In a recent study, increasing hospital volume was significantly associated with improved perioperative outcomes.
“Journal Article of the Month” is a new Urology Times section in which Badar M. Mian, MD (left), offers perspective on noteworthy research in the peer-reviewed literature. Dr. Mian is associate professor of surgery in the division of urology at Albany Medical College, Albany, NY.
Seventy percent of hospitals offering robot-assisted radical prostatectomy averaged one or fewer cases per week, while hospitals with a higher volume of cases offered lower costs and fewer complications, according to a recent study.
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In a retrospective analysis of the data from the Nationwide Inpatient Sample, Gershman et al report that a substantial number of robotic prostatectomy procedures are performed at hospitals with fewer than 30 cases per year. In order to study the impact of case volume on perioperative outcomes, they divided the hospital case volume between January 2009 and December 2011 into quartiles: very low (12 or fewer cases), low (13 to 30), medium (31 to 66), and high (67 to 820).
The authors, who published their findings in the Journal of Urology (2017; 198:92-9), analyzed the differences in the intraoperative complications (bowel or vascular or organ injury), postoperative complications (cardiac, gastrointestinal, pulmonary), longer-than-expected hospital stay, and rate of blood transfusion. Increasing hospital volume was significantly associated with improved perioperative outcomes and lower costs. These differences were quite pronounced when comparing the lowest quartile to the highest quartile hospitals. As expected, the shorter stays and fewer complications were associated with lower total hospital costs at the high-volume centers.
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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