhere meant some centers faced the risk of closures as they were no longer performing a sufficient number of procedures to sustain their service.”
Robot-assisted prostatectomy is a type of keyhole (laparoscopic) surgery that is also known as da Vinci surgery.
Surgeons began using this approach in 2000. Previous research has shown that robot-assisted surgery could be better at removing cancer than other types of surgery; however, not enough information is available on how well men undergoing this type of surgery do in the long run, compared to men who have regular prostate cancer surgery.
Overall, the evidence points to improvements only during the procedure itself, such as less bleeding, less scarring, shorter hospital stays and quicker recovery. Some studies also suggest quicker recoveries of bladder control after surgery, as well as the ability to get an erection again sooner.
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