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    Investig Clin Urol. 2024 Mar;65(2):124-131. English.
    Published online Mar 04, 2024.
    https://doi.org/10.4111/icu.20230333
    © The Korean Urological Association
    Original Article

    Analysis of trend in the role of national and regional hubs in prostatectomy after prostate cancer diagnosis in the past 5 years: A nationwide population-based study

    Seong Cheol Kim,1,2,* Seungbong Han,3,* Ji Hyung Yoon,1 Sungchan Park,1,2 Kyung Hyun Moon,1 Sang Hyeon Cheon,1 Gyung-Min Park,4 and Taekmin Kwon1
      • 1Department of Urology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
      • 2Basic-Clinical Convergence Research Center, University of Ulsan, Ulsan, Korea.
      • 3Department of Biostatistics, Korea University College of Medicine, Seoul, Korea.
      • 4Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
    • Corresponding Author: Taekmin Kwon. Department of Urology, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan 44033, Korea. TEL: +82-52-250-7190, FAX: +82-52-250-7199, Email: tmkwon@uuh.ulsan.kr

      *These authors contributed equally to this study and should be considered co-first authors.
    Received October 04, 2023; Revised November 11, 2023; Accepted December 29, 2023.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    Purpose

    The regions where patients diagnosed with prostate cancer by biopsy receive prostatectomy are divided into national hub and regional hubs, and to confirm the change in the role of regional hubs compared to national hub.

    Materials and Methods

    Data from July 2013 to June 2017 encompassing 218,155 patients aged ≥18 years diagnosed with prostate cancer were analyzed using the Health Insurance Review & Assessment Service database. The degree of patient outflow was assessed by dividing the regional diagnosis-to-surgery ratio with the national ratio for each year. Based on this ratio, national and regional hubs were determined.

    Results

    Seoul consistently maintained a patient influx with a ratio above 1.6. Busan and Gyeonggi consistently exceeded 0.9, while Ulsan and Daegu steadily increased, exceeding 1.0 between 2015 and 2016. Jeonnam province also consistently maintained the ratio above 0.7. Jeju, Daejeon, Gangwon, and Incheon remained below 0.5, indicative of substantial patient outflows, whereas Gwangju and Gyeongbuk had the highest patient outflows with ratios below 0.15. Therefore, Seoul was designated as a national hub, whereas Busan, Gyeonggi, Ulsan, Daegu, and Jeonnam were classified as regional hubs. Jeju, Daejeon, Gangwon, and Incheon were the dominant outflow areas, while Gwangju and Gyeongbuk were the highest outflow areas.

    Conclusions

    Seoul, as the national hub for prostate cancer surgery, operated on 1.76 times more patients than any other region during 2013–2017. Busan, Gyeonggi, Ulsan, Daegu, and Jeonnam functioned as regional hubs, but approximately 10%–20% of patients sought treatment at national hubs.

    Graphical Abstract

    Keywords
    Geography; Health services accessibility; Prostatectomy; Prostatic neoplasms

    INTRODUCTION

    Prostate cancer has consistently had the highest incidence among males in the United States for several years. In 2023, the number of new cases reached 288,300 which is more than two times higher than the second and third most common cancers, lung & bronchus (117,550), and colon & rectum (81,860), respectively [1]. In Korea, prostate cancer ranks as the third most prevalent cancer with the highest rate of increase [2, 3]. This surge in prostate cancer has led to a rise in the number of patients treated for the condition, particularly through radical prostatectomy, which is now accepted as the standard treatment for intermediate- and high-risk prostate cancer [4, 5].

    Public health strategies to optimize cancer-specific mortality associated with prostate cancer, a major contributor to the overall cancer burden, are important; however, there is also a pressing need to address the socioeconomic burden of prostate cancer [6, 7]. Similar to other countries, the shift and increase in demand for medical services in metropolitan areas has become an important public health concern and one of the contributing factors to rising socioeconomic costs [6, 8, 9]. Radical prostatectomy, a primary treatment for prostate cancer, is expected to be regionally concentrated in metropolitan areas, much like other cancer surgeries. In particular, prostate cancer is diagnosed through a prostate biopsy before surgery, which can serve as an important indicator to determine whether the location of diagnosis the site for surgery differed. This information can be valuable in identifying and developing countermeasures against patients’ medical travel and regional concentrations, which are significant public health and socioeconomic concerns.

    Therefore, we aimed to determine the extent of patient outflow and regional concentration in prostate cancer cases across different regions. To this end, the regions where patients diagnosed with prostate cancer through prostate biopsy undergo prostatectomy were divided into national hubs (moving by national unit) and regional hubs (moving by regional unit) to confirm the change in the roles of regional hubs compared with national hubs.

