Case Studies

Summary

Reorganization of complex cancer care can be achieved through the establishment of conventions between payers and providers but must include data monitoring elements that enable comprehensive analysis of the pivotal impact of care reorganization across providers.

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A study on upper gastrointestinal cancer conducted in Belgium showed that hospital centres performing at least 20 oesophagectomies annually had improved outcomes with significantly lower postoperative mortality than centres performing fewer than six (Vlayen et al., 2013). Yet, the average annual surgical treatment volume per hospital for complex procedures such as oesophagectomies and pancreatectomies is low and in 2014, the National Health Care Knowledge Centre (KCE) in Belgium published recommendations to reorganize care for rare and complex cancers (Stordeur et al., 2014).

In response, the Ministry of Health appointed the National Institute for Health and Disability Insurance (NIHDI) to look into how to reorganize healthcare facilities for rare and complex cancers, putting oesophageal and pancreatic cancer first on the agenda. The NIHDI developed an approach in two steps:

1. an evaluation of the volume-outcome association on the hospital level for oesophageal and pancreatic cancer resections to assess the need for concentration of surgical care in these types of cancers; and pending the results of this evaluation,
2. the implementation of nation-wide centralization of oesophageal and pancreatic cancer surgeries.

The evaluation (1), conducted with the Belgian Cancer Registry and using nationwide population-based data, found a large variation in hospital volumes for complex surgical procedures for oesophageal and pancreatic cancers with lower postoperative mortality rates 90 days after the surgery and higher five-year overall survival rates in hospitals with higher surgical volumes in comparison with low- and medium-volume hospitals (van Walle et al., 2023).

The NIHDI created a task force, composed of health professional associations, hospital federations, health insurance companies and clinical experts, to prepare for the implementation of centralized oesophageal and pancreatic cancer surgeries (2). The centralization was enforced by establishing oesophagus and pancreatic surgery conventions between the NIHDI and hospital centres that met certain selection criteria. To be eligible, hospital centres must have performed at least 20 complex surgical procedures of the oesophagus or pancreas per convention, respectively, in the years 2016, 2017 or 2018. If hospital centres recorded at least 10 complex surgeries in 2016, 2017 or 2018, they also could merge their oesophageal and pancreatic surgery volumes with another hospital that recorded similar numbers of surgeries by signing a temporary collaboration convention stipulating that the two hospitals committed to moving all their oesophageal and/or pancreatic surgery activities in one centre only after a six-month period.

By 1 July 2019, the former 79 hospital centres performing oesophageal surgeries were centralized into 10 centres, and the 93 centres performing pancreatic surgeries into 15 centres. The convention included mandatory monitoring of the indication and type of surgeries performed, as well as clinical process and outcome indicators such as the documentation of time between diagnosis and treatment, length of hospital stay, lymph node removal, resection margin status, postoperative complications and 90-day mortality. The first evaluation of the initiative took place after three years of implementation and showed that all 15 hospital centres for pancreatic surgeries were still active but two centres out of 10 for oesophageal surgeries stopped their clinical activity due to too low volumes (Dekoninck et al., 2023a; Dekoninck et al., 2023b). Further evaluation is ongoing, and results will contribute to the decision in continuing, adapting or discontinuing the conventions. Yet, based on this initiative, and making use of the gained experience and encountered obstacles, already similar experimentations for other types of complex cancers (for example, head and neck cancers, ovarian cancers) are under consideration.

Enablers: Political will from the government to reorganize care for complex cancers (Governance), as well as the availability of population-based data from the Belgian Cancer Registry to make evidence-based assessments of hospitals’ eligibility (Information).

Barriers: Lack of financial compensation for the necessary administrative and organizational investments caused by the conventions and the difficulty in convincing healthcare providers in the context of the current payment mechanism (Financing), the challenge of balancing all three geographical regions expectations and demands (Government), and the public opposition of health professionals in low-volume hospitals (Resources). Consequently, the final number of hospital centres is higher than the initially targeted number, and while the centralization was aimed to include the multidisciplinary care of oesophageal and pancreatic cancer patients, it only focused on surgical care.

Overall, efficiency, equity, quality of care, access to high-quality care, and people-centredness are all considered to be positively impacted by the implemented initiative.

Lessons learned: When implementing the centralization of cancer care, it is important to integrate data monitoring elements to be able to assess the effect of the centralization. While this was successfully included in the initiative, the use of standardized datasets and strict guidelines would have facilitated uniform data collection and reporting. Also, data on patient-reported outcomes/experiences would have been important to integrate.