Top-Down versus Bottom-Up Approach in Children Presenting with Urinary Tract Infection: Comparative Effectiveness Analysis Using RIVUR and CUTIE Data. Letter.

Abstract

surgeons are directed to a hub center for surgery, there was an absence of income level influence on quality of care metrics used in kidney cancer, including the use of nephron-sparing surgery and minimally invasive surgery, and survival outcomes. These findings may suggest a benefit of centralizing cancer care to ensure patients have access to adequate expertise. Importantly, the surgical management of kidney cancer is quite different than prostate cancer and is largely based on the experience and recommendation of the surgeon, including the decision to undergo radical vs partial nephrectomy or open vs minimally invasive surgery. While centralization may improve access to specialized services, it is important to remember that patients often incur additional costs and logistical complexities with this required travel that can be a barrier. 3 In fact, some patients may choose to have treatment closer to home even at the expense of inferior survival outcomes. 4 In the present study, we included patient residence (rural vs urban) as a surrogate for access to care and found that this was not significantly associated with treatment selection. Part of this may be due to the unique preexisting organization of prostate cancer care in our province, whereby the vast majority of patients are treated (with either surgery or radiation) in the capital city. Since treatments are naturally centralized in our jurisdiction, the referral hospital or volume of the center has a null effect. Outside of this unique position, we acknowledge that for specialized cancer care a centralized model of care delivery may work well in a universal health care system; however, we must remain sensitive to the unintended costs and sacrifices that patients are required to make to travel for such care.