1
|
Kuchenbecker J, Peters F, Kreutzburg T, Marschall U, L'Hoest H, Behrendt CA. The Relationship Between Hospital Procedure Volume and Outcomes After Endovascular or Open Surgical Revascularisation for Peripheral Arterial Disease: An Analysis of Health Insurance Claims Data. Eur J Vasc Endovasc Surg 2023; 65:370-378. [PMID: 36464221 DOI: 10.1016/j.ejvs.2022.11.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/22/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE There is a paucity of data on the relationship between hospital procedure volume and outcomes after inpatient treatment of symptomatic peripheral arterial disease (PAD). This study aimed to generate meaningful hypotheses to support the ongoing discussion. METHODS Data derived from BARMER, Germany's second largest insurance provider, were linked with nationwide hospital procedure volumes from mandatory hospital quality reports. All endovascular (EVR) and open surgical revascularisations (OSR) provided to patients (≥ 40 years) with symptomatic PAD between 1 January 2013 and 31 December 2018 were included. Hospital volume was defined as the number of procedures performed by a hospital in the previous calendar year (in quartiles). Freedom from re-intervention, amputation, and overall mortality rate within 12 months after discharge were analysed using multivariable Cox proportional hazards models. In hospital mortality was determined by generalised estimating equations logistic regression models. RESULTS There were 88 187 revascularisations (72.4% EVR; EVR: 72.7 years and 45.2% females; OSR: 71.9 years and 41.9% females) registered by 668 hospitals. No statistically significant association was found between 12 month freedom from re-intervention and hospital volume (EVR: 4; quartile HR 1.05; 95% CI 0.94 - 1.16. OSR: 4; quartile HR 1.05; 95% CI 0.92 - 1.21). Patients with OSR had a decreased hazard of 12 month mortality in a high volume hospital compared with a low volume hospital (HR 0.85; 95% CI 0.73 - 0.98), but not with EVR (HR 1.03; 95% CI 0.91 - 1.16). Patients who were treated in hospitals with highest volumes showed decreased hazards of 12 month freedom from amputation when compared with low volume hospitals (EVR: HR 0.72; 95% CI 0.52 - 0.99. OSR: HR 0.61; 95% CI 0.44 - 0.85). CONCLUSION This large retrospective analysis of insurance claims suggests that higher procedure volume is associated with lower major amputation rates, although there is a need for standardisation of the definition of volume stratification. Future studies should address the impact of subsequent outpatient care and surveillance to further examine the complex interaction between treatment and outcomes.
Collapse
Affiliation(s)
- Jenny Kuchenbecker
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Frederik Peters
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Thea Kreutzburg
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Christian-Alexander Behrendt
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.
| |
Collapse
|
2
|
Sedhom R, Elbadawi A, Megaly M, Jaber WA, Cameron SJ, Weinberg I, Mamas MA, Elgendy IY. Hospital procedural volume and outcomes with catheter-directed intervention for pulmonary embolism: a nationwide analysis. Eur Heart J Acute Cardiovasc Care 2022; 11:684-692. [PMID: 35830539 DOI: 10.1093/ehjacc/zuac082] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/20/2022] [Accepted: 06/22/2022] [Indexed: 06/15/2023]
Abstract
AIMS There is limited data on the association between hospital catheter-directed intervention (CDI) volume and outcomes among patients with acute pulmonary embolism (PE). METHODS AND RESULTS The Nationwide Readmissions Database years 2016-2019 was utilized to identify hospitalizations undergoing CDI for acute PE. Hospitals were divided into tertiles based on annual CDI volume; low-volume (1-3 procedures), moderate-volume (4-12 procedures) and high-volume (>12 procedures). The primary outcome was all-cause in-hospital mortality. Among 1 436 382 PE admissions, 2.6% underwent CDI; 5.6% were in low-volume, 17.3% in moderate-volume and 77.1% in high-volume hospitals. There was an inverse relationship between hospital CDI volume and in-hospital mortality (coefficient -0.344, P < 0.001). On multivariable regression analysis, hospitals with high CDI volume were associated with lower in-hospital mortality compared with hospitals with low CDI volume (adjusted odds ratio [OR] 0.71; 95% confidence interval [CI] 0.53, 0.95). Additionally, there was an inverse association between CDI volume and length of stay (LOS) (regression coefficient -0.023, 95% CI -0.027, -0.019) and cost (regression coefficient -74.6, 95% CI -98.8, -50.3). There were no differences in major bleeding and 30-day unplanned readmission rates between the three groups. CONCLUSION In this contemporary observational analysis of PE admissions undergoing CDI, there was an inverse association between hospital CDI volume and in-hospital mortality, LOS, and cost. Major bleeding and 30-day unplanned readmission rates were similar between the three groups.
