Re-examining the significance of surgical volume to breast cancer survival and recurrence versus process quality of care in Taiwan

Health Serv Res. 2013 Feb;48(1):26-46. doi: 10.1111/j.1475-6773.2012.01430.x. Epub 2012 Jun 7.


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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Age Factors
  • Aged
  • Breast Neoplasms / mortality*
  • Breast Neoplasms / surgery*
  • Comorbidity
  • Female
  • Hospital Administration / statistics & numerical data*
  • Humans
  • Middle Aged
  • Neoplasm Recurrence, Local / epidemiology*
  • Neoplasm Recurrence, Local / mortality
  • Neoplasm Staging
  • Outcome and Process Assessment, Health Care / statistics & numerical data
  • Proportional Hazards Models
  • Quality of Health Care / statistics & numerical data*
  • Registries / statistics & numerical data
  • Survival Analysis
  • Taiwan / epidemiology