Advertisement
No AccessJournal of UrologyAdult Urology1 Jul 2017

Redefining and Contextualizing the Hospital Volume-Outcome Relationship for Robot-Assisted Radical Prostatectomy: Implications for Centralization of Care

    View All Author Information

    Purpose:

    Robot-assisted radical prostatectomy has undergone rapid dissemination driven in part by market forces to become the most frequently used surgical approach in the management of prostate cancer. Accordingly, a critical analysis of its volume-outcome relationship has important health policy implications. Therefore, we evaluated the association of hospital robot-assisted radical prostatectomy volume with perioperative outcomes, and examined the distribution of hospital procedure volume to contextualize the volume-outcome relationship.

    Materials and Methods:

    We identified 140,671 men who underwent robot-assisted radical prostatectomy from 2009 to 2011 in NIS (Nationwide Inpatient Sample). The associations of hospital volume with perioperative outcomes and total hospital costs were evaluated using multivariable logistic regression and generalized linear models.

    Results:

    In 2011, 70% of hospitals averaged 1 robot-assisted radical prostatectomy per week or less, accounting for 28% of surgeries. Compared to patients treated at the lowest quartile hospitals, those treated at the highest quartile hospitals had significantly lower rates of intraoperative complications (0.6% vs 1.4%), postoperative complications (4.8% vs 13.9%), perioperative blood transfusion (1.5% vs 4.0%), prolonged hospitalization (4.3% vs 13.8%) and mean total hospital costs ($12,647 vs $15,394, all ptrend <0.001). When modeled as a nonlinear continuous variable, increasing hospital volume was independently associated with improved rates of each perioperative end point up to approximately 100 robot-assisted radical prostatectomies per year, beyond which there appeared to be marginal improvement.

    Conclusions:

    Increasing hospital robot-assisted radical prostatectomy volume was associated with improved perioperative outcomes up to approximately 100 surgeries per year, beyond which there appeared to be marginal improvement. A substantial proportion of these procedures is performed at low volume hospitals.

    References

    • 1 : Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol2010; 28: 1117. Google Scholar
    • 2 : Prostate cancer, version 2.2014. J Natl Compr Canc Netw2014; 12: 686. Google Scholar
    • 3 : Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era. J Clin Oncol2014; 32: 1419. Google Scholar
    • 4 : Direct-to-consumer Internet promotion of robotic prostatectomy exhibits varying quality of information. Health Aff (Millwood)2012; 31: 760. Google Scholar
    • 5 : Robot-assisted versus open radical prostatectomy: a contemporary analysis of an all-payer discharge database. Eur Urol2016; 70: 837. Google Scholar
    • 6 : Adverse effects of robotic-assisted laparoscopic versus open retropubic radical prostatectomy among a nationwide random sample of Medicare-age men. J Clin Oncol2012; 30: 513. Google Scholar
    • 7 : Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA2009; 302: 1557. Google Scholar
    • 8 : Hospitalization costs for radical prostatectomy attributable to robotic surgery. Eur Urol2013; 64: 11. Google Scholar
    • 9 : Searching robotic prostatectomy online: what information is available?. Urology2011; 77: 941. Google Scholar
    • 10 : Factors associated with adoption of robotic surgical technology in US hospitals and relationship to radical prostatectomy procedure volume. Ann Surg2014; 259: 1. Google Scholar
    • 11 : The association of robotic surgical technology and hospital prostatectomy volumes: increasing market share through the adoption of technology. Cancer2012; 118: 371. Google Scholar
    • 12 : Trends in radical prostatectomy: centralization, robotics, and access to urologic cancer care. Cancer2012; 118: 54. Google Scholar
    • 13 : Blood transfusions in radical prostatectomy: a contemporary population-based analysis. Urology2012; 79: 332. Google Scholar
    • 14 : Variations in morbidity after radical prostatectomy. N Engl J Med2002; 346: 1138. Google Scholar
    • 15 : The surgical learning curve for prostate cancer control after radical prostatectomy. J Natl Cancer Inst2007; 99: 1171. Google Scholar
    • 16 : Cancer control and functional outcomes after radical prostatectomy as markers of surgical quality: analysis of heterogeneity between surgeons at a single cancer center. Eur Urol2011; 59: 317. Google Scholar
    • 17 : A systematic review of the volume-outcome relationship for radical prostatectomy. Eur Urol2013; 64: 786. Google Scholar
    • 18 : A new frontier in patient safety. JAMA2011; 305: 2221. Google Scholar
    • 19 : Comorbidity measures for use with administrative data. Med Care1998; 36: 8. Google Scholar
    • 20 : Utilization and outcomes of minimally invasive radical prostatectomy. J Clin Oncol2008; 26: 2278. Google Scholar
    • 21 : Dose-response analyses using restricted cubic spline functions in public health research. Stat Med2010; 29: 1037. Google Scholar
    • 22 : Regression Modeling Strategies: With Applications to Linear Models, Logistic Regression, and Survival Analysis. New York: Springer2001. Google Scholar
    • 23 : A Wilcoxon-type test for trend. Stat Med1985; 4: 87. Google Scholar
    • 24 : Centralization of radical prostatectomy in the United States. J Urol2013; 189: 500. LinkGoogle Scholar
    • 25 : Hospital volume, utilization, costs and outcomes of robot-assisted laparoscopic radical prostatectomy. J Urol2012; 187: 1632. LinkGoogle Scholar
    • 26 : Robot-assisted versus open radical prostatectomy: the differential effect of regionalization, procedure volume and operative approach. J Urol2013; 189: 1289. LinkGoogle Scholar
    • 27 : The diminishing returns of robotic diffusion: complications following robot-assisted radical prostatectomy. BJU Int2016; 117: 211. Google Scholar
    • 28 : Should we regionalize major surgery? Potential benefits and policy considerations. J Am Coll Surg2000; 190: 341. Google Scholar
    • 29 Guidance on Cancer Services: Improving Outcomes in Urological Cancers. London, United Kingdom: National Institute for Health and Care Excellence2002. Google Scholar
    • 30 : Achieving quality assurance of prostate cancer surgery during reorganisation of cancer services. Eur Urol2015; 68: 22. Google Scholar
    Advertisement