Hospital Characteristics and Use of Innovative Surgical Therapies Among Patients With Kidney Cancer

Background:Despite their potential benefits to patients, the adoption of partial nephrectomy and laparoscopic kidney cancer surgery has been both gradual and concentrated in select hospitals. Objective:We assessed the degree to which adjusting for hospital structural characteristics modifies the association between hospital nephrectomy volume and patient receipt of partial nephrectomy and/or laparoscopic kidney cancer surgery. Research Design and Subjects:From the Nationwide Inpatient Sample, we identified an unweighted sample of 4943 patients who underwent kidney cancer surgery in 2003. Main Outcome Measure:Our primary outcomes were patient receipt of (1) partial nephrectomy and/or (2) laparoscopic kidney cancer surgery. Results:Our weighted analytic cohort comprised 34,045 cases. Overall, 16% of patients received a partial nephrectomy, and 17% underwent laparoscopic surgery; at high-nephrectomy-volume hospitals the proportions increased to 22% and 26%, respectively. Hospital structural characteristics varied across nephrectomy-case volume strata. In unadjusted models, patients treated at hospitals in the highest-nephrectomy-volume tercile were more likely than those treated at low-volume facilities to receive a partial nephrectomy [Risk RatioPN (RRPN) 2.2; 95% confidence interval (CI), 1.6–2.8] or laparoscopic surgery (RRlap 2.9; 95% CI, 2.0–4.0). Adjusting for differences in hospital structure attenuated the association between hospital nephrectomy volume and use of partial nephrectomy or laparoscopy by 60% (adjusted RRPN 1.4; 95% CI, 0.9–2.2) and 12% (adjusted RRlap 2.5; 95% CI, 1.4–4.1), respectively. Conclusions:Changes to the hospital environment may facilitate greater use of partial nephrectomy at hospitals that infrequently perform kidney cancer surgery. Efforts to increase the uptake of laparoscopy are probably best directed at surgeon-specific adoption barriers.

[1]  Paul Russo,et al.  Natural history of chronic renal insufficiency after partial and radical nephrectomy. , 2002, Urology.

[2]  R. Clayman,et al.  Short-term impact of a laparoscopic "mini-residency" experience on postgraduate urologists' practice patterns. , 2006, Journal of the American College of Surgeons.

[3]  J. Escarce,et al.  Externalities in hospitals and physician adoption of a new surgical technology: an exploratory analysis. , 1996, Journal of health economics.

[4]  Sankey V. Williams,et al.  Hospital and Patient Characteristics Associated With Death After Surgery: A Study of Adverse Occurrence and Failure to Rescue , 1992, Medical care.

[5]  L. Aiken,et al.  Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. , 2002, JAMA.

[6]  P. Russo,et al.  Complications of radical and partial nephrectomy in a large contemporary cohort. , 2004, The Journal of urology.

[7]  Andrew J Vickers,et al.  Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. , 2006, The Lancet. Oncology.

[8]  E. Rogers,et al.  Diffusion of innovations , 1964, Encyclopedia of Sport Management.

[9]  T. Ahlering,et al.  Initial impact of a dedicated postgraduate laparoscopic mini-residency on clinical practice patterns. , 2005, Journal of endourology.

[10]  A. Basiri,et al.  Comparison of laparoscopic and open donor nephrectomy: a randomized controlled trial , 2005, BJU international.

[11]  J. Myers,et al.  How to teach an old dog new tricks and how to teach a new dog old tricks: bridging the generation gap to push the envelope of advanced laparoscopy , 2006, Surgical Endoscopy And Other Interventional Techniques.

[12]  John T. Wei,et al.  Trends in the diffusion of laparoscopic nephrectomy. , 2006, JAMA.

[13]  J. Weissman,et al.  Teaching hospitals and quality of care: a review of the literature. , 2002, The Milbank quarterly.

[14]  B. Edwin,et al.  LAPAROSCOPIC VS OPEN LIVING DONOR NEPHRECTOMY EXPERIENCES FROM A PROSPECTIVE, RANDOMISED, SINGLE CENTER STUDY; FOCUSING ON DONOR SAFETY , 2004, Transplantation.

[15]  R. Sylvester,et al.  A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. , 2007, European urology.

[16]  D Draper,et al.  Hospital characteristics and quality of care. , 1992, JAMA.

[17]  L. Kavoussi,et al.  Trends in the operative management of renal tumours over a 14‐year period , 2006, BJU international.

[18]  L. Kavoussi,et al.  Long-term survival analysis after laparoscopic radical nephrectomy. , 2005, The Journal of urology.

[19]  A. Novick,et al.  Nephron sparing surgery for localized renal cell carcinoma: impact of tumor size on patient survival, tumor recurrence and TNM staging. , 1999, The Journal of urology.

[20]  A. Novick,et al.  Laparoscopic and Partial Nephrectomy , 2004, Clinical Cancer Research.

[21]  F A Sloan,et al.  Effects of admission to a teaching hospital on the cost and quality of care for Medicare beneficiaries. , 1999, The New England journal of medicine.

[22]  J. Wennberg,et al.  Practice variation: implications for our health care system. , 2004, Managed care.

[23]  C. Mulrow,et al.  From understanding health care provider behavior to improving health care: the QUERI framework for quality improvement. Quality Enhancement Research Initiative. , 2000, Medical care.

[24]  A. K. Sachdeva,et al.  Acquiring skills in new procedures and technology: the challenge and the opportunity. , 2005, Archives of surgery.

[25]  J. Zhang,et al.  What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. , 1998, JAMA.

[26]  K Sheikh,et al.  Urban-rural differences in the quality of care for medicare patients with acute myocardial infarction. , 2001, Archives of internal medicine.

[27]  J. Wolf,et al.  Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy. , 2001, Transplantation.

[28]  A. Rimm,et al.  The Relationship of Hospital Characteristics and the Results of Peer Review in Six Large States , 1991, Medical care.

[29]  John T. Wei,et al.  National utilization trends of partial nephrectomy for renal cell carcinoma: a case of underutilization? , 2006, Urology.

[30]  R. Clayman,et al.  Laparoscopic versus open radical nephrectomy: a 9-year experience. , 2000, The Journal of urology.

[31]  M. Blute,et al.  Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery. , 1996, The Journal of urology.

[32]  S. Joniau,et al.  Comparison between open partial and radical nephrectomy for renal tumours: perioperative outcome and health-related quality of life. , 2007, European urology.

[33]  David C. Miller,et al.  Partial nephrectomy for small renal masses: an emerging quality of care concern? , 2006, The Journal of urology.

[34]  John T. Wei,et al.  Laparoscopy for renal cell carcinoma: diffusion versus regionalization? , 2006, The Journal of urology.

[35]  Did Postoperative Mortality Increase After the Implementation of the Medicare Balanced Budget Act? , 2006, Medical care.

[36]  P. Russo,et al.  Surgical management of renal tumors 4 cm. or less in a contemporary cohort. , 2000, The Journal of urology.

[37]  C. Steiner,et al.  Comorbidity measures for use with administrative data. , 1998, Medical care.

[38]  P. Ramchandani,et al.  Incidence of benign pathologic findings at partial nephrectomy for solitary renal mass presumed to be renal cell carcinoma on preoperative imaging. , 2006, Urology.

[39]  Stephanie Daignault,et al.  Rising incidence of small renal masses: a need to reassess treatment effect. , 2007, Journal of the National Cancer Institute.