Study Examines Impact of Hospital Volume on Complication Rates in Patients Undergoing Robotic Prostate Surgery
A disincentive for hospitals that have invested in expensive technology for robotic surgery may be jeopardizing prostate cancer patients who seek out the procedure, concluded a study published by Sammon et al in BJU International.
The study compared complication rates in hospitals with low volumes of robot-assisted radical prostatectomies to institutions with high volumes of the procedure. The results suggested that current pay-for-performance health-care models are to blame.
“Patients pursue robotic surgery based on perceived benefit, such as its minimally invasive nature and faster recovery time compared to conventional open surgery,” said Jesse Sammon, DO, a researcher at the Vattikuti Urology Institute, and lead author of the study. “But they fail to take into account the importance of hospital and surgeon experience on outcomes.”
Now the most common surgical method for treating prostate cancer in the United States, robot-assisted radical prostatectomy allows a surgeon to remove the diseased prostate by manipulating robotic arms holding undersized instruments through tiny incisions in the patient's skin. Besides avoiding the higher risk of infection and blood loss posed by open surgery, successful robot-assisted procedures reduce patient hospital stay and recovery time.
Study Details
Researchers at Henry Ford Hospital saw a rapid increase in U.S. hospitals investing in the technology and performing the procedure during the past decade.
Building on earlier research that showed higher-volume hospitals had more success with the procedure than smaller institutions, the study focused on all patients listed in the National Inpatient Sample (NIS) who underwent a robot-assisted radical prostatectomy between 2009 and 2011. Researchers also collected the number of these procedures performed at the hospitals where the patients were treated, categorized the hospitals according to that volume, and recorded the complication rates for each.
They found the number of hospitals performing robot-assisted radical prostatectomy remained relatively stable over the study period: 802 hospitals performed the procedure in 2009, 792 did in 2010, and 808 did in 2011.
They also found the overall complication rate after surgery was significantly related to the volume of robot-assisted radical prostatectomies performed at a hospital: 14.7% of patients treated at very-low-volume institutions experienced complications, while those treated at very-high-volume institutions experienced a complication rate of 5.7%.
In addition, patients treated at very-high-volume hospitals were less than half as likely to experience a complication as those treated at very-low-volume hospitals.
Discrepancy in Surgical Methods
Researchers noted that during the 1990s, centralization of surgical treatment for cancers of the bladder and kidney resulted in a greater percentage of cases being sent to high-volume hospitals. The same was not true for prostate cancers during that decade.
“But between 2000 and 2008,” Dr. Sammon explained, “there was a 74% increase in the number of radical prostatectomies performed, and a 19% decrease in the number of hospitals performing radical prostatectomy.”
“By 2009, the median hospital volume for open radical prostate surgery was 32 cases per year, compared to 137 cases per year using the robotic approach.”
What this suggests, Dr. Sammon said, is that “market forces” behind the adoption of robotic surgery may have unintentionally had the salutary effect of centralizing prostate cancer care.
Complications From Lower Costs
Yet the new study explains that, with the boom in robotic surgery, fewer patients are seeking care at very-high volume hospitals. They’re instead choosing low-volume institutions that have invested in the technology but have less experience in using it—and may be placing themselves at higher risk of complications.
“This migration of patients away from very-high-volume hospitals is likely the result of the current pay-for-performance models in U.S. health care,” Dr. Sammon said. “For institutions that have invested millions in robotic technology, this removes the incentive to refer patients to other, higher volume hospitals.”
He continued, “This disincentive is probably jeopardizing patients, and calls for a renewed focus on the benefits of centralized care at larger providers.”
Dr. Sammon is the corresponding author for the BJU International article.
The research was conducted by Vattikuti Urology Institute, Center for Outcomes Research Analytics & Evaluation, Henry Ford Health System; and the Center for Surgery and Public Health and Division of Urologic Surgery, Brigham & Women's Hospital, Harvard Medical School.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
