Hospital Volume of Elective Abdominal Aortic Aneurysm Repair as a Predictor of Mortality After Ruptured Abdominal Aortic Aneurysm Repair.

OBJECTIVE: Registry data suggest that centralising abdominal aortic aneurysm (AAA) surgery decreases the mortality rate after AAA repair. However, the impact of higher elective volumes on ruptured AAA (rAAA) repair associated mortality rates remains uncertain. This study aimed to examine associations between intact AAA (iAAA) repair volume and post-operative rAAA death. METHODS: Using data from official national registries between 2015 - 2019, all iAAA and rAAA repairs were separately analysed across 10 public hospitals. The following were assessed: 30 day and 12 month mortality rate following open surgical repair (OSR) and endovascular aneurysm repair (EVAR). Associations between the 5 year hospital iAAA repair volumes (organised into tertiles) and rAAA associated mortality rate were analysed, regardless of treatment modality. Receiver operating characteristic (ROC) curves were generated to identify iAAA volume thresholds for decreasing the rAAA mortality rate. Subanalysis by treatment type was conducted. Threshold analysis was repeated with the Markov chain Monte Carlo (MCMC) procedure to confirm the findings. RESULTS: A total of 1 599 iAAAs (80.2% EVAR, 19.8% OSR) and 196 rAAAs (66.3% EVAR, 33.7% OSR) repairs were analysed. The median and interquartile range of the volume/hospital/year for all iAAA repairs were 39.2 (31.2, 47.4). The top volume iAAA tertile exhibited lower rAAA associated 30 day (odds ratio [OR] 0.374; p = .007) and 12 month (OR 0.264; p < .001) mortality rates. The ROC analysis revealed a threshold of 40 iAAA repairs/hospital/year (EVAR + OSR) for a reduced rAAA mortality rate. Middle volume hospitals for open iAAA repair had reduced 30 day (OR 0.267; p = .033) and 12 month (OR 0.223; p = .020) mortality rates, with a threshold of five OSR procedures/year. The MCMC procedure found similar thresholds. No significant association was found between elective EVAR volumes and ruptured EVAR mortality. CONCLUSION: Higher iAAA repair volumes correlated with a lower rAAA mortality rate, particularly for OSR. The recommended iAAA repair threshold is 40 procedures/year and five procedures/year for OSR. These findings support high elective volumes for improving the rAAA mortality rate, especially for OSR.

Distribution and outcomes of paediatric anaesthesia services in Sweden: an epidemiological study.

BACKGROUND: Centralisation of perioperative care for small children to a limited number of specialised paediatric centres has many theoretical advantages, but neither the optimal balance nor the current distribution of paediatric anaesthesia on a national scale are well elucidated. The aim of this study was to describe the distribution, adverse events, and mortality in children undergoing anaesthesia in Sweden. METHODS: In this cohort study, data from all paediatric anaesthesia procedures registered in Sweden during the years 2019-22 were extracted from the Swedish Perioperative Register (SPOR). Data were analysed according to hospital level of care and ASA physical status. RESULTS: Data from 81 hospitals were analysed. During the 4-yr period, 214,964 procedures were registered. Most procedures in neonates and infants were managed in paediatric (73%) and other university hospitals (21%). Adverse events occurred in 2.71% of cases and severe adverse events in 0.067%. The all-cause 24-h mortality rate was 6.6:10,000 anaesthetics and the all-cause 30-day mortality was 14.7:10,000 anaesthetics. The 30-day all-cause estimated mortality was highest in paediatric hospitals (95% confidence interval [CI] 30-39) compared with other university hospitals (95% CI 6.1-12), county (95% CI 1.9-4.8), district (95% CI 0.07-2.2), and smaller hospitals (95% CI 0.0-22). CONCLUSIONS: Most procedures in neonates and infants were performed in tertiary centres, with county hospitals managing mainly older children, in accordance with national recommendations. Mortality was more common in tertiary centres, reflecting increased comorbidity and centralisation of anaesthesia of neonates and infants.

Swedish registry study showed that 50% of paediatric operations were performed in university hospitals and mortality was low.