Collapse
Affiliation(s)
- Ramy Sedhom
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA 19141, USA
| | - Ayman Elbadawi
- Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Michael Megaly
- Division of Cardiology, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Wissam A Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Scott J Cameron
- Section of Vascular Medicine, Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Ido Weinberg
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele ST55BG, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent ST46QG, UK
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY 40536, USA
| |
Collapse
|
3
|
Baum P, Diers J, Haag J, Klotz L, Eichhorn F, Eichhorn M, Wiegering A, Winter H. Nationwide effect of high procedure volume in lung cancer surgery on in-house mortality in Germany. Lung Cancer 2020; 149:78-83. [PMID: 32980612 DOI: 10.1016/j.lungcan.2020.08.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND The literature reports that hospital caseload volume is associated with survival for lung cancer resection. The aim of this study is to explore this association in a nationwide setting according to individual hospital caseload volume of every inpatient case in Germany. METHODS This retrospective analysis of nationwide hospital discharge data in Germany between 2014 and 2017 comprises 121,837 patients of whom 36,051 (29.6 %) underwent surgical anatomic resection. Hospital volumes were defined according to the number of patient resections for lung cancer in each hospital, and patients were categorized into 5 quintiles based on hospital caseload volume. A logistic regression model accounting for death according to sex, age, comorbidity, and resection volume was calculated, and effect modification was evaluated using the Mantel-Haenszel method. RESULTS In-house mortality ranged from 2.1 % in very high-volume centers to 4.0 % in very low-volume hospitals (p < 0.01). In multivariable logistic regression analysis, lower in-house mortality in very high-volume centers performing > 140 anatomic lung resections per year was observed compared with very low-volume centers performing < 27 resections (OR, 0.58; CI, 0.46 to 0.72; p < 0.01). This relationship also held for failure to rescue rates (12.9 vs 16.7 %, p = 0.01), although a greater number of extended resections were performed (23.1 vs. 14.8 %, p < 0.01). CONCLUSIONS Hospitals with high volumes of lung cancer resections performed surgery with a higher ratio of complex procedures and achieved reduced in-house mortality, fewer complications, and lower failure to rescue rates.
Collapse
Affiliation(s)
- Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany.
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Straße 6, 97080 Wuerzburg, Germany.
| | - Johannes Haag
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany.
| | - Laura Klotz
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany.
| | - Florian Eichhorn
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany.
| | - Martin Eichhorn
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany.
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Straße 6, 97080 Wuerzburg, Germany.
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany.
