title: Achieving Quality Assurance of Prostate Cancer Surgery During Reorganisation of Cancer Services.
abstract: 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.
  
  
  METHODS
  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.
  
  
  METHODS
  Image-based surgical planning of cancer surgery and monthly peer review of individual surgeon outcomes incorporating rating and assessment of edited surgical video clips.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  RESULTS
  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.
authors.affiliation: Department of Urology, University College Hospital London, London, UK; Division of Surgery and Interventional Science, University College London, London, UK; Centre for Experimental Cancer Medicine, Bart's Cancer Institute, Queen Mary University of London, London, UK. Electronic address: pjcathcart@hotmail.com.
authors.forename: Paul
authors.initials: P
authors.lastname: Cathcart
authors.affiliation: Department of Urology, University College Hospital London, London, UK.
authors.forename: Ashwin
authors.initials: A
authors.lastname: Sridhara
authors.affiliation: Department of Radiology, University College Hospital London, London, UK.
authors.forename: Navin
authors.initials: N
authors.lastname: Ramachandran
authors.affiliation: Department of Urology, University College Hospital London, London, UK.
authors.forename: Timothy
authors.initials: T
authors.lastname: Briggs
authors.affiliation: Department of Urology, University College Hospital London, London, UK.
authors.forename: Senthil
authors.initials: S
authors.lastname: Nathan
authors.affiliation: Department of Urology, University College Hospital London, London, UK; Division of Surgery and Interventional Science, University College London, London, UK.
authors.forename: John
authors.initials: J
authors.lastname: Kelly
mesh_terms: D015331:Cohort Studies; D007172:Erectile Dysfunction / Q000453:epidemiology*; D006298:Health Services Administration; D006801:Humans; D065186:Interrupted Time Series Analysis; D016015:Logistic Models; D008131:London; D008297:Male; D008875:Middle Aged; D018365:Neoplasm, Residual; D016017:Odds Ratio; D011183:Postoperative Complications / Q000453:epidemiology*; D016016:Proportional Hazards Models; D011468:Prostatectomy / Q000592:standards*; D011471:Prostatic Neoplasms / Q000601:surgery*; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D011787:Quality of Health Care; D065287:Robotic Surgical Procedures / Q000592:standards; D013222:State Medicine / Q000458:organization & administration*; D016896:Treatment Outcome; D014549:Urinary Incontinence / Q000453:epidemiology*; D014741:Video Recording
keywords: Outcomes research; Prostate cancer; Quality of care; Radical prostatectomy