AIM: To investigate the distribution of paediatric surgery in various hospitals and to study postoperative risk factors of mortality. METHODS: Retrospective registry-based cohort study of children aged 0-14 years undergoing surgery from 2017 to 2021. Data were extracted from the Swedish Perioperative Registry. A mixed logistic regression was applied for the all-risk mortality analysis. RESULTS: A total of 126 539 cases were identified, 50% in university, 36% in county and 14% in district hospitals. The dominating operations were appendectomy in 6667, orchidopexy in 5287, inguinal hernia repair in 4200 and gastrostomy in 1152 children. Among children under 1 year of age or American Society of Anesthesiologists Physical Status classification (ASA-PS-Class) 3-5, the majority underwent surgery in university hospitals. The 30-day mortality in university hospitals was 0.5% and in county hospitals 0%. The proportion of emergency surgery was similar in university and county hospitals. Independent risk factors of mortality were being under 1 year of age, ASA-PS-class 4-5, emergency surgery and surgery at university hospitals. CONCLUSION: Half of all operations in children were performed in university hospitals, with low postoperative mortality despite effective centralisation of high risk patients <1 year of age or ASA-PS-Class 3-5.

Quantifying the impact of centralised neonatal care following interhospital transfer of preterm infants on families.

AIM: Evaluate the additional burden of centralised neonatal care on families of extremely preterm infants cared for away from their planned hospital of birth. METHODS: Retrospective cohort study using national data for infants 23+0 to 27+6 weeks of gestation admitted for neonatal care from 2011 to 2016. The number of transfers on the first day of life (potential maternal-infant separation), time away from the maternal booking hospital (BH) and distance from the maternal residence were quantified. RESULTS: Of 14 719 included infants, 2803 (19%) underwent postnatal transfer on the first day of life. A total of 8622 (59%) infants were cared for away from their BH for a median of 39 days (interquartile range [IQR] 15-69), 30% spending >60 days away over a median of two episodes (range 1-12). Median return road travelling distances for parents to their local BH was 13 km (IQR 8-26), but this increased to 74 km (IQR 32-148) for those cared for in a non-BH. CONCLUSION: Centralised neonatal care improves infant outcomes but introduces additional burdens on the families of extremely preterm infants cared for away from their BH. Additional support, including accommodation and financial aid, could help minimise the impact on these families, facilitate family integrated care and improve parental wellbeing.

Centralisation of extremely preterm births and decreased early postnatal mortality in Sweden, 2004-2007 versus 2014-2016.

AIM: We evaluated the increased centralisation of extremely preterm (EPT) births in Sweden in relation to the changes in mortality and morbidity. METHODS: Population-based data covering Swedish live births from 22 + 0 to 26 + 6 weeks of gestation during 2004-2007 and 2014-2016 were analysed for associations between time-period, birth within (inborn) or outside (outborn) regional centres, and outcomes. RESULTS: Among 1626 liveborn infants, 703 were born in 2004-2007 and 923 in 2014-2016. Birth outside (vs. within) regional centres was associated with a higher infant mortality even after adjustment for birth cohort, gestational age, birthweight standard deviation score and infant sex (adjusted odds ratio 2.01, 95% confidence interval 1.31-3.07, p = 0.001). The higher 1-year mortality in outborn infants was mainly due to more deaths within 24 h after birth. Outborn infants had a higher incidence of intraventricular haemorrhage grade 3-4 than inborn infants (22% vs. 14% in 2004-2007, and 22% vs. 13% in 2014-2016, both p < 0.05). While survival to 1 year without major morbidity increased in inborn infants (33%-40%, p = 0.008), it remained unchanged in outborn infants (29% vs. 30%, p = 0.88). CONCLUSION: Centralisation of EPT births contributed to a lower 1-year mortality in 2014-2016 than that in 2004-2007, attributed to a decrease in deaths before 24 h among inborn infants.

Phallus preservation and reconstruction: 5-year outcomes of national penile cancer centralisation in the Republic of Ireland.

