Abstract
IntroductionThere is limited evidence on the impact of centralization of cancer treatment services on patient travel burden and access to treatment. Using prostate cancer surgery as an example, this national study analysis aims to simulate the effect of different centralization scenarios on the number of center closures, patient travel times, and equity in access.MethodsWe used patient‐level data on all men (n = 19,256) undergoing radical prostatectomy in the English National Health Service between January 1, 2010 and December 31, 2014, and considered three scenarios for centralization of prostate cancer surgery services A: procedure volume, B: availability of specialized services, and C: optimization of capacity. The probability of patients travelling to each of the remaining centers in the choice set was predicted using a conditional logit model, based on preferences revealed through actual hospital selections. Multivariable linear regression analysed the impact on travel time according to patient characteristics.ResultsScenarios A, B, and C resulted in the closure of 28, 24, and 37 of the 65 radical prostatectomy centers, respectively, affecting 3993 (21%), 5763 (30%), and 7896 (41%) of the men in the study. Despite similar numbers of center closures the expected average increase on travel time was very different for scenario B (+15 minutes) and A (+28 minutes). A distance minimization approach, assigning patients to their next nearest center, with patient preferences not considered, estimated a lower impact on travel burden in all scenarios. The additional travel burden on older, sicker, less affluent patients was evident, but where significant, the absolute difference was very small.ConclusionThe study provides an innovative simulation approach using national patient‐level datasets, patient preferences based on actual hospital selections, and personal characteristics to inform health service planning. With this approach, we demonstrated for prostate cancer surgery that three different centralization scenarios would lead to similar number of center closures but to different increases in patient travel time, whilst all having a minimal impact on equity.
Highlights
There is limited evidence on the impact of centralization of cancer treatment services on patient travel burden and access to treatment
We studied 19,256 patients who were diagnosed with prostate cancer between January 2010 and December 2014, and who subsequently underwent a radical prostatectomy in the English National Health Service (NHS)
For each of the centralization scenarios an overall increase in average travel burden is apparent, with the smallest impact found for scenario B (+15 minutes) and the biggest impact found for scenarios A (+28 minutes) and C (+32 minutes)
Summary
The centralization of complex cancer surgery into high-volume units is occurring in most high-income countries as a consequence of a range of policies aiming to improve the quality and efficiency of cancer services.[1,2,3] This has been in response to studies from predominantly Europe and the United States identifying improved outcomes of care for patients treated by specialized and experienced teams at centers performing a high volume of surgical procedures,[4,5] for more complex surgery such as pancreatic, esophageal, and prostate cancers. Increased travel times for cancer care could reduce treatment uptake for specific patient groups This is relevant for prostate cancer where competing radical treatment strategies exist (eg surgery, radiotherapy, and brachytherapy), which are often located at different geographic locations.[14,15] In addition, apparent advantages of the volume-outcome relationship that may emerge from centralization of care may not be shared across the population, but instead concentrated in patients best able to access the benefit of centralization. Those patients are likely to be closer to high performing centers, or else younger, fitter, and more affluent. Can be applied by any authority, public or private, that is seeking to rationalize its health services into fewer centers nationally or regionally or within particular insurer catchment areas
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