title: Provision of radical pelvic urological surgery in England, and compliance with improving outcomes guidance.
abstract: OBJECTIVE
  To investigate compliance with Improving Outcomes Guidance (IOG) for radical pelvic surgery in England, and explore the pattern of service provision for radical cystectomy (RC) and radical prostatectomy (RP) before and after the introduction of IOG.
  
  
  METHODS
  For the period 2000/01-2006/07, all admissions for RC and RP were extracted from Hospital Episode Statistics (HES). At the institutional level, the numbers of RC and RP cases were combined to assess adherence to IOG. The IOG catchment populations for each institution were calculated by linking HES data to census ward population data. The pattern of service provision for RC and RP was independently assessed by assigning institutions into low-, medium- and high-volume groups of roughly equal volumes a priori, based on the ascending order of annual RC or RP rate, respectively. For RC it was also possible to explore the between-institution referral activity for RC by identifying the 'final endoscopic bladder procedure' that occurred immediately before the RC for each patient. This gave an indication of where the diagnosis and decision for RC had been made.
  
  
  RESULTS
  The percentage of institutions achieving the recommended IOG minimal case volume of 50 per year increased significantly between 2000/01 and 2006/07 (36% in odds per year, P < 0.001; odds ratio 1.36, 95% confidence interval 1.24-1.50), although absolute numbers remained relatively low (34% in 2006/07). Only one institution had a catchment population greater than the recommended 1 million. The total number of institutions performing RC decreased significantly over the years (P = 0.03), whereas for RP the decrease was not significant (P = 0.6). The decrease reflected a decline in the number of low-volume institutions, both for RC and RP, although this decline was not more than expected by chance. There had been a significant increase in the percentage of patients referred to another provider for their RC, from 5.5% in 2000/01 to 19.6% in 2006/07 (28% rise in odds per year, P < 0.001: odds ratio 1.28, 95% confidence interval 1.23-1.33).
  
  
  CONCLUSIONS
  There was evidence of centralization of radical pelvic urological surgery, although it is only relatively recently that this seems to have taken place with any certainty. The absolute numbers of providers achieving the IOG minimum caseload standard was relatively low. What impact this has had, if any, on the quality of patient care is yet to be fully determined.
authors: Department of Biosurgery and Surgical Technology (Section of Surgical Quality and Epidemiology), St Mary's Hospital Campus, Imperial College London, London, UK. e.mayer@imperial.ac.uk
authors: Erik K
authors: EK
authors: Mayer
authors: Alex
authors: A
authors: Bottle
authors: Ara W
authors: AW
authors: Darzi
authors: Thanos
authors: T
authors: Athanasiou
authors: Justin A
authors: JA
authors: Vale
mesh_terms: D000368:Aged; D015653:Cystectomy / Q000706:statistics & numerical data*; D004739:England / Q000453:epidemiology; D004812:Epidemiologic Methods; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D011468:Prostatectomy / Q000706:statistics & numerical data*; D011469:Prostatic Diseases / Q000453:epidemiology / Q000601:surgery*; D016896:Treatment Outcome; D001745:Urinary Bladder Diseases / Q000453:epidemiology / Q000601:surgery*