Relationship between ovarian cancer survival and surgery volume in hospitals in the state of Sao Paulo

Introdução: O câncer epitelial de ovário é uma doença altamente heterogênea. Cirurgia e quimioterapia são ambos componentes importantes do tratamento. Nós avaliamos neste estudo a importância do tipo de hospital na sobrevida global de pacientes portadoras de câncer epitelial ovariano. Objetivos: Nosso objetivo foi identificar se as características do hospital impactaram a sobrevida global do paciente. Nós consideramos tanto características quantitativas (o volume de pacientes portadoras de câncer de ovário) quanto qualitativas (ser um hospital escola ou não). Métodos: Uma coorte histórica foi estabelecida com os dados fornecidos pela Fundação Oncocentro de São Paulo (FOSP). Pacientes eram mulheres tratadas para câncer de ovário no estado de São Paulo de janeiro de 2000 a dezembro de 2018. Informação foi coletada quanto a idade, tipo histológico, estadio, cirurgia, quimioterapia e tipo do hospital. Nós classificamos os hospitais tanto quantiativamente quanto qualitativamente. Quando a mediana de número de pacientes com câncer de ovário tratados na instituição era 20 ou mais, ela era considerada um hospital de alto volume; do contrário, era considerado um hospital de baixo volume. Nós usamos a portaria interministerial do Ministério da Saúde e da Educação para determinar quais instituições eram hospitals escola; todos os outros foram classificados como hospitais regulares. Resultado: Hospitais de alto volume (HR 0.86, 95% IC: 0.80-0.92, p < 0.001) e hospitais escola (HR 0.91, 95% IC: 0.85- 0.99, p = 0.019) foram associados a um risco menor de morte. Probabilidade de ser submetido a cirurgia foi maior em hospitais de alto volume comparado a hospitais de baixo volume (80.0% contra 71.1%, p < 0.001). Um menor número de pacientes em hospitais de alto volume foi submetido a quimioterapia comparado a hospitais de baixo volume (68.5% contra 74.5%, p < 0.001). Mais de 52% dos pacientes com câncer de ovário epitelial no estado de São Paulo foram tratados em hospitais de alto volume. Conclusão: A sobrevida global foi melhor de forma independente quando o paciente foi tratado em hospitais de alto volume ou hospitais escola. A análise exploratória demonstrou uma alta porcentagem de pacientes tratados em hospitais de alto volume e um uso inesperadamente mais alto de quimioterapia em hospitais de baixo volume. Estudos adicionais são necessários para explicar esses resultados.Introduction: Epithelial ovarian cancer is a highly heterogenous disease. Surgery and chemotherapy both are important parts of the treatment. We assessed in this study the importance of the type of hospital in the overall survival of epithelial ovarian cancer patients. Objectives: Our goal was to identify whether hospital characteristics impacted the overall survival of the patient. We considered both quantitative characteristics (the ovarian cancer patient volume) and qualitative characteristics (being either teaching or community hospital). Methods: A retrospective cohort study was established with data recorded by the Fundação Oncocentro de São Paulo (FOSP). Patients were women treated for ovarian cancer in the state of Sao Paulo from January 2000 to December 2018. Information was gathered on age, histology, staging, surgery, chemotherapy and the type of hospital. We classified hospitals both quantitatively and qualitatively. When the median ovarian cancer number of patients treated in that institution was 20 or higher, it was considered a high-volume hospital; otherwise, it was considered a low-volume hospital. We used the interministerial ordinance by the Ministry of Health and Education to determinate which institutions were teaching hospitals; all others were classified as community hospitals. Results: High volume hospitals (HR: 0.86, 95% CI 0.8-0.92, p < 0.001) and teaching hospitals (HR: 0.91, 95% CI 0.85-0.99, p = 0.019) were associated with low risk of death. Likelihood of undergoing surgery was higher in high-volume compared to low-volume hospitals (80.0% versus 71.1%, p < 0.001). A smaller number of patients in high-volume hospitals were submitted to chemotherapy compared to low-volume hospitals (68.5% versus 74.5%, p < 0.001). More than 52% of the epithelial ovarian cancer patients in the state of Sao Paulo were treated in high-volume hospitals. Conclusion: Overall survival improved independently when patients were treated in high-volume hospitals and teaching hospitals. Exploratory analysis showed a high percentage of patients treated in high-volume hospitals and an unexpected higher usage of chemotherapy in low-volume hospitals. Additional studies are required to further explain these results

Ovarian cancer hospitalization rates during the COVID-19 pandemic in the state of Sao Paulo and correlation with pandemic-related variables

