Hospital.Help

Dresden With the project Effectiveness of Care in Oncology Centers (WiZen), the Innovation Fund supported a broad-based study that compared the outcome of care for cancer patients in certified centers with that in non-certified hospitals.

The result was clear: patients are treated better in oncology centers. In conversation with the German Medical Journal (D) Study director Jochen Schmitt, who is also a member of the Government Hospital Commission, explains to what extent the findings from the project have now become part of standard care and where there is still potential for improvement in the Innovation Fund.

5 questions for Jochen Schmitt, Head of the Center for Evidence-Based Healthcare at the University Hospital Carl Gustav Carus Dresden

Professor Schmitt, how did the WiZen project come about?
The background to the project is the National Cancer Plan from 2008. It requires that all people suffering from cancer should receive high-quality care in accordance with evidence-based treatment guidelines in uniformly qualified centers.

Against this background, the German Cancer Society (DKG), in cooperation with all professional societies active in oncology, has set up a certification system to ensure that these requirements are met.

However, contrary to the National Cancer Plan, a large number of cancer patients continue to be treated in hospitals that are not appropriately certified; in many types of cancer, this even represents the majority of patients.

Before the WiZen study, there was only regional or limited empirical evidence that cancer patients are better treated in a certified center than in a non-certified hospital. With the WiZen project, we wanted to check whether these positive effects are also evident nationwide and in a total of eleven cancer entities.

What conclusion did you come to?
First, the methodology: Using controlled cohort studies, the WiZen study investigated the effect of initial treatment in hospitals with and without DKG certification on overall survival and recurrence-free survival.

The basis was nationwide data from adult AOK insured persons as well as cancer cases from the clinical cancer registries in Erfurt, Dresden, Regensburg and Brandenburg/Berlin from 2009 to 2017. Based on a total population of around 22 million adults, patient cohorts with incident tumor disease for the individual types of cancer were examined, ranging from 10,596 patients with cervical cancer to 172,901 patients with lung cancer.

The results are very consistent and robust: Both the nationwide statutory health insurance routine data and the cancer registry data showed advantages in favor of initial treatment in a certified hospital in all outcomes.

The hazard ratio (HR) for overall survival after extensive adjustment for patient- and clinic-related confounders was between HR=0.97; [95%-KI 0,94; 1,00] in lung cancer and HR=0.77 [0,74; 0,81] in breast cancer. This corresponds to an absolute risk reduction in overall survival of 0.62 months in lung cancer to 4.61 months in cervical cancer.

In a further analysis, we were able to show that concentrating the initial treatment of those affected by the eleven types of cancer examined in a certified center would have saved around 33,000 years of life per year, extrapolated to the German population.

What happened after the results were published?
Even during the project period, the results of the study attracted a lot of attention: at the German Cancer Congress, at the annual congresses of the German Network for Health Services Research and clinical professional societies.

The Innovation Committee viewed the results of the study as evidence that treatment in certified oncology centers can significantly increase the chances of survival for patients and asked the Federal Joint Committee to examine, among other things within the framework of quality assurance, whether the findings from the WiZen study can be taken into account in a timely manner, for example when setting minimum requirements for structural, process and outcome quality.

Based on this positive assessment, we expected the implementation of initial treatment of cancer patients in certified hospitals as a regulatory measure. However, no corresponding measures have been implemented to date and we have not received any results from the G-BA’s Quality Assurance Subcommittee’s consultation.

In its 3rd opinion, the government commission recommended that the initial treatment of cancer patients should only be carried out in certified centers in clinics from level II onwards. In its 5th opinion, the commission explained that concentrating the initial treatment of cancer patients in oncology centers would result in a high patient benefit without significantly affecting accessibility. However, in the negotiations on hospital reform, the level concept was abandoned and no oncology service group is planned.

A great deal of casual surgery and care for patients with cancer still takes place outside of certified centers. We hope that the broad communication of the results and conclusions of the WiZen study will help patients to choose certified centers more often and that colleagues in private practice will advise their patients accordingly.

In your opinion, what should happen next?
In my opinion, regulatory measures are now required. The cabinet draft of the Hospital Care Improvement Act, the KHVVG, provides for a concentration of 15 percent in the area of ​​oncological surgery.

Although this will reduce occasional surgery to a certain extent, it will not implement the results of the WiZen study. It should be noted that the WiZen study did not refer to surgical interventions, but to initial treatments for cancer patients and therefore also included adjuvant chemotherapies, which were discussed in tumor boards, insofar as these were initial treatments.

Furthermore, appropriate quality treatment in oncology requires interdisciplinary and interprofessional cooperation between qualified specialists along the entire care pathway.

This is the only way to create patient-specific, complex tumor- and stage-specific treatment plans and to implement them with a high level of expertise for the surgical and systemic therapeutic procedures.

The strict adherence to evidence-based guidelines in DKG-certified centers is crucial to ensure that all patients receive appropriate, high-quality care, especially given the rapid progress currently being made in the field of cancer medicine.

The hospital reform is intended to identify the 15 percent of hospitals in Germany that perform the fewest onco-surgical procedures in order to prohibit them from billing. Under certain circumstances, this could even create an incentive for hospitals with very low numbers of procedures to perform a few more operations and to withhold other, non-surgical treatment options from those affected.

For this reason, in my view, the G-BA should take up the proposals of the Innovation Committee and take the relevant certification criteria into account when setting minimum requirements for structural, process and outcome quality. This could be done independently of or in addition to hospital reform.

In your opinion, how great is the influence of the Innovation Fund on improving the supplyquality in Germany?
The German Network for Health Services Research recently published a position paper on this issue. It shows that the Innovation Committee has recommended numerous projects for inclusion in standard care.

In fact, only very few of these projects have resulted in a regulatory development of standard care. From the network’s point of view, one reason for this is that the transfer process is not systematically continued after the Innovation Committee’s recommendations have been discussed.

Today, the Innovation Shot asks various players in the health care system to examine whether the project results can be incorporated into standard care. There is only a very small amount of information available about the feedback from these players.

In this respect, it is not at all clear how the transfer of the results into standard care will proceed and it is not uncommon for the transfer to simply come to nothing. The WiZen study is just one of many examples.

In order to leverage the innovation fund’s potential for improving care, which I believe is very high, we need a fundamental path for the transfer and promotion of an implementation or transfer phase of successful projects.

Likewise, considerations regarding transfer and implementation should be formulated in the full application at the latest. A transfer assessment should then be carried out in the results report. The G-BA and the Innovation Committee should be allowed to coordinate the initiative to transfer projects into standard care more actively than before. © fos/aerzteblatt.de