    MATERIALS AND METHODS

    1. Data sources

    In Korea, all healthcare providers join the National Health Insurance (NHI) system on a fee-for-service basis. The Health Insurance Review & Assessment Service (HIRA) is a quasi-governmental organization that systematically reviews medical fees to minimize the risk of redundant and unnecessary medical services. Consequently, all NHI claims are reviewed by HIRA [10]. For this study, data from HIRA’s claims records from 2013–2017 were used. Diagnostic codes were assigned according to the International Classification of Diseases 10th revision (ICD-10). In addition, specific information about the drugs, devices, and procedures were identified using codes from the HIRA database [10, 11]. This study was approved by the local Institutional Review Board of Ulsan University Hospital, Ulsan, Korea (approval number: UUH 2021-10-029). Because the study was based on routinely collected administrative data and was kept anonymous, the requirement for informed consent was waived.

    2. Study population

    From the HIRA database, we identified patients aged ≥18 years who were diagnosed with prostate cancer (ICD-10 code C61) between July 2013 and June 2017. We selected patients who had a minimum of six months of eligibility prior to the index day of prostate cancer diagnosis. The exclusion criteria were as follows: (1) patients who had already been diagnosed with prostate cancer from January 2013 to June 2013, (2) patients who did not undergo prostatic biopsy (codes C8551, C8552, C5911, C5912, C5913, C5914, or C5915) or transurethral resection of prostate (codes R3975, R3976, or R3977) after one month and within three months following their prostate cancer diagnosis, (3) patients who did not undergo prostatic biopsy or transurethral resection of prostate between July 2013 and June 2017, and (4) patients with insufficient records. Out of 218,155 patients aged 18 years or older diagnosed with prostate cancer between July 2013 and June 2017, 53,421 patients were analyzed, excluding 51,727 patients diagnosed with prostate cancer between January 2013 and June 2013, 112,750 who did not undergo prostatic biopsy or transurethral resection of the prostate before 3 months and after 1 month of prostate cancer diagnosis, and 257 who had not undergone prostatic biopsy or transurethral resection of the prostate between July 2013 and June 2017 (Fig. 1).

    Fig. 1
    Overview of patients.

    Information regarding patients who underwent prostatectomy was obtained from the HIRA database. Prostatectomy was divided into three types: open, laparoscopic, and robot assisted. We applied a hierarchical approach to classify the data (Supplementary Fig. 1). C5918 to C5508 are pathology codes, and R3960 and R3950 are prostatectomy codes. Lastly, N0031XXX is the material cost code for laparoscopic surgery. Therefore, if N0031XXX is present, it is Laparoscopy, if not, it is open. If there was only a pathology code without any other code, it was classified as robot. Furthermore, we examined regions where prostate cancer was diagnosed and operated on from the HIRA databases.

    3. Clinical outcomes

    The number of newly diagnosed prostate cancer and radical prostatectomy cases in that year was confirmed according to age group and region. Additionally, we ascertained the grade of the hospital where the diagnosis and surgery were performed (primary, secondary, or tertiary hospitals). To assess the degree of regional surgery concentration, we examined the number of surgeries performed in each region. The total number of surgeries in a given year was divided by the total number of diagnoses made in that year to determine the number of surgeries performed compared with the expected number of surgeries in the region. The degree of patient outflow was calculated by dividing the regional diagnosis-to-surgery ratio by the national diagnosis-to-surgery ratio for that year (regional surgery-diagnosis ratio/national surgery-diagnosis ratio). A ratio of 1 indicated that the number of surgeries performed in that area matched with that of patients who underwent surgery, while a ratio >1 signified that more patients underwent surgery, indicating that they came to the hospital for surgery from outside the region. A ratio <1 indicated that fewer patients underwent surgery locally, indicating surgeries being performed in other regions. National and regional hubs were determined based on this ratio.

    4. Statistical analyses

    We summarized patient age, diagnosis method, type of surgery, and region as continuous (mean±standard deviation) or categorical variables (frequency, percentage) from 2013 to 2017 and analyzed trends over the five years. We conducted a 5-year trend using χ2 test, logistic regression, or linear regression according to the categorical or the continuous variables. In cases of more than three categories (e.g., regional information), we employed a multinomial logistic regression model. Statistical significance was set at p<0.05 for all two-tailed tests. All data analyses were performed using the R software version 3.3.1 (R Foundation for Statistical Computing; https://www.r-project.org/).

    5. Ethical approval

    All procedures involving human participants performed in this study were in accordance with the ethical standards of the institutional and/or national research committee (approval number: UUH 2021-10-029) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The requirement for informed consent was waived because clinical data, including patient information and laboratory test results, were retrospectively obtained and analyzed.