Introdução: A pandemia de COVID-19 que teve início em 2020 prejudicou o funcionamento de serviços de saúde e modificou o comportamento de pacientes. Há relatos de mudanças na atividade cirúrgica coincidindo com o período do surto Nós buscamos verificar se houve mudanças na taxa de hospitalização dentre pacientes portadoras de câncer de ovário no Estado de São Paulo, no Brasil. Objetivos: Nosso objetivo foi identificar se mudanças poderiam ser encontradas na taxa de hospitalização de pacientes com câncer de ovário entre 2016 e 2020, comparando níveis pré-pandemia e na pandemia. Nós também buscamos determinar, caso essas mudanças tenham acontecido, se elas estavam correlacionadas com variáveis relativas a pandemia. Métodos: Dados agregados foram obtidos na Secretaria de Saúde do Estado de São Paulo relativas a hospitalização por câncer de ovário, taxa média de distanciamento social, incidência, mortalidade e letalidade por COVID-19 e taxa de ocupação de leitos específicos para COVID-19 tanto de enfermaria quanto de UTI. Hospitalizações por câncer de ovário foram categorizadas como para tratamento clínico ou cirúrgico. Esses dados foram avaliados tanto em nível estadual quando para cada subdivisão do Estado. Nós realizamos uma análise Joinpoint para verificar se havia mudanças na taxa de hospitalização durante o período do estudo. Nós também calculamos razões de taxa de hospitalização e verificamos se eles se correlacionavam com variáveis relativas a pandemia. Resultado: Taxas de hospitalização gerais para câncer de ovário cairiam no Estado coincidindo com o início da pandemia. Em nível estadual, taxas de hospitalização clínicas não exibiram mudanças no período do estudo, enquanto taxas de hospitalização cirúrgicas caíram dois trimestres antes do início da pandemia e mantiveram-se em queda. Razões de taxas de hospitalização cirúrgicas apresentavam correlação inversa com taxa de ocupação de leitos de UTI específicos para COVID no terceiro trimestre de 2020, com um coeficiente de correlação de Pearson de -0,50 (IC 95%: -0,78 a -0,05, p = 0,03). Um aumento no número de indivíduos exclusivamente dependentes do SUS foram identificados no Estado, com um coeficientes de correlação de Pearson de 0,95 (IC 95%: 0,88-0,98, p < 0,001). Conclusão: Razões de taxa de hospitalização cirúrgicas caíram no terceiro trimestre de 2020 e estiveram inversamente correlacionados com taxa de ocupação de UTI. Isso demonstra o impacto da pandemia por COVID-19 no tratamento de condições que competem pelos mesmos recursos de saúde.Abstract: The COVID-19 pandemic which began in 2020 disrupted healthcare services and changed patient behavior. There are reports of changes in surgical activity coinciding with the outbreak period. We aimed to assess whether any changes happened in hospitalization rates among ovarian cancer patients in the state of Sao Paulo, Brazil. Objectives: Our goal was to identify if any changes could be determined in hospitalization rates of ovarian cancer patients from 2016 to 2020, comparing pre-pandemic and pandemic levels. We also aimed to assess, if these changes happened, whether they were correlated with pandemic-related variables. Methods: Aggregated data was obtained from the State of Sao Paulo Secretary of Health regarding both ovarian cancer hospitalization and average social distancing rates, COVID-19 incidence, mortality, lethality and both COVID-specific infirmary and ICU bed occupation rates. Hospitalizations for ovarian cancer could be categorized as either for clinical or surgical treatments. These data were available both for state level and for each of the state\'s subdivisions. We performed a Joinpoint analysis in order to verify if there were changes regarding hospitalization rates during the study period. We also calculated hospitalization rate ratios and verified if they were correlated with pandemic-related variables. Results: Overall hospitalization rates in the state fell coinciding with the start of the pandemic. At state-level, clinical hospitalization rates did not show changes in its trend during the study period, while surgical hospitalization rates started to decrease two trimesters before the pandemic began and remained decreasing. Surgical hospitalization rate ratios were inversely correlated with COVID-specific ICU bed occupation rates during the third trimester of 2020, with a Pearson Correlation coefficient of -0.50 (95% CI: -0.78 to -0.05, p = 0.03). An increasing number of exclusively public-insured persons were identified in the state, with a Pearson Correlation coefficient of 0.95 (95% CI: 0.88-0,98, p < 0.001). Conclusion: Surgical hospitalization rate ratios fell during the third trimester of 2020 and were inversely correlated with ICU occupation. This demonstrates the impact of COVID-19 pandemic on the treatment of conditions which compete for the same healthcare resources

Assessment of healthcare accessibility and travel distance on intrapartum fetal death: a retrospective cohort study

Objective. To determine if there was an association between intrapartum stillbirths and both traveled distance for delivery and delivery care accessibility, assessing periods before and during the COVID-19 pandemic. Methods. This is a population-based cohort study. Patients had birth occurring after the onset of labor; the primary outcome was intrapartum stillbirth. City of residence was classified according to the ratio between deliveries performed and total births among its residents; values lower than 0.1 indicated low delivery care accessibility. Travel distance was calculated using the Haversine formula. Education level, maternal age, and birth sex were included. In each period, relative risk was assessed by generalized linear model with Poisson variance. Results. There were 2 267 534 deliveries with birth occurring after the onset of labor. Most patients were between age 20 and 35 years, had between 8 and 11 years of education, and resided in cities with high delivery care accessibility. Low delivery care accessibility increased risk of intrapartum stillbirth in the pre-pandemic (relative risk [RR] 2.02; 95% CI [1.64, 2.47]; p < 0.01) and the pandemic period (RR 1.69; 95% CI [1.09, 2.55]; p = 0.015). This was independent of other risk-increasing factors, such as travel distance and fewer years of education. Conclusions. Low delivery care accessibility is associated with the risk of intrapartum stillbirths, and accessibility reduced during the pandemic. Delivery of patients by family physicians and midwives, as well as official communication channels between primary care physicians and specialists, could improve patient healthcare-seeking behavior