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Keywords:

  • Quality of care;
  • volume-outcome relationship;
  • breast cancer;
  • multilevel analysis;
  • survival analysis

Objective

This study explored the association of surgical volume versus process quality with breast cancer survival and recurrence.

Data Sources/Study Setting

Population-based cancer registration data and National Health Insurance claim data.

Study Design

This population-based study linked Taiwan's Cancer Database with Taiwan's National Health Insurance Database to collect data on all patients diagnosed with breast cancer in 2003–2004 who received surgical treatment.

Principal Findings

This study included 6,396 female breast cancer patients, reported by 26 hospitals. After controlling for patient and provider characteristics, Cox's regression models did not reveal any association between a physician's surgical volume and breast cancer recurrence or survival, although hospital volume was marginally associated with positive 5-year recurrence (HR: 1.001, 95%CI: 1.000, 1.001). After controlling for hospital or physician volume of surgery, we found a significant association between quality of care and both 5-year survival and recurrence. Random effects were also identified between patients and providers based on 5-year survival and 5-year recurrence.

Conclusions

Process quality of care was significantly more related to survival or recurrence than to surgical volume. The random effects found within hospital-patient clustered data indicated that the effect of the clustered feature of this data should be considered when performing volume-outcome related studies.