Decline in highest quartile hospitals seen
Another interesting finding was that between 2009 and 2011, the number of hospitals classified as the highest quartile had decreased while the number of low- and medium-volume quartiles had increased. There was no difference noted in the total annual number of cases during the study period. The shifting of cases from higher volume hospitals to low- and medium-volume hospitals runs counter to previous reports that robotic prostatectomy procedures had become more centralized.
The authors also analyzed hospital volume as a non-linear continuous variable (as opposed to quartiles) to show that the improvement in perioperative outcomes mentioned above, and total costs, continued to improve for up to 100 procedures per year. After that, the increasing volume yielded limited improvement in outcomes.
The reasons for the decentralization of these procedures during the study period remain unclear. As more hospitals acquire robotic surgery capabilities, there may be certain market and financial pressures to utilize the technology available at those hospitals. Alternatively, acquisition of the robotic surgical platform may have allowed more hospitals to recruit surgeons with interest in robotic surgery, resulting in the increased decentralization noted in this study.
While there are certain health policy implications of the findings from this study, the virtues of centralization of services are still debatable. Further, surgeon volume, which is a well-known predictor of perioperative outcomes, cannot be captured from this dataset. While the differences in the outcomes measured in this study between the high-volume and medium-volume centers appear to be small, there is clearly a significantly worse outcomes profile noted at the low- and very low volume centers. This information may be of equal interest to both patients and payers alike.
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