Achieving Quality Assurance of Prostate Cancer Surgery During Reorganisation of Cancer Services

Background: National Health Service England recently oversaw a whole-scale reconfiguration of cancer services in London, UK, for a number of different cancer pathways. Centralisation of cancer surgery has occurred with prostate cancer (PCa) surgery only being commissioned at a single designated pelvic cancer surgical centre. This process has required surgeons to work in teams providing a hub-and-spoke model of care. Objective: To report the extent to which the initiation of a quality assurance programme (QAP) can improve the quality of PCa surgical care during reorganisation of cancer services in London. Design, setting, and participants: A pre- and postintervention study was initiated with 732 men undergoing robot-assisted radical PCa surgery over a 3-yr period, 396 men before the introduction of the QAP and 336 afterwards. Intervention: Image-based surgical planning of cancer surgery and monthly peer review of individual surgeon outcomes incorporating rating and assessment of edited surgical video clips. Outcome measurements and statistical analysis: We observed margin status (positive/negative), complication rate of surgery, 3-mo urinary continence, use of nerve-sparing surgery, and potency at 12 mo after surgery. Multivariable logistic regression modelling was used to compare outcomes before and after initiation of the QAP. Cox regression analysis was used to evaluate the return of potency over time. Results and limitations: Demographics of patients undergoing surgery did not change following the reorganisation of cancer services. Patient-reported 3-mo urinary continence improved following the initiation of the QAP, both in terms of requirement for incontinence pads (57% continent vs 67% continent; odds ratio [OR]: 2.19; 95% confidence interval [CI], 1.08-4.46; p = 0.02) and International Consultation on Incontinence Questionnaire score (5.6 vs 4.2; OR: 0.82; 95% CI, 0.70-0.95; p = 0.009). Concurrently, use of nerve-sparing surgery increased significantly (OR: 2.99; 95% CI, 2.14-4.20; p < 0.001) while margin status remained static. Potency at 12 mo increased significantly from 21% to 61% in those patients undergoing bilateral nerve-sparing surgery (hazard ratio: 3.58; 95% CI, 1.29-9.87; p = 0.04). Interaction was noted between surgeon and 3-mo urinary continence. On regression analysis, incontinence scores improved significantly for all but one surgeon who had low incontinence rates at study initiation. Conclusions: The implementation of a QAP improved quality of care in terms of consistency of patient selection and outcomes of surgery during a period of major reorganisation of cancer services in London. The QAP framework presented could be adopted by other organisations providing complex surgical care across a large network of referring hospitals. Patient summary: The introduction of a quality assurance programme improved the quality of prostate cancer care in terms of consistency of patient selection and outcomes of surgery during a period of major reorganisation of cancer services. (C) 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.