Comments The diminishing returns of robotic diffusion: complications after robot-assisted radical prostatectomy Jesse D. Sammon*†, Firas Abdollah*, Dane E. Klett*, Daniel Pucheril*, Akshay Sood*, Quoc-Dien Trinh*‡ and Mani Menon* *VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, †Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, and ‡Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
In the USA, robot-assisted radical prostatectomy (RARP) has supplanted open retropubic RP as the most common approach for the operative management of prostate cancer, despite the absence of large clinical trials and limited observational evidence demonstrating its superiority [1]. There is concrete evidence to suggest that patients are pursuing robotic surgery due to its perceived benefits [2,3] without fully considering the implications of hospital- and provider-volume characteristics. Studies to date reflect outcomes at high-volume centres with high-volume surgeons, but are exceedingly difficult to generalise to the medical community as a whole, especially as robotics continues to diffuse across the medical landscape [4]. Therefore, we examined the three most contemporaneous years (2009–2011) of the Nationwide Inpatient Sample (NIS) to elucidate the extent of robotic diffusion for prostate cancer surgery, and to
explore the effects of wider robotic adoption on RP complication rates. Patients undergoing RP (International Classification of Diseases, ninth revision [ICD-9] procedure code 60.5) for prostate cancer (ICD-9 diagnostic code 185), between 2009 and 2011, were extracted from the NIS database. The NIS provides data on all discharges from a 20% sample of non-federal hospitals. Hospital volume was calculated as the number of RARPs performed annually by an institution; each volume quintile represents the range of annual hospital volume of onefifth of patients undergoing RARP (Very-low: 1–45, Low: 46– 82, Intermediate: 83–161, High: 162–333, Very High: 333–869). The occurrence of complications was ascertained and categorised as described previously [5]. The independent effect of hospital volume quartile was assessed with ordinal logistic regression fitted with generalised estimating equations to
Fig. 1 Postoperative complications of RARP, NIS 2009–2011.
30%
Overall Complication Rate
25% Median Volume: 2010 20% Median Volume: 2011 15% Median Volume: 2009 10% 5% 0%
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50
100
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350
400
450
500
Annual Hospital RARP Volume
© 2015 The Authors BJU International © 2015 BJU International | doi:10.1111/bju.13111, 13117 Published by John Wiley & Sons Ltd. www.bjui.org
BJU Int 2016; 117: 211–214 wileyonlinelibrary.com
Comments
control for hospital clustering. It was then adjusted for age, race, comorbidity, and insurance status, as well as hospital region, location, bed size and academic status. Analyses were conducted using the R statistical package (the R foundation for Statistical Computing, version 3.1.0, Vienna, Austria). The number of sampled hospitals performing RARP remained stable over the study period: 802 in 2009, 792 in 2010, and 808 in 2011. The median hospital volume fell sharply after 2009 (Fig. 1). The overall rate of postoperative complications was significantly correlated with hospital volume quartile: patients treated at very-low-volume institutions had a complication rate of 14.7%, while those treated at very-high-volume institutions had a complication rate of 5.7%. In multivariable analyses, patients treated at very-high-volume hospitals were less than half as likely to have a complication as compared with those treated at verylow-volume hospitals (odds ratio 0.40; 95% CI 0.29–0.54). Centralisation of care for urological malignancies of the bladder and kidney began in the 1990s, with a greater percentage of cystectomies and nephrectomies diverted to high-volume institutions; interestingly, the same phenomenon was not seen for prostate cancer care [6]. However, between 2000 and 2008 there was a 74% increase in the number of RPs performed, and a 19% decrease in the number of hospitals performing RP [7], such that by 2009 the median hospital volume for RP with the open approach was 32 cases/ year vs 137 cases/year with the robotic approach [5]. These findings suggest that market forces propelling the adoption of the robotic approach may have had the unintended and salutary consequence of inducing the centralisation of care for prostate cancer. However, the present study findings are concerning, suggesting that after dissemination of robotic technology fewer patients are seeking care at very-highvolume institutions. This may have deleterious consequences, as patients treated at low-volume institutions may be placed at a higher risk of postoperative complications. The migration of patients away from very-high-volume institutions probably reflects the effect of current fee-forservice models in USA healthcare, in which institutions that
have invested millions of dollars in robotic technology are disincentivised to refer patients to higher volume institutions. This perverse disincentive is likely jeopardising patient care, and a renewed focus on the benefits of centralisation of care is warranted.