    RESULTS

    1. Study population and characteristics

    The biopsy-related characteristics of 53,421 newly diagnosed patients with prostate cancer included in this study are shown in Table 1. The median age of these patients remained constant at 70 years over the years, and the majority of patients were diagnosed in Seoul (n=16,537, 31.0%), with more than half of them residing in metropolitan areas (n=26,774, 50.1%). Excluding the metropolitan area, the highest number of cases was observed in Gyeongsang province, including Busan (n=13,034, 24.4%). No significant difference was found between secondary and tertiary hospitals.

    Table 1
    Characteristics of patients newly diagnosed with prostate cancer in Korea between 2013 and 2017

    Table 2 outlines characteristics associated with radical prostatectomy. The mean age of the patients was 67.1 years, with a more than half of surgeries in Seoul alone. In the metropolitan area, 70.9% of patients underwent surgery, followed by Gyeongsang province, including Busan, at 17.1%. Radical prostatectomy showed an increasing trend every year, with robotic surgery in particular showing the highest increase. Tertiary hospitals performed more than three times as many surgeries as primary and secondary hospitals.

    Table 2
    Characteristics of patients underwent radical prostatectomy in Korea between 2013 and 2017

    2. Trends in prostatectomy-to-prostate cancer diagnosis ratio in Korea

    Seoul is the only city where the prostatectomy rate exceeded 50% compared to that of biopsies, and this rate has continued to increase. In other regions, the ratios of prostatectomy to biopsy had steadily increased. Over time, the prostatectomy-to-biopsy ratio exceeded 40% in Ulsan, Daegu, Busan, Gyeonggi, and Jeonnam (Fig. 2). However, given the overall increase in the prostatectomy-to-biopsy ratio, further investigation is required to determine whether patient outflow occurred.

    Fig. 2
    Trends in ratio of prostatectomy to diagnosis of prostate cancer in Korea.

    3. National and regional hubs for prostatectomy in Korea

    The degree of patient outflow remained consistently above 1.6 in Seoul, indicating a steady inflow of patients. Busan and Gyeonggi province consistently exceeded 0.9, while Ulsan and Daegu steadily increased, surpassing 1.0 between 2015 and 2016. Jeonnam province also consistently maintained a ratio above 0.7. Conversely, Jeju, Daejeon, Gangwon, and Incheon remained below 0.5, indicating a significant patient outflow, whereas Gwangju and Gyeongbuk had the highest patient outflows, with ratios below 0.15 (Fig. 3). Therefore, Seoul can be categorized as a national hub, whereas Busan, Gyeonggi, Ulsan, Daegu, and Jeonnam can be classified as regional hubs. Jeju, Daejeon, Gangwon, and Incheon were the dominant outflow areas, while Gwangju and Gyeongbuk were the highest outflow areas.

    Fig. 3
    The degree of patient outflow (regional surgery-diagnosis ratio/national surgery-diagnosis ratio).

    DISCUSSION

    In our study, we analyzed the NHI claims data for prostate cancer and our findings revealed that more than half of the prostatectomies were performed in Seoul, Gyeonggi, and other metropolitan areas. In addition, many surgeries were performed in Busan and Daegu; however, even if the two locations are combined, combining their figure was still lower than that of Gyeonggi. These differences could be attributed to the difference in number of hospitals and population in each region. Therefore, we determined regional imbalances by examining differences in surgery rates following prostate cancer diagnosis. As a result, we uncovered a large influx of patients into Seoul and high outflow from Jeju, Daejeon, Gangwon, Incheon, Gwangju, and Gyeongbuk. This study underscores the concentration of medical services in Seoul and its metropolitan areas, particularly for prostate cancer.

    A patient’s choice of healthcare facility that leads to this imbalance is a combination of various factors. In a Western study, medical travel distance was identified as one of the factors influencing the choice of treatment facility and type [12, 13, 14]. Muralidhar et al. [12] reported that radiotherapy is not an option for prostate cancer patients if the distance between their residential area and medical facilities is long. This may discourage medical travel for radiotherapy, given the continuous daily practice pattern of radiotherapy [12]. However, a significant distinction between medical travel in Korea and other countries is that they are less affected by distance. Other studies have also reported that distance was not the determining factor in choosing medical travel to Seoul [6]. Interestingly, it was reported that the rate of medical travel to Seoul for radiation therapy was highest in Jeju, the region furthest from Seoul in Korea. This phenomenon could be attributed to the development of Korea’s public transportation system, such as the expansion of high-speed train routes and the emergence of low-cost airlines. However, the relatively shorter distances in Korea compared to foreign countries likely played a role in this trend. Encouragingly, regional hubs are playing a steady role, and it is believed that revitalizing these regional hubs offers a potential avenue to alleviate the concentration phenomenon in metropolitan areas.

