Improving survival and local control in rectal cancer in Catalonia (Spain) in the context of centralisation: A full cycle audit assessment.
BACKGROUND
Rectal cancer surgery in Catalonia has been involved in a process of centralisation. We assessed the impact of this health policy strategy on quality of care and clinical results.


METHODS
We compared patterns of care and clinical outcomes of all rectal cancer patients receiving radical surgery for the first time in public hospitals in two time periods, before (2005 and 2007) and after (2011-2012) centralisation, analysing indicators of care quality according to the regional clinical practice guidelines. Clinical outcomes at two years were also assessed.


RESULTS
A total of 3780 patients were included. From 2005 to 2012, the proportion of patients treated surgically for the first time in centres whose annual surgical caseload was more than 11 increased from 84.0% to 90.4%. The rate of locoregional recurrence at two years fell from 4.5 to 3.06/100 person-years (p = 0.005). The crude mortality rate at three months, one and two years was reduced by 55%, 40% and 34% (p < 0.001).


CONCLUSIONS
Improvements in quality of care might be associated with the centralisation of surgery and with the selective focus effect derived from the process of auditing. Our results support the continuation of clinical auditing and surveillance of authorised centres.
Catalonian Cancer Strategy, Department of Health, Government of Catalonia, Avd. Gran Via de l'Hospitalet, 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona, C/Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain. Electronic address: pmanchon@iconcologia.net.
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Manchon-Walsh
Catalonian Cancer Strategy, Department of Health, Government of Catalonia, Avd. Gran Via de l'Hospitalet, 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona, C/Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
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Aliste
Catalonian Cancer Strategy, Department of Health, Government of Catalonia, Avd. Gran Via de l'Hospitalet, 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona, C/Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
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Espinàs
Catalonian Cancer Strategy, Department of Health, Government of Catalonia, Avd. Gran Via de l'Hospitalet, 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona, C/Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
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Prades
Health Service Procurement and Assessment, Catalonian Health Service (CatSalut), Travessera de les Corts, 131-159, 08028, Barcelona, Spain.
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Guarga
Department of Radiation Oncology, Hospital de la Santa Creu i Sant Pau, C/de Sant Quintí, 89, 08026, Barcelona, Spain.
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Balart
Department of General and Digestive Surgery, University Hospital of Bellvitge, C/Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
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Biondo
Department of Gastroenterology, Clinic University Hospital, C/Villarroel, 170, 08036, Barcelona, Spain.
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Castells
Pathology Department, University Hospital of Bellvitge, C/Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
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Sanjuan
Department of Medical Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Pº de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
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Tabernero
Catalonian Cancer Strategy, Department of Health, Government of Catalonia, Avd. Gran Via de l'Hospitalet, 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, Biomedical Research Institute of Bellvitge (IDIBELL), University of Barcelona, C/Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
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Borras
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017024:Chemotherapy, Adjuvant / Q000706:statistics & numerical data* / Q000639:trends; D003695:Delivery of Health Care / Q000458:organization & administration; D013505:Digestive System Surgical Procedures / Q000706:statistics & numerical data* / Q000639:trends; D005260:Female; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data / Q000639:trends; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data / Q000639:trends; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data / Q000639:trends; D008197:Lymph Node Excision / Q000706:statistics & numerical data* / Q000639:trends; D008297:Male; D008485:Medical Audit; D008643:Mesentery / Q000601:surgery; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000706:statistics & numerical data* / Q000639:trends; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D009367:Neoplasm Staging; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care / Q000706:statistics & numerical data* / Q000639:trends; D018714:Radiotherapy, Adjuvant / Q000706:statistics & numerical data* / Q000639:trends; D012004:Rectal Neoplasms / Q000473:pathology / Q000628:therapy*; D012007:Rectum / Q000601:surgery; D013030:Spain
Centralisation; Clinical audit; Population based; Quality assessment; Rectal cancer; Surgery