INTRODUCTION: Penile cancer is a rare urological malignancy with an age-standardised incidence of 0.8 per 100,000 person-years [1]. Given this low incidence it has been suggested that centralised care may improve patient outcomes in relation to phallus sparing surgery and nodal assessment [2]. We aim to assess the outcomes after 5-years of national centralisation of penile cancer care. METHODS: A retrospective analysis of prospectively collected data was performed. All patients undergoing penile cancer surgery from January 2018 to December 2022 following centralisation of care were included. The primary outcome was proportion of phallus sparing procedures performed. Secondary outcomes were patient characteristics, histologic outcomes and procedures performed. RESULTS: 124 patients underwent surgery in the study period. Mean age was 64.49 (±13.87). Overall, 82.3% of patients underwent phallus sparing surgery. This remained stable over the 5-year period from 2018 to 2022 â€‹at 92%, 85%, 76%, 79% and 78% respectively (p â€‹= â€‹0.534). 62.7% had reconstruction performed, including split-thickness skin graft neoglans formation, (57.8% [n â€‹= â€‹37]), preputial flap (32.8% [n â€‹= â€‹21]), glans resurfacing (4.7% [n â€‹= â€‹3]), shaft advancement flap (1.6% [n â€‹= â€‹1]), penile shaft skin graft (1.6% [n â€‹= â€‹1]), and partial penectomy with urethral centralisation (1.6% [n â€‹= â€‹1]). Phallus preservation was not affected by positive nodal status (OR 0.75 [95% CI 0.249-2.266], p â€‹= â€‹0.564) or T-stage ≥1b (OR 0.51 [95% CI 0.153-1.711], p â€‹= â€‹0.276). There has been a significant reduction in Nx nodal status from 64% in 2017 to 15% in 2021 (p â€‹= â€‹0.009). CONCLUSION: Centralisation of treatment for rare malignancies such as penile cancer may improve oncologic outcomes and rates of phallus preservation. This study has shown centralisation to has a high rate of phallus preservation. Further long-term analysis of outcomes in Ireland is required.

What is the impact of hospital and surgeon volumes on outcomes in rectal cancer surgery?

AIM: Evidence for a positive volume-outcome relationship for rectal cancer surgery is unclear. This study aims to evaluate the volume-outcome relationship for rectal cancer surgery at hospital and surgeon level in the English National Health Service (NHS). METHOD: All patients undergoing a rectal cancer resection in the English NHS between 2015 and 2019 were included. Multilevel multivariable logistic regression was used to model relationships between outcomes and mean annual hospital and surgeon volumes (using a linear plus a quadratic term for volume) with adjustment for patient characteristics. RESULTS: A total of 13 858 patients treated in 166 hospitals were included. Six hospitals (3.6%) performed fewer than 10 rectal cancer resections per year, and 381 surgeons (45.0%) performed fewer than five such resections per year. Patients treated by high-volume surgeons had a reduced length of stay (p = 0.016). No statistically significant volume-outcome relationships were demonstrated for 90-day mortality, 30-day unplanned readmission, unplanned return to theatre, stoma at 18 months following anterior resection, positive circumferential resection margin and 2-year all-cause mortality at either hospital or surgeon level (p values > 0.05). CONCLUSION: Almost half of colorectal surgeons in England do not meet national guidelines for rectal cancer surgeons to perform a minimum of five major resections annually. However, our results suggest that centralizing rectal cancer surgery with the main focus of increasing operative volume may have limited impact on NHS surgical outcomes. Therefore, quality improvement initiatives should address a wider range of evidence-based process measures, across the multidisciplinary care pathway, to enhance outcomes for patients with rectal cancer.

Centralisation of oesophageal cancer services: experiences and outcomes of the first year of implementation at a Belgian non-academic teachinghospital.

INTRODUCTION: Oesophageal surgery recently became centralised in Belgium. This study aims to evaluate surgical outcomes and service delivered one year after implementation of centralisation. PATIENTS AND METHODS: All patients undergoing an oesophagectomy between the start of the centralisation; 1st of June 2019 and 31st of May 2020, were included from a prospectively maintained database. RESULTS: 53 patients (41 male, 12 female) underwent an oesophagectomy during the study period. Most oesophagectomies were performed through an open left thoracoabdominal approach (64.2%), 30.2% via a minimally invasive approach and hybrid approaches were carried out in 5.7% of patients. In this study population, the 30 day mortality rate was 0% and the 90 day mortality rate was 3.8%, equating to 2 deaths. The overall 30 day readmission rate was 7.5%. Clinically significant anastomotic leaks occurred in 4 patients, (7.5%). Pneumonia and atrial fibrillation were the most frequent complications, both having a prevalence of 32.1%. The median length of stay was 11 days (IQR 9.5-14.5). CONCLUSION: The results from our centre are comparable to those from international registers which demonstrate that centralisation of complex cancer services can be safely implemented.

Optimising acute stroke pathways through flexible use of bed capacity: a computer modelling study.