Acknowledgments None.
Conflicts of Interest Firas Abdollah is a consultant for GenomeDx biosciences.
References 1
2 3
4
5
6
7
Kang DC, Hardee MJ, Fesperman SF, Stoffs TL, Dahm P. Low quality of evidence for robot-assisted laparoscopic prostatectomy: results of a systematic review of the published literature. Eur Urol 2010; 57: 930–7 Eastham JA. Robotic-assisted prostatectomy: is there truth in advertising? Eur Urol 2008; 54: 720–2 Schroeck FR, Krupski TL, Stewart SB et al. Pretreatment expectations of patients undergoing robotic assisted laparoscopic or open retropubic radical prostatectomy. J Urol 2012; 187: 894–8 Chang SL, Kibel AS, Brooks JD, Chung BI. The impact of robotic surgery on the surgical management of prostate cancer in the USA. BJU Int 2014; 115: 929–36 Sammon JD, Karakiewicz PI, Sun M et al. Robot-assisted versus open radical prostatectomy: the differential effect of regionalization, procedure volume and operative approach. J Urol 2013; 189: 1289–94 Cooperberg MR, Modak S, Konety BR. Trends in regionalization of inpatient care for urological malignancies, 1988 to 2002. J Urol 2007; 178: 2103–8 Anderson CB, Penson DF, Ni S, Makarov DV, Barocas DA. Centralization of radical prostatectomy in the United States. J Urol 2013; 189: 500–6
Correspondence: Jesse D. Sammon, VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, 2799 W. Grand Boulevard, Detroit, MI 48202, USA. e-mail: [email protected]; [email protected] Abbreviations: ICD-9, International Classification of Diseases, ninth revision; NIS, Nationwide Inpatient Sample; (RA)RP, robot-assisted radical prostatectomy.
Observations on transatlantic renal cell cancer surgery outcomes Grant D. Stewart*†, Alexander Laird*†, Stuart. A. McNeill*† and Bradley C. Leibovich‡ *Edinburgh Urological Cancer Group, University of Edinburgh, †Department of Urology, NHS Lothian, Edinburgh, UK, and ‡Department of Urology, Mayo Clinic, Rochester, MN, USA
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© 2015 The Authors BJU International © 2015 BJU International
In the USA, robot-assisted radical prostatectomy (RARP) has supplanted open retropubic RP as the most common approach for the operative management of prostate cancer, despite the absence of large clinical trials and limited observational evidence demonstrating its superiority [1]. There is concrete evidence to suggest that patients are pursuing robotic surgery due to its perceived benefits [2,3] without fully considering the implications of hospital- and provider-volume characteristics. Studies to date reflect outcomes at high-volume centres with high-volume surgeons, but are exceedingly difficult to generalise to the medical community as a whole, especially as robotics continues to diffuse across the medical landscape [4]. Therefore, we examined the three most contemporaneous years (2009–2011) of the Nationwide Inpatient Sample (NIS) to elucidate the extent of robotic diffusion for prostate cancer surgery, and to
explore the effects of wider robotic adoption on RP complication rates. Patients undergoing RP (International Classification of Diseases, ninth revision [ICD-9] procedure code 60.5) for prostate cancer (ICD-9 diagnostic code 185), between 2009 and 2011, were extracted from the NIS database. The NIS provides data on all discharges from a 20% sample of non-federal hospitals. Hospital volume was calculated as the number of RARPs performed annually by an institution; each volume quintile represents the range of annual hospital volume of onefifth of patients undergoing RARP (Very-low: 1–45, Low: 46– 82, Intermediate: 83–161, High: 162–333, Very High: 333–869). The occurrence of complications was ascertained and categorised as described previously [5]. The independent effect of hospital volume quartile was assessed with ordinal logistic regression fitted with generalised estimating equations to
Fig. 1 Postoperative complications of RARP, NIS 2009–2011.
