title: Higher caseload improves cervical cancer survival in patients treated with brachytherapy.
abstract: OBJECTIVE
  Increased caseload has been associated with better patient outcomes in many areas of health care, including high-risk surgery and cancer treatment. However, such a positive volume vs. outcome relationship has not yet been validated for cervical cancer brachytherapy. The purpose of this study was to examine the relationship between physician caseload and survival rates in cervical cancer treated with brachytherapy using population-based data.
  
  
  METHODS
  Between 2005 and 2010, a total of 818 patients were identified using the Taiwan National Health Insurance Research Database. Multivariate analysis using a Cox proportional hazards model and propensity scores was used to assess the relationship between 5-year survival rates and physician caseloads.
  
  
  RESULTS
  As the caseload of individual physicians increased, unadjusted 5-year survival rates increased (P=0.005). Using a Cox proportional hazard model, patients treated by high-volume physicians had better survival rates (P = 0.03), after adjusting for comorbidities, hospital type, and treatment modality. When analyzed by propensity score, the adjusted 5-year survival rate differed significantly between patients treated by high/medium-volume physicians vs. patients treated by low/medium-volume physicians (60% vs. 54%, respectively; P=0.04).
  
  
  CONCLUSIONS
  Provider caseload affected survival rates in cervical cancer patients treated with brachytherapy. Both Cox proportional hazard model analysis and propensity scores showed association between high/medium volume physicians and improved survival.
authors.affiliation: Department of Radiation Oncology, Buddhist Dalin Tzu Chi Hospital, 2, Ming Sheng Road, Dalin, Chiayi, Taiwan. rt@url.com.tw.|School of Medicine, Tzu Chi University, Hualien, Taiwan. rt@url.com.tw.
authors.forename: Moon-Sing
authors.initials: MS
authors.lastname: Lee
authors.affiliation: Department of Radiation Oncology, Buddhist Dalin Tzu Chi Hospital, 2, Ming Sheng Road, Dalin, Chiayi, Taiwan. df800938@tzuchi.com.tw.
authors.forename: Shiang-Jiun
authors.initials: SJ
authors.lastname: Tsai
authors.affiliation: Department of Otolaryngology, Buddhist Dalin Tzu Chi Hospital, Chiayi, Taiwan. LCC@tzuchi.com.tw.|School of Medicine, Tzu Chi University, Hualien, Taiwan. LCC@tzuchi.com.tw.
authors.forename: Ching-Chih
authors.initials: CC
authors.lastname: Lee
authors.affiliation: Department of Hematology Oncology, Buddhist Dalin Tzu Chi Hospital, Chiayi, Taiwan. hepatoma@ms3.hinet.net.|School of Medicine, Tzu Chi University, Hualien, Taiwan. hepatoma@ms3.hinet.net.
authors.forename: Yu-Chieh
authors.initials: YC
authors.lastname: Su
authors.affiliation: Department of Radiation Oncology, Buddhist Dalin Tzu Chi Hospital, 2, Ming Sheng Road, Dalin, Chiayi, Taiwan. armstrong_washington@hotmail.com.|School of Medicine, Tzu Chi University, Hualien, Taiwan. armstrong_washington@hotmail.com.
authors.forename: Wen-Yen
authors.initials: WY
authors.lastname: Chiou
authors.affiliation: Department of Radiation Oncology, Buddhist Dalin Tzu Chi Hospital, 2, Ming Sheng Road, Dalin, Chiayi, Taiwan. DOC31221@ndmctsgh.edu.tw.|School of Medicine, Tzu Chi University, Hualien, Taiwan. DOC31221@ndmctsgh.edu.tw.
authors.forename: Hon-Yi
authors.initials: HY
authors.lastname: Lin
authors.affiliation: Department of Radiation Oncology, Buddhist Dalin Tzu Chi Hospital, 2, Ming Sheng Road, Dalin, Chiayi, Taiwan. oncology158@yahoo.com.tw.|School of Medicine, Tzu Chi University, Hualien, Taiwan. oncology158@yahoo.com.tw.
authors.forename: Shih-Kai
authors.initials: SK
authors.lastname: Hung
mesh_terms: D000328:Adult; D000368:Aged; D001918:Brachytherapy / Q000401:mortality*; D005260:Female; D005500:Follow-Up Studies; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data*; D006801:Humans; D008875:Middle Aged; D010820:Physicians; D011379:Prognosis; D016016:Proportional Hazards Models; D015996:Survival Rate; D013624:Taiwan / Q000453:epidemiology; D002583:Uterine Cervical Neoplasms / Q000453:epidemiology / Q000401:mortality* / Q000532:radiotherapy*; D016526:Workload