BACKGROUND: Optimising capacity along clinical pathways is essential to avoid severe hospital pressure and help ensure best patient outcomes and financial sustainability. Yet, typical approaches, using only average arrival rate and average lengths of stay, are known to underestimate the number of beds required. This study investigates the extent to which averages-based estimates can be complemented by a robust assessment of additional 'flex capacity' requirements, to be used at times of peak demand. METHODS: The setting was a major one million resident healthcare system in England, moving towards a centralised stroke pathway. A computer simulation was developed for modelling patient flow along the proposed stroke pathway, accounting for variability in patient arrivals, lengths of stay, and the time taken for transfer processes. The primary outcome measure was flex capacity utilisation over the simulation period. RESULTS: For the hyper-acute, acute, and rehabilitation units respectively, flex capacities of 45%, 45%, and 36% above the averages-based calculation would be required to ensure that only 1% of stroke presentations find the hyper-acute unit full and have to wait. For each unit some amount of flex capacity would be required approximately 30%, 20%, and 18% of the time respectively. CONCLUSIONS: This study demonstrates the importance of appropriately capturing variability within capacity plans, and provides a practical and economical approach which can complement commonly-used averages-based methods. Results of this study have directly informed the healthcare system's new configuration of stroke services.

Penile cancer in Ireland - A national review.

OBJECTIVE: Penile cancer is a rare malignancy, with a reported incidence of 1.5/100,000 males in the Republic of Ireland in 2015. The aim of this study was to perform the first national review and to evaluate clinicopathological factors affecting survival. SUBJECTS AND METHODS: All cases of penile cancer in Ireland between 1995 and 2010 were identified through the National Cancer Registry Ireland (NCRI) and analysed to identify factors affecting survival. RESULTS: 360 cases of penile cancer were identified, with a mean age at diagnosis of 65.5 years and 88% (n = 315) of cases occurred in those over 50. 91% (n = 328) of cases were squamous cell carcinomas (SCC). The majority of patients were treated surgically (n = 289), with 57% (n = 206) and 24% (n = 87) undergoing partial penectomy and total penectomy respectively. Only 18% (n = 65) received radiotherapy, and 8% (n = 27) received chemotherapy. Mean overall survival (OS) was 113 months, and five year disease specific survival (DSS) was 70% (95%CI: 59.1-77.8%). Age at diagnosis, nodal status and presence of metastatic disease were independent prognostic markers on multivariate analysis. CONCLUSION: This study represents the first national review of penile cancer in Ireland. The annual incidence and survival rates are comparable to European figures, though superior DSS has previously been reported from our institution, highlighting the role for centralisation of care in Ireland. LEVEL OF EVIDENCE: 2b.

Centralization and innovation: Competing priorities for health systems?

Over the last 15 years, there has been a trend in Canada to centralise the provision of health services that were previously administratively and fiscally decentralised. Canadian policy rhetoric on centralisation often identifies improved innovation as an anticipated outcome. This paper challenges the assumed relationship between centralisation and innovation. We incorporate evidence from the management literature into the debate on the structure of health systems to explore the effects that centralisation is likely to have on innovation in health systems. The findings of this paper will be of interest to international policymakers, who are currently grappling with the prospect of maintaining a decentralised approach or adopting a more centralised health system structure in the future.

New Zealand's Bold New Structural Health Reforms: The Pae Ora (Healthy Futures) Act 2022.

New Zealand has implemented a transformative overhaul of its public health system. Regulated by the Pae Ora (Healthy Futures) Act 2022 (NZ), the system has two key objectives: first, greater centralisation, with 20 regional district health boards replaced by two central commissioning agencies. New Zealand has a truly national health system for the first time, an aim being to end the "post code lottery". The second driver is to finally "get real" in tackling persistent inequities in health outcomes and access of disadvantaged groups, especially Maori, New Zealand's indigenous people, via various initiatives, including creation of a Maori Health Authority. A revolutionary aspect of the reforms is that the principles of the founding Treaty of Waitangi between Maori and the Crown have been embedded in the legislation as high-level guiding principles for all entities. Well-intentioned aims are a good start, but will need to be matched by realistic funding if the reforms are to have any chance of success.

Political alignment, centralisation, and the sense of government unpreparedness during the COVID-19 pandemic.

We rely on a periodic public opinion poll indicator of the performance of mayors collected for 103 large cities in Italy and in three waves (2015, 2017, and 2020) to examine whether and to what extent the exogenous shift in policy-making decisions induced by the COVID-19 pandemic has affected citizens' perceptions regarding attributions of responsibility. We leverage the variation in political alignment between central and local governments and implement a difference-in-differences research design, finding that when decisions are fully centralised (during the lockdown), voter approval for the mayor of an aligned city decreases by around 7%. Further analyses suggest that our results are more marked (i) during pre-electoral years and (ii) in cities with a lower level of social capital. Lastly, we document that the decrease in the approval ratings of aligned mayors is entirely guided by cities not severely hit by the pandemic, thereby reflecting a sense of 'discontent' in these areas for the policy decisions adopted by the central government to tackle the pandemic.

