ÀNPA PET CT scan in the oncology department of the Haaglanden Medical Center Antoniushove.
NOS Nieuws•vandaag, 15:00
The quality of operations to remove the prostate of cancer patients in the Netherlands varies enormously per hospital. The result is that many more patients at one hospital have to live incontinently than at another hospital.
This is evident from research by Maike Schepens, PhD candidate at Leiden UMC. Her findings have been published in the scientific journal European Urology Open Science.
For the study, patients were followed between 2016 and 2020 in the 19 hospitals that performed prostate operations at the time. In the best hospital, almost 20 percent of patients became incontinent after prostate removal. In the least performing hospital this was more than 84 percent.
The differences between hospitals’ results in the field of incontinence have been made transparent through an analysis of the declaration data of health insurer Zilveren Kruis. In a representative group of patients, it was determined whether there was incontinence after the operation by checking whether these people declared costs for anti-incontinence products.
After previous similar research by Schepens in 2018, the professional group decided to oblige treatment centers to perform many more operations. The standard was increased from twenty operations per year to one hundred.
The more often a doctor operates, the better he or she becomes, was the thought. But the national percentage of incontinent patients after surgery has hardly decreased since 2018. One side note is that the patients are somewhat older than in the previous study. Older age is an important risk factor for incontinence.
It is therefore likely that the quality of doctors has improved somewhat. Otherwise, the number of patients with incontinence would have increased since 2018 and not remained the same.
‘Live near the right hospital’
But the slight increase in patient age does not explain the significant difference in level between doctors. This difference in level is a thorn in the side of the Patient Federation and the Dutch Federation of Cancer Patient Organizations (NFK). They argue that this creates inequality in care.
“With prostate cancer you should be lucky that you live near the right hospital,” says Linda Daniels of the Patient Federation. “And no one actually knows which hospital that is. The results of operations are not public.”
Irene Dingemans, from the NFK, endorses this problem. “This study shows the absolute necessity of transparency for patients. Now they cannot choose their hospital based on quality data.”
The research is sensitive within the professional group of urologists. Some doctors are confronted with the fact that they perform significantly worse than colleagues.
Rik Somford, urologist and chairman of the oncological urology working group at the scientific professional association for urology (NVU), believes that focusing solely on incontinence is too simplistic.
“The success of the operation is also determined by other things. For example, what matters in the first place: whether the removal of the entire tumor was successful. A continent patient does not automatically mean that the operation is successful on all fronts.”
However, he must recognize that the risk difference for incontinence is very large. For example, the chance of incontinence at the handful of hospitals where hundreds of operations are performed annually is 52 percent smaller than at hospitals that perform just above the standard of 100 operations.
According to Somford, the solution is for all operating urologists, regardless of experience, to apprentice with doctors who score the best, within or outside their own hospital.
“The problem is that we cannot properly determine which doctor is doing well or less well. To do this, we now use questionnaires about incontinence, among other things, that patients often do not complete. And so we really need health insurer data.”
It turns out to be complicated to get it. “But if we can obtain that information more often and in a more accessible manner and include it in our quality registration, which started this year, that would help enormously.”
‘Hardly any change in 10 years’
This response does not go down well with the patient organizations. “Maike Schepens’ first study in 2018 made it clear that there were major differences between hospitals,” says Dingemans of the NFK.
She believes that urologists and hospitals should have already taken their responsibility to implement the necessary improvements.
“We have been discussing making quality data about treatments public since 2013,” says Daniels of the Patient Federation. “But hardly anything has changed in the past ten years.”
Which hospitals perform well and which do not?
Zilveren Kruis’s declaration data, on which the research is based, was anonymized. It is therefore not exactly clear which hospitals are performing well or poorly. Still, a rough sketch is possible.
The research shows that the hospitals can be divided into three groups. The best-performing group consists of hospitals where more than 120 operations were performed annually during the entire study period (2016-2020). These are hospitals where hundreds of operations were performed in 2020. The middle group consists of hospitals that had fewer than 120 operations at the start of the study, but were above that limit at the end. The hospitals that performed the least performed fewer than 120 operations annually during the study period.
This link opens an Excel file from the Dutch Healthcare Institute in which the number of operations per hospital in 2020 can be found. Click on the indicator set name ‘curative treatment for prostate cancer’ in the table to get an idea of the number of operations per hospital.