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Diffusion of surgical innovation among patients with kidney cancer
David C Miller1, Christopher S Saigal, Mousumi Banerjee
1Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California 90095-1738, USA.
Background:
Despite their potential benefits to patients with kidney cancer, the adoption of partial nephrectomy and laparoscopy has been gradual and asymmetric. To clarify whether this trend reflects differences in kidney cancer patients or differences in surgeon practice styles, the authors compared the magnitude of surgeon-attributable variance in the use of partial nephrectomy and laparoscopic radical nephrectomy with that attributable to patient and tumor characteristics.
Methods:
By using linked Surveillance, Epidemiology, and End Results-Medicare data, the authors identified a cohort of 5483 Medicare beneficiaries who underwent surgery for kidney cancer between 1997 and 2002. Two primary outcomes were defined: 1) the use of partial nephrectomy and (2) the use of laparoscopy among patients undergoing radical nephrectomy. By using multilevel models, surgeon- and patient-level contributions to observed variations in the use of partial nephrectomy and laparoscopic radical nephrectomy were estimated.
Results:
Of the 5483 cases identified, 611 (11.1%) underwent partial nephrectomy (43 performed laparoscopically), and 4872 (88.9%) underwent radical nephrectomy (515 performed laparoscopically). After adjusting for patient demographics, comorbidity, tumor size, and surgeon volume, the surgeon-attributable variance was 18.1% for partial nephrectomy and 37.4% for laparoscopy. For both outcomes, the percentage of total variance attributable to surgeon factors was consistently higher than that attributable to patient characteristics.
Conclusions:
For many patients with kidney cancer, the surgery provided depends more on their surgeon's practice style than on the characteristics of the patient and his or her disease. Consequently, dismantling barriers to surgeon adoption of partial nephrectomy and laparoscopy is an important step toward improving the quality of care for patients with early-stage kidney cancer.
Insights
Surgeon practice style, not patient or tumor factors, significantly influences kidney cancer surgery choices like partial nephrectomy and laparoscopy. Improving surgeon adoption of these techniques is key to better early-stage kidney cancer care.
Area of Science:
- Urology
- Surgical Oncology
- Health Services Research
Background:
- Partial nephrectomy and laparoscopic approaches for kidney cancer show gradual and uneven adoption.
- Variations in adoption may stem from patient/tumor differences or surgeon practice styles.
Purpose of the Study:
- To compare surgeon-attributable variance versus patient/tumor-attributable variance in partial nephrectomy and laparoscopic radical nephrectomy use.
- To identify factors driving disparities in kidney cancer surgical technique selection.
Main Methods:
- Utilized Surveillance, Epidemiology, and End Results-Medicare data (1997-2002) for 5483 kidney cancer surgery patients.
- Defined outcomes: partial nephrectomy use and laparoscopy use in radical nephrectomy.
- Employed multilevel models to estimate surgeon- and patient-level variance contributions.
Main Results:
- Surgeon variance accounted for 18.1% of partial nephrectomy use and 37.4% of laparoscopy use in radical nephrectomy.
- Surgeon factors contributed more to variance than patient characteristics for both outcomes.
- Partial nephrectomy was used in 11.1% of cases; laparoscopy in 11.6% of radical nephrectomies.
Conclusions:
- Surgeon practice style is a more significant determinant of kidney cancer surgery than patient or disease characteristics.
- Addressing barriers to surgeon adoption of partial nephrectomy and laparoscopy is crucial for enhancing care quality in early-stage kidney cancer.
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