| |
Collapse
|
4
|
Becher PM, Goßling A, Schrage B, Twerenbold R, Fluschnik N, Seiffert M, Bernhardt AM, Reichenspurner H, Blankenberg S, Westermann D. Procedural volume and outcomes in patients undergoing VA-ECMO support. Crit Care 2020; 24:291. [PMID: 32503646 PMCID: PMC7275456 DOI: 10.1186/s13054-020-03016-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/25/2020] [Indexed: 01/11/2023]
Abstract
Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in patients with critical cardiopulmonary failure. To investigate the association between hospital VA-ECMO procedure volume and outcomes in a large, nationwide registry. Methods By using administrative data from the German Federal Health Monitoring System, we analyzed all VA-ECMO procedures performed in Germany from 2013 to 2016 regarding the association of procedural volumes with outcomes and complications. Results During the study period, 10,207 VA-ECMO procedures were performed; mean age was 61 years, 43.4% had prior CPR, and 71.2% were male patients. Acute coronary syndrome was the primary diagnosis for VA-ECMO implantation (n = 6202, 60.8%). The majority of implantations (n = 5421) were performed at hospitals in the lowest volume category (≤ 50 implantations per year). There was a significant association between annualized volume of VA-ECMO procedures and 30-day in-hospital mortality for centers with lower vs. higher volume per year. Multivariable logistic regression showed an increased 30-day in-hospital mortality at hospitals with the lowest volume category (adjusted odds ratio 1.13, 95% confidence interval [CI] 1.01–1.27, p = 0.034). Similarly, higher likelihood for complications was observed at hospitals with lower vs. higher annual VA-ECMO volume (adjusted odds ratio 1.46, 95% CI 1.29–1.66, p = 0.001). Conclusions In this analysis of more than 10,000 VA-ECMO procedures for cardiogenic shock, the majority of implantations were performed at hospitals with the lowest annual volume. Thirty-day in-hospital mortality and likelihood for complications were higher at hospitals with the lowest annual VA-ECMO volume.
Collapse
Affiliation(s)
- Peter Moritz Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nina Fluschnik
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Moritz Seiffert
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany. .,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
| |
Collapse
|
5
|
Badawy M, Fenstad AM, Bartz-Johannessen CA, Indrekvam K, Havelin LI, Robertsson O, W-Dahl A, Eskelinen A, Mäkelä K, Pedersen AB, Schrøder HM, Furnes O. Hospital volume and the risk of revision in Oxford unicompartmental knee arthroplasty in the Nordic countries -an observational study of 14,496 cases. BMC Musculoskelet Disord 2017; 18:388. [PMID: 28882132 PMCID: PMC5590160 DOI: 10.1186/s12891-017-1750-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/31/2017] [Indexed: 12/13/2022] Open
Abstract
Background High procedure volume and dedication to unicompartmental knee arthroplasty (UKA) has been suggested to improve revision rates. This study aimed to quantify the annual hospital volume effect on revision risk in Oxfordu nicompartmental knee arthroplasty in the Nordic countries. Methods 14,496 cases of cemented medial Oxford III UKA were identified in 126 hospitals in the four countries included in the Nordic Arthroplasty Register Association (NARA) database from 2000 to 2012. Hospitals were divided by quartiles into 4 annual procedure volume groups (≤11, 12-23, 24-43 and ≥44). The outcome was revision risk after 2 and 10 years calculated using Kaplan Meier method. Multivariate Cox regression analysis was used to assess the Hazard Ratio (HR) of any revision due to specific reasons with 95% confidence intervals (CI). Results The implant survival was 80% at 10 years in the volume group ≤11 procedures per year compared to 83% in other volume groups. The HR adjusted for age category, sex, year of surgery and nation was 0.87 (95% CI: 0.76-0.99, p = 0.036) for the group 12-23 procedures per year, 0.78 (95% CI: 0.68-0.91, p = 0.002) for the group 24-43 procedures per year and 0.82 (95% CI: 0.70-0.94, p = 0.006) for the group ≥44 procedures per year compared to the low volume group. Log-rank test was p = 0.003. The risk of revision for unexplained pain was 40-50% higher in the low compared with other volume groups. Conclusion Low volume hospitals performing ≤11 Oxford III UKAs per year were associated with an increased risk of revision compared to higher volume hospitals, and unexplained pain as revision cause was more common in low volume hospitals.