Centralisation of acute obstetric care in the Netherlands: a qualitative study to explore the experiences of stakeholders with adaptations in organisation of care.

BACKGROUND: In the past decade, acute obstetric care (AOC) has become centralised in many high-income countries. In this qualitative study, we explored how stakeholders in maternity care perceived and experienced adaptations in the organisation of maternity care in areas in the Netherlands where AOC was centralised. METHODS: A heterogenic group of fifteen maternity care stakeholders, including patients, were purposively selected for semi-structured interviews. An inductive thematic analysis was used. RESULTS: Three main themes were identified: (1) lack of involvement. (2) the process of making adaptations in the organisation of maternity care. (3) maintaining quality of care. Stakeholders in this study were highly motivated to maintain a high quality of maternity care and therefore made adaptations at several organisational levels. However, they felt a lack of involvement during the planning of centralisation of AOC and highlighted the importance of a collaborative process when making adaptations after centralisation of AOC. CONCLUSIONS: Regions with AOC centralisation plans should invest time and money in change management, encourage early involvement of all maternity care stakeholders and acknowledge centralisation of AOC as a professional life event with associated emotions, including a feeling of unsafety.

Impact of hospital nephrectomy volume on intermediate- to long-term survival in renal cell carcinoma.

OBJECTIVE: To evaluate the relationship between hospital volume and intermediate- and long-term patient survival for patients undergoing nephrectomy for renal cell carcinoma (RCC). PATIENTS AND METHODS: Adult patients with RCC treated with nephrectomy between 2000 and 2010 were identified from the English Hospital Episode Statistics database and National Cancer Data Repository. Patients with nodal or metastatic disease were excluded. Hospitals were categorised into low- (LV; <20 cases/year), medium- (20-39 cases/year) and high-volume (HV; ≥40 cases/year), based on annual cases of RCC nephrectomy. Multivariable Cox regression analyses were used to calculate hazard ratios (HRs) for all-cause mortality by hospital volume, adjusting for patient, tumour and surgical characteristics. We assessed conditional survival over three follow-up periods: short (30 days to 1 year), intermediate (1-3 years) and long (3-5 years). We additionally explored whether associations between volume and outcomes varied by tumour stage. RESULTS: A total of 12 912 patients were included. Patients in HV hospitals had a 34% reduction in mortality risks up to 1 year compared to those in LV hospitals (HR 0.66, 95% confidence interval 0.53-0.83; P < 0.01). Assuming causality, treatment in HV hospitals was associated with one fewer death in every 71 patients treated. Benefit of nephrectomy centralisation did not change with higher T stage (P = 0.17). No significant association between hospital volume and survival was observed beyond the first year. CONCLUSIONS: Nephrectomy for RCC in HV hospitals was associated with improved survival for up to 1 year after treatment. Our results contribute new insights regarding the value of nephrectomy centralisation.

Guideline adherence for the surgical treatment of T1 renal tumours correlates with hospital volume: an analysis from the British Association of Urological Surgeons Nephrectomy Audit.

OBJECTIVE: To assess European Association of Urology guideline adherence on the surgical management of patients with T1 renal tumours and the effects of centralisation of care. PATIENTS AND METHODS: Retrospective data from all kidney tumours that underwent radical nephrectomy (RN) or partial nephrectomy (PN) in the period 2012-2016 from the British Association of Urological Surgeons Nephrectomy Audit were retrieved and analysed. We assessed total surgical hospital volume (HV; RN and PN performed) per centre, PN rates, complication rates, and completeness of data. Descriptive analyses were performed, and confidence intervals were used to illustrate the association between hospital volume and proportion of PN. Chi- squared and Cochran-Armitage trend tests were used to evaluate differences and trends. RESULTS: In total, 13 045 surgically treated T1 tumours were included in the analyses. Over time, there was an increase in PN use (39.7% in 2012 to 44.9% in 2016). Registration of the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) complexity score was included in March 2016 and documented in 39% of cases. Missing information on postoperative complications appeared constant over the years (8.5-9%).  A clear association was found between annual HV and the proportion of T1 tumours treated with PN rather than RN (from 18.1% in centres performing <25 cases/year [lowest volume] to 61.8% in centres performing ≥100 cases/year [high volume]), which persisted after adjustment for PADUA complexity. Overall and major (Clavien-Dindo grade ≥III) complication rate decreased with increasing HV (from 12.2% and 2.9% in low-volume centres to 10.7% and 2.2% in high-volume centres, respectively), for all patients including those treated with PN. CONCLUSION: Closer guideline adherence was exhibited by higher surgical volume centres. Treatment of T1 tumours using PN increased with increasing HV, and was accompanied by an inverse association of HV with complication rate. These results support the centralisation of kidney cancer specialist cancer surgical services to improve patient outcomes.

