title: Improving clinical outcomes through centralization of rectal cancer surgery and clinical audit: a mixed-methods assessment.
abstract: The aim of centralizing rectal cancer surgery in Catalonia (Spain) was to improve the quality of patient care. We evaluated the impact of this policy by assessing patterns of care, comparing the clinical audits carried out and analysing the implications of the healthcare reform from an organizational perspective.
  
  
  
  A mixed methods approach based on a convergent parallel design was used. Quality of rectal cancer care was assessed by means of a clinical audit for all patients receiving radical surgery for rectal cancer in two time periods (2005-2007 and 2011-2012). The qualitative study consisted of 18 semi-structured interviews in September-December 2014, with healthcare professionals, managers and experts.
  
  
  
  From 2005-2007 to 2011-2012, hospitals performing rectal cancer surgery decreased from 51 to 32. The proportion of patients undergoing surgery in high volume centres increased from 37.5% to 52.8%. Improved report of total mesorectal excision (36.2 vs. 85.7), less emergency surgery (5.6% vs. 3.6%) and more lymph node examinations (median: 14.1 vs. 16) were observed (P < 0.001). However, centralizing highly complex cancers using different critical masses and healthcare frameworks prompted the need for rearticulating partnerships at a hospital, rather than disease, level.
  
  
  
  The centralization of rectal cancer surgery has been associated with better quality of care and conformity with clinical guidelines. However, a more integrated model of care delivery is needed to strengthen the centralization strategy.
authors.affiliation: 1 Department of Health, Catalonian Cancer Strategy, Hospital Duran i Reynals, Gran via 199, 08908 Hospitalet, Barcelona, Spain 2 Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona (UB), Hospital Duran i Reynals, Gran via 199, 08908 Hospitalet, Barcelona, Spain jlprades@iconcologia.net.
authors.forename: Joan
authors.initials: J
authors.lastname: Prades
authors.affiliation: 1 Department of Health, Catalonian Cancer Strategy, Hospital Duran i Reynals, Gran via 199, 08908 Hospitalet, Barcelona, Spain 2 Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona (UB), Hospital Duran i Reynals, Gran via 199, 08908 Hospitalet, Barcelona, Spain.
authors.forename: Paula
authors.initials: P
authors.lastname: Manchon-Walsh
authors.affiliation: 1 Department of Health, Catalonian Cancer Strategy, Hospital Duran i Reynals, Gran via 199, 08908 Hospitalet, Barcelona, Spain 2 Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona (UB), Hospital Duran i Reynals, Gran via 199, 08908 Hospitalet, Barcelona, Spain.
authors.forename: Judit
authors.initials: J
authors.lastname: Solà
authors.affiliation: 1 Department of Health, Catalonian Cancer Strategy, Hospital Duran i Reynals, Gran via 199, 08908 Hospitalet, Barcelona, Spain 2 Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona (UB), Hospital Duran i Reynals, Gran via 199, 08908 Hospitalet, Barcelona, Spain.
authors.forename: Josep A
authors.initials: JA
authors.lastname: Espinàs
authors.affiliation: 3 Health Service Procurement & Assessment, Catalonian Health Service (CatSalut), Travessera de les Corts 131-159, Barcelona, 08028, Spain.
authors.forename: Alex
authors.initials: A
authors.lastname: Guarga
authors.affiliation: 1 Department of Health, Catalonian Cancer Strategy, Hospital Duran i Reynals, Gran via 199, 08908 Hospitalet, Barcelona, Spain 2 Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona (UB), Hospital Duran i Reynals, Gran via 199, 08908 Hospitalet, Barcelona, Spain.
authors.forename: Josep M
authors.initials: JM
authors.lastname: Borras
mesh_terms: D002497:Centralized Hospital Services / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D008485:Medical Audit / Q000706:statistics & numerical data*; D017063:Outcome Assessment, Health Care / Q000379:methods* / Q000706:statistics & numerical data; D058996:Quality Improvement / Q000706:statistics & numerical data*; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000601:surgery; D013030:Spain