Collapse
Affiliation(s)
| | - Anne M Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | | | - Kari Indrekvam
- Coastal Hospital, 5253, Hagavik, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Leif I Havelin
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Otto Robertsson
- The Swedish Knee Arthroplasty Register, Lund, Sweden.,Department of Clinical Sciences, Lund University Faculty of Medicine, Orthopedics, Lund, Sweden
| | - Annette W-Dahl
- The Swedish Knee Arthroplasty Register, Lund, Sweden.,Department of Clinical Sciences, Lund University Faculty of Medicine, Orthopedics, Lund, Sweden
| | | | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland
| | - Alma B Pedersen
- The Danish Knee Arthroplasty Register, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik M Schrøder
- Department of Orthopaedic surgery, Næstved Hospital, Næstved, Denmark
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, Bergen, Norway
| |
Collapse
|
6
|
Møller H, Riaz SP, Holmberg L, Jakobsen E, Lagergren J, Page R, Peake MD, Pearce N, Purushotham A, Sullivan R, Vedsted P, Luchtenborg M. High lung cancer surgical procedure volume is associated with shorter length of stay and lower risks of re-admission and death: National cohort analysis in England. Eur J Cancer 2016; 64:32-43. [PMID: 27328450 DOI: 10.1016/j.ejca.2016.05.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 05/16/2016] [Accepted: 05/17/2016] [Indexed: 12/14/2022]
Abstract
It is debated whether treating cancer patients in high-volume surgical centres can lead to improvement in outcomes, such as shorter length of hospital stay, decreased frequency and severity of post-operative complications, decreased re-admission, and decreased mortality. The dataset for this analysis was based on cancer registration and hospital discharge data and comprised information on 15,738 non-small-cell lung cancer patients resident and diagnosed in England in 2006-2010 and treated by surgical resection. The number of lung cancer resections was computed for each hospital in each calendar year, and patients were assigned to a hospital volume quintile on the basis of the volume of their hospital. Hospitals with large lung cancer surgical resection volumes were less restrictive in their selection of patients for surgical management and provided a higher resection rate to their geographical population. Higher volume hospitals had shorter length of stay and the odds of re-admission were 15% lower in the highest hospital volume quintile compared with the lowest quintile. Mortality risks were 1% after 30 d and 3% after 90 d. Patients from hospitals in the highest volume quintile had about half the odds of death within 30 d than patients from the lowest quintile. Variations in outcomes were generally small, but in the same direction, with consistently better outcomes in the larger hospitals. This gives support to the ongoing trend towards centralisation of clinical services, but service re-organisation needs to take account of not only the size of hospitals but also referral routes and patient access.
Collapse
Affiliation(s)
- Henrik Møller
- King's College London, Cancer Epidemiology, Population and Global Health, Research Oncology, 3rd Floor Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK; Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Charterhouse Square, London EC1M 6BQ, UK; Public Health England, UK National Cancer Analysis and Registration Service, 2nd Floor Skipton House, 80 London Road, London SE1 6LH, UK; Research Unit for General Practice and Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Bartholins Allé 2, DK-8000 Aarhus C, Denmark.
| | - Sharma P Riaz
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Charterhouse Square, London EC1M 6BQ, UK.
| | - Lars Holmberg
- King's College London, Cancer Epidemiology, Population and Global Health, Research Oncology, 3rd Floor Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK.
| | - Erik Jakobsen
- The Danish Lung Cancer Registry, Department of Thoracic Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark.
| | - Jesper Lagergren
- King's College London, Cancer Epidemiology, Population and Global Health, Research Oncology, 3rd Floor Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK; Department of Molecular Medicine and Surgery (MMK), K1, Upper Gastrointestinal Research, Övre gastrointestinal forskning, NS 67, Institutionen för molekylär medicin och kirurgi, Karolinska Institutet, 171 76 Stockholm, Sweden.
| | - Richard Page
- Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK.
| | - Michael D Peake
- Public Health England, UK National Cancer Analysis and Registration Service, 2nd Floor Skipton House, 80 London Road, London SE1 6LH, UK.
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
| | - Arnie Purushotham
- King's College London, Cancer Epidemiology, Population and Global Health, Research Oncology, 3rd Floor Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK.
| | - Richard Sullivan
- King's College London, Cancer Epidemiology, Population and Global Health, Research Oncology, 3rd Floor Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK.
| | - Peter Vedsted
- Research Unit for General Practice and Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Bartholins Allé 2, DK-8000 Aarhus C, Denmark.
| | - Margreet Luchtenborg
- King's College London, Cancer Epidemiology, Population and Global Health, Research Oncology, 3rd Floor Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK; Public Health England, UK National Cancer Analysis and Registration Service, 2nd Floor Skipton House, 80 London Road, London SE1 6LH, UK.
| |
Collapse
|