gms | German Medical Science

Background: As early screenings and diagnoses and improved treatment measures have allowed breast cancer patients to live longer, it is important to understand factors that may help or hinder breast cancer patients in maintaining a high quality of life (QoL). While previous work has studied cancer patients’ QoL-related functions and symptoms, little is known about the role of the hospitals in the long-term QoL of breast cancer survivors. This study therefore contributes to existing work through analyzing the relationship between hospitals and breast cancer patients’ QoL one year after surgery.

Research question: One aim of yearly accreditation requirements set forth by medical associations in Germany is that high quality patient care should be relatively standardized across certified breast care centers. As a consequence, differences in patient QoL should be minimal across hospitals, particularly in regards to the long-term outcomes of patients. However, there has not yet been a study that has studied possible variation in patient QoL across hospitals. The objective of this study is to therefore explore whether there is a relationship between the treatment hospital and patients’ long-term QoL and symptoms. More specifically, the central research questions motivating this study are: Do patients who are treated in higher-evaluated hospitals (i.e. hospitals that score the highest on patient surveys) also display better QoL outcomes one year after surgery, even after extensively controlling for all other relevant predictors? And are there hospital-specific factors that may influence the QoL outcomes of breast cancer patients?

Methods: This study uses data from a sample of 3596 breast cancer patients who received primary breast surgery in one of 88 certified breast centers in one federal state in Germany. Patients were surveyed at two time points- shortly after discharge and one year later. Patients who declared consent to participation in the study were sent a postal survey in 2017 and a follow-up survey in 2018 based on the Total Design Method by Dillman. Multilevel logistic and linear regression models were estimated in order to examine the relationship between treatment hospital and QoL (EORTC QLQ-C30/-BR23 scores) one year later. Based on the summed and scaled means of a comprehensive patient survey with high response rate, hospitals that ranked in the first quintile among the highest-evaluated hospitals in the state in 2017 were compared with all other hospitals. The models controlled for clinical indicators (UICC Stage, type of treatment, chemotherapy received), background (age, education, native language), and hospital-level indicators (teaching status, number of beds).

Results: Preliminary results found that patients who received surgery in the highest-evaluated hospitals in the state had significantly less severe systematic therapy side effects and significantly less problems with physical functioning compared with patients who were treated in other hospitals. These results remained consistent even after extensively controlling for patients' sociodemographic background, sickness and treatment data, and hospital type and size. No significant differences were found among patients in global health, emotional functioning, or arm and breast symptoms. Hospital size and teaching status did not play a role in QoL-related outcomes.

Discussion: The results of this study offer a first look into analyzing patient QoL across hospitals and suggest that there may be some long-term health-related advantages regarding systemic therapy side effects and physical functioning for patients who are treated in the most-positively evaluated hospitals. Future research could examine these relationships across hospitals over time, as well as specific differences in ongoing treatment and care that might be contributing to differences in patients’ QoL.

Practical implications: Accredited breast centers follow specified guidelines from their designated medical association and receive yearly re-certification in Germany, which should ensure consistently good health care no matter what hospital a patient is treated in. However, differences in patient outcomes across hospitals underscore the importance of examining and implementing the best practices of highly-evaluated hospitals.