Impact of Centralisation on Abdominal Aortic Aneurysm Repair Outcomes: Early Experience in Catalonia.

OBJECTIVE: Several studies have revealed high volume centres have better outcomes in the treatment of abdominal aortic aneurysms (AAAs), thus supporting centralisation of this procedure into selected centres based on volume. To date however, the real benefit of centralisation of this pathology has not been well demonstrated. The aim of this study was to analyse the impact of centralisation in to high volume centres (defined as those performing more than 30 cases per year) on AAA treatment outcomes carried out in Catalonia (Spain). METHODS: Data were collected from official national registries (HDMBD) for AAA treated by endovascular aneurysm repair (EVAR) or open repair (OR) over a nine year period. Two time periods were selected for comparison: before centralisation (2009-2014) and after complete centralisation (2015-2017). The primary objective was to determine short term mortality (in hospital and 30 day mortality) and length of stay (LOS) after intact AAA (iAAA) and ruptured AAA (rAAA) repair, before and after centralisation. Uni- and multivariable analyses were performed in order to identify independent outcomes predictors. RESULTS: A total of 3 501 iAAAs, including 1 124 (32.1%) OR and 2377 (67.9%) EVAR, and 409 rAAAs, including 218 (53.3%) OR and 191 (46.7%) EVAR, were identified. After centralisation, there was a significant decrease in overall mortality in iAAA repair (4.7% vs. 2.0%, p < .001) and rAAA repair (53.1% vs. 41.9%, p = .028). Mortality reduction in iAAAs was significant for OR (8.7% vs. 3.6%, p = .005), but not for EVAR (2.2% vs. 1.5%, p = .25). Overall LOS decreased as well, mainly in iAAAs (9.49 ± 10.84 vs. 7.44 ± 12.23 days, p < .001), and in particular in elective EVAR (7.32 ± 7.73 vs. 6.00 ± 8.97 days, p < .001). Multivariable analysis was identified before the centralisation period as an independent predictor for both mortality (odds ratio 1.484, 95% CI 1.098-2.005, p = .010) and LOS (B coefficient 1.146, 95% CI 0.218-2.073, p = .016). CONCLUSION: The implementation of a country based centralisation programme for AAA treatment led to a significant reduction in short term mortality, for both iAAA and rAAA, and mainly for elective OR. LOS also significantly decreased, mainly for elective EVAR. These results support the benefit of centralisation of AAA repair procedures.

Impact of cancer service centralisation on the radical treatment of men with high-risk and locally advanced prostate cancer: A national cross-sectional analysis in England.

In many countries, specialist cancer services are centralised to improve outcomes. We explored how centralisation affects the radical treatment of high-risk and locally advanced prostate cancer in the English NHS. 79,085 patients diagnosed with high-risk and locally advanced prostate cancer in England (April 2014 to March 2016) were identified in the National Prostate Cancer Audit database. Poisson models were used to estimate risk ratios (RR) for undergoing radical treatment by whether men were diagnosed at a regional co-ordinating centre ('hub'), for having surgery by the presence of surgical services on-site, and for receiving high dose-rate brachytherapy (HDR-BT) in addition to external beam radiotherapy by its regional availability. Men were equally likely to receive radical treatment, irrespective of whether they were diagnosed in a hub (RR 0.99, 95% CI 0.91-1.08). Men were more likely to have surgery if they were diagnosed at a hospital with surgical services on site (RR 1.24, 1.10-1.40), and more likely to receive additional HDR-BT if they were diagnosed at a hospital with direct regional access to this service (RR 6.16, 2.94-12.92). Centralisation of specialist cancer services does not affect whether men receive radical treatment, but it does affect treatment modality. Centralisation may have a negative impact on access to specific treatment modalities.

Making a difference for children born with a cleft in the UK.

This short review is an opportunity to focus on significant positive changes for those children born with some form of oro-facial clefting and who are treated in a centralised service within the National Health Service (NHS). There has also been an opportunity to provide a focus for research as part of this service model. Orthodontists have played a key role in all aspects of this and will continue to be central to further improvements in caring for cleft children.