Variation in rates of breast cancer surgery: A national analysis based on French Hospital Episode Statistics.
OBJECTIVE
Minimum volume thresholds were introduced in France in 2008 to improve the quality of cancer care. We investigated whether/how the quality of treatment decisions in breast cancer surgery had evolved before and after this policy was implemented.


METHODS
We used Hospital Episode Statistics for all women having undergone breast conserving surgery (BCS) or mastectomy in France in 2005 and 2012. Three surgical procedures considered as better treatment options were analyzed: BCS, immediate breast reconstruction (IBR) and sentinel lymph node biopsy (SLNB). We studied the mean rates and variation according to the hospital profile and volume.


RESULTS
Between 2005 and 2012, the volume of breast cancer surgery increased by 11% whereas one third of the hospitals no longer performed this type of surgery. In 2012, the mean rate of BCS was 74% and similar in all hospitals whatever the volume. Conversely, IBR and SLNB rates were much higher in cancer centers (CC) and regional teaching hospitals (RTH) [IBR: 19% and 14% versus 8% on average; SLNB: 61% and 47% versus 39% on average]; the greater the hospital volume, the higher the IBR and SLNB rates (p < 0.0001). Overall, whatever the surgical procedure considered, inter-hospital variation in rates declined substantially in CC and RTH.


CONCLUSIONS
We identified considerable variation in IBR and SLNB rates between French hospitals. Although more complex and less standardized than BCS, most clinical guidelines recommended these procedures. This apparent heterogeneity suggests unequal access to high-quality procedures for women with breast cancer.
Service de Biostatistique et d'Epidemiologie, Gustave Roussy, Villejuif, France.
E
E
Rococo
Gustave Roussy, Department of Surgery, Division of Breast and Plastic Surgery, Villejuif, F-94805, France.
C
C
Mazouni
Institut de recherche et documentation en économie de la santé (IRDES), Paris, France.
Z
Z
Or
Institut de recherche et documentation en économie de la santé (IRDES), Paris, France.
V
V
Mobillion
Service de Biostatistique et d'Epidemiologie, Gustave Roussy, Villejuif, France.
M
M
Koon Sun Pat
Service de Biostatistique et d'Epidemiologie, Gustave Roussy, Villejuif, France; INSERM U1018, CESP Centre for Research in Epidemiology and Population Health, Université Paris-Sud, Université Paris-Saclay, Villejuif, France. Electronic address: julia.bonastre@gustaveroussy.fr.
J
J
Bonastre
D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery*; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D005602:France / Q000453:epidemiology; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D016462:Mammaplasty / Q000379:methods / Q000706:statistics & numerical data*; D015412:Mastectomy, Segmental / Q000379:methods / Q000706:statistics & numerical data*; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D058996:Quality Improvement; D012189:Retrospective Studies; D018570:Risk Assessment; D021701:Sentinel Lymph Node Biopsy / Q000379:methods / Q000706:statistics & numerical data*; D016896:Treatment Outcome
Breast neoplasms; Hospital Episode Statistics; Surgical procedures