    In addition to geographical distance, several factors influence a patient’s decision to pursue medical travel, including higher education levels, stronger motivation for treatment, better economic status, younger age, and fewer comorbidities [13, 15, 16]. Equally significant is the patient’s disease status, which correlates with the stage of the disease at diagnosis and the need for complex treatments, including adjuvant chemotherapy or radiotherapy [12, 17, 18]. A study conducted in Korea also confirmed the inflow of patients requiring radiation and multimodal treatments into Seoul, and like other countries, medical travel to Seoul for prostatectomy showed a decreasing trend [5, 6]. This is believed to be related, in part, to the introduction of several robotic platforms in regions outside Seoul. The Da Vinci robot, a representative robotic surgical platform, was introduced in Korea at the end of 2006. In 2016, of the 58 units nationwide, 38 units (65.5%) were installed in metropolitan areas alone, including 27 units in Seoul [19]. In the case of the 152 da Vinci robots installed in 2023, many are still installed in the metropolitan area, but we confirmed that the number of installed units is increasing mainly in Busan, Ulsan, Daegu, and Jeonnam, which were classified as regional hubs in our study [20]. Therefore, improving local medical facilities and environments can alleviate the phenomenon of regional concentration.

    However, our study has some limitations, as it relies on administrative data from HIRA in Korea. While the diagnosis and treatment of prostate cancer in each region are undoubtedly influenced by population size and the number of hospitals in each region, it was challenging to pinpoint the characteristics of each region. Therefore, it is difficult to analyze the underlying causes of these regional disparities. A primary limitation lies in our inability to trace the inflow and outflow routes of patients, that is, their movements. We can only approximate the magnitude of inflow and outflow based on the comparison between the number of surgeries and diagnoses. Identifying individual patient movement patterns and the characteristics of patients exhibiting such movements will be vital in identifying and addressing the root cause of these movement in the future. Nevertheless, despite the well-established phenomenon of patients traveling to metropolitan areas for medical care, our study is the first to determine how much outflow and inflow occurred, which could help formulate future strategies and countermeasures.

    CONCLUSIONS

    Seoul, as the national hub for prostate cancer surgeries, handled 1.76 times as many patients as those where prostate cancer was initially diagnosed. While Busan, Gyeonggi, Ulsan, Daegu, and Jeonnam served as regional hubs, approximately 10%–20% of patients flew out to national hubs to seek treatment. To restore the imbalance between regions in prostate cancer surgery, it is necessary to further enhance the capacity and functions of these regional hubs. Our study marks a pioneering effort in quantifying the extent of these patient movements, offering valuable insights for shaping future strategies and implementing remedial measures.

    SUPPLEMENTARY MATERIAL

    Supplementary material can be found via https://doi.org/10.4111/icu.20230333.

    Supplementary Fig. 1

    Hierarchy.

    Click here to view.(20K, pdf)

    Notes

    CONFLICTS OF INTEREST:The authors have nothing to disclose.

    FUNDING:This research was supported by a grant from the Big Data Analysis Research Support Project through the Health Insurance Review & Assessment Service (HIRA) funded by the Korean Urological Association (2021-KUA-003).

    AUTHORS’ CONTRIBUTIONS:

    • Research conception and design: Seong Cheol Kim and Taekmin Kwon.

    • Data acquisition: Ji Hyung Yoon, Sungchan Park, Kyung Hyun Moon, and Sang Hyeon Cheon.

    • Statistical analysis: Seungbong Han and Gyung-Min Park.

    • Data analysis and interpretation: Seungbong Han and Gyung-Min Park.

    • Drafting of the manuscript: Seong Cheol Kim and Taekmin Kwon.

    • Critical revision of the manuscript: Seong Cheol Kim and Taekmin Kwon.

    • Obtaining funding: Seong Cheol Kim.

    • Administrative, technical, or material support: Seungbong Han and Gyung-Min Park.

    • Supervision: Seungbong Han and Taekmin Kwon.

    • Approval of the final manuscript: Seong Cheol Kim and Taekmin Kwon.

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    MeSH Terms
    Biopsy
    Busan
    Daegu
    Diagnosis*
    Gangwon-do
    Geography
    Gwangju
    Gyeonggi-do
    Gyeongsangbuk-do
    Health Services Accessibility
    Humans
    Incheon
    Insurance, Health
    Jeollanam-do
    Prostate*
    Prostatectomy*
    Prostatic Neoplasms*
    Seoul
    Ulsan
    Metrics
    Share
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