30%
Overall Complication Rate
25% Median Volume: 2010 20% Median Volume: 2011 15% Median Volume: 2009 10% 5% 0%
0
50
100
150
200
250
300
350
400
450
500
Annual Hospital RARP Volume
© 2015 The Authors BJU International © 2015 BJU International | doi:10.1111/bju.13111, 13117 Published by John Wiley & Sons Ltd. www.bjui.org
BJU Int 2016; 117: 211–214 wileyonlinelibrary.com
Comments
control for hospital clustering. It was then adjusted for age, race, comorbidity, and insurance status, as well as hospital region, location, bed size and academic status. Analyses were conducted using the R statistical package (the R foundation for Statistical Computing, version 3.1.0, Vienna, Austria). The number of sampled hospitals performing RARP remained stable over the study period: 802 in 2009, 792 in 2010, and 808 in 2011. The median hospital volume fell sharply after 2009 (Fig. 1). The overall rate of postoperative complications was significantly correlated with hospital volume quartile: patients treated at very-low-volume institutions had a complication rate of 14.7%, while those treated at very-high-volume institutions had a complication rate of 5.7%. In multivariable analyses, patients treated at very-high-volume hospitals were less than half as likely to have a complication as compared with those treated at verylow-volume hospitals (odds ratio 0.40; 95% CI 0.29–0.54). Centralisation of care for urological malignancies of the bladder and kidney began in the 1990s, with a greater percentage of cystectomies and nephrectomies diverted to high-volume institutions; interestingly, the same phenomenon was not seen for prostate cancer care [6]. However, between 2000 and 2008 there was a 74% increase in the number of RPs performed, and a 19% decrease in the number of hospitals performing RP [7], such that by 2009 the median hospital volume for RP with the open approach was 32 cases/ year vs 137 cases/year with the robotic approach [5]. These findings suggest that market forces propelling the adoption of the robotic approach may have had the unintended and salutary consequence of inducing the centralisation of care for prostate cancer. However, the present study findings are concerning, suggesting that after dissemination of robotic technology fewer patients are seeking care at very-highvolume institutions. This may have deleterious consequences, as patients treated at low-volume institutions may be placed at a higher risk of postoperative complications. The migration of patients away from very-high-volume institutions probably reflects the effect of current fee-forservice models in USA healthcare, in which institutions that
have invested millions of dollars in robotic technology are disincentivised to refer patients to higher volume institutions. This perverse disincentive is likely jeopardising patient care, and a renewed focus on the benefits of centralisation of care is warranted.
Acknowledgments None.
Conflicts of Interest Firas Abdollah is a consultant for GenomeDx biosciences.
References 1
2 3
4
5
6
7
Kang DC, Hardee MJ, Fesperman SF, Stoffs TL, Dahm P. Low quality of evidence for robot-assisted laparoscopic prostatectomy: results of a systematic review of the published literature. Eur Urol 2010; 57: 930–7 Eastham JA. Robotic-assisted prostatectomy: is there truth in advertising? Eur Urol 2008; 54: 720–2 Schroeck FR, Krupski TL, Stewart SB et al. Pretreatment expectations of patients undergoing robotic assisted laparoscopic or open retropubic radical prostatectomy. J Urol 2012; 187: 894–8 Chang SL, Kibel AS, Brooks JD, Chung BI. The impact of robotic surgery on the surgical management of prostate cancer in the USA. BJU Int 2014; 115: 929–36 Sammon JD, Karakiewicz PI, Sun M et al. Robot-assisted versus open radical prostatectomy: the differential effect of regionalization, procedure volume and operative approach. J Urol 2013; 189: 1289–94 Cooperberg MR, Modak S, Konety BR. Trends in regionalization of inpatient care for urological malignancies, 1988 to 2002. J Urol 2007; 178: 2103–8 Anderson CB, Penson DF, Ni S, Makarov DV, Barocas DA. Centralization of radical prostatectomy in the United States. J Urol 2013; 189: 500–6
Correspondence: Jesse D. Sammon, VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, 2799 W. Grand Boulevard, Detroit, MI 48202, USA. e-mail: [email protected]; [email protected] Abbreviations: ICD-9, International Classification of Diseases, ninth revision; NIS, Nationwide Inpatient Sample; (RA)RP, robot-assisted radical prostatectomy.
Observations on transatlantic renal cell cancer surgery outcomes Grant D. Stewart*†, Alexander Laird*†, Stuart. A. McNeill*† and Bradley C. Leibovich‡ *Edinburgh Urological Cancer Group, University of Edinburgh, †Department of Urology, NHS Lothian, Edinburgh, UK, and ‡Department of Urology, Mayo Clinic, Rochester, MN, USA
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© 2015 The Authors BJU International © 2015 BJU International
