Certification Does not Necessarily Reduce Mortality

Letters to the Editor regarding the article Initial Cancer Treatment in Certified Versus Non-certified Hospitals: Results of the WiZen Comparative Cohort Study by Prof. Dr. med. Jochen Schmitt, Prof. Dr. med. Monika Klinkhammer-Schalke, Dr. rer. nat. Veronika Bierbaum, Dr. med. Michael Gerken, Christoph Bobeth, Dr. rer. pol. Martin Rößler, Patrik Dröge, Thomas Ruhnke, Christian Günster, Kees Kleihues-van Tol, and PD Dr. rer. nat. Olaf Schoffer, on behalf of the WiZen Study Group in issue 39/2023

Centralizing elective procedures with the corresponding shift in resources can worsen healthcare in one region without improving it in another. For this reason, analyses that intend to support such redistributions need to be cautious in interpreting the data. This is particularly the case if they are funded and conducted by interested parties.

On the basis of patient data from the AOK statutory insurance carrier in 2009–2017, Schmitt et al. found that overall mortality after treatment for prostate cancer was lower in the hospitals certified by the German Cancer Society (hazard ration 0.83, difference in 5-year overall survival about 8%). This difference can be plausibly explained by a concentration of patients who are young, otherwise healthy, asymptomatic, mobile, more easily classifiable on imaging, and suitable for radical prostatectomy. Patients with late symptoms such as bone pain are more likely to seek out a hospital in their vicinity—independently of its certification status. Certification as a limited structural intervention cannot bring about a survival difference of 8% after five years (2) in early prostate cancer. A randomized trial can illustrate the order of magnitude of the maximum effects achieved by an intervention in this setting. When radical prostatectomy was compared with predominantly conservative therapy, the hazard ratio for overall survival was 0.84 in favor of surgery. The difference in 5-year overall survival was about 4% (3). Because of competition pressure, radical prostatectomy is often carried out by well versed surgeons, even in non-certified hospitals. These are occasionally more experienced than the average surgeon working in certified hospitals. This is also reflected in continence rates after radical prostatectomy, which are sensitive to different levels of expertise, and which did not differ between certified and non-certified hospitals in 2009–2017 (3).

DOI: 10.3238/arztebl.m2023.0264

Prof. Dr. med. Michael Fröhner

Klinik für Urologie

Zeisigwaldkliniken Bethanien Chemnitz,

im Verbund von AGAPLESION

Conflict of interest statement

The author is the senior consultant/head of department at a denominational provider that is certified as a prostate cancer center.

References

1. Schmitt J, Klinkhammer-Schalke M, Bierbaum V, et al., on behalf of the WiZen Study Group: Initial cancer treatment in certified versus non-certified hospitals: results of the WiZen comparative cohort study. Dtsch Arztebl Int 2023;120: 647–54

2. Wilt TJ, Vo TN, Langsetmo L, et al.: Radical prostatectomy or observation for clinically localized prostate cancer: extended follow-up of the prostate cancer intervention versus observation trial (PIVOT). Eur Urol 2020; 77: 713–24

3. Briel C, Lent V, Strauß L: Belastungsharninkontinenz nach radikaler Prostatektomie in der Versorgungswirklichkeit. Ergebnisse einer Reha-Klinik 2009 und 2016. Urologie 2022;61:1093–8