Variations in Morbidity after Radical Prostatectomy
Colin B. Begg, Ph.D., Elyn R. Riedel, M.A., Peter B. Bach, M.D., M.A.P.P., Michael W. Kattan, Ph.D., Deborah Schrag, M.D., M.P.H., Joan L. Warren, Ph.D., and Peter T. Scardino, M.D.
Background Recent studies of surgery for cancer have demonstratedvariations in outcomes among hospitals and among surgeons. Wesought to examine variations in morbidity after radical prostatectomyfor prostate cancer.
Methods We used the Surveillance, Epidemiology, and End Results–Medicarelinked data base to evaluate health-related outcomes after radicalprostatectomy. The rates of postoperative complications, lateurinary complications (strictures or fistulas 31 to 365 daysafter the procedure), and long-term incontinence (more than1 year after the procedure) were inferred from the Medicareclaims records of 11,522 patients who underwent prostatectomybetween 1992 and 1996. These rates were analyzed in relationto hospital volume and surgeon volume (the number of proceduresperformed at individual hospitals and by individual surgeons,respectively).
Results Neither hospital volume nor surgeon volume was significantlyassociated with surgery-related death. Significant trends inthe relation between volume and outcome were observed with respectto postoperative complications and late urinary complications.Postoperative morbidity was lower in very-high-volume hospitalsthan in low-volume hospitals (27 percent vs. 32 percent, P=0.03)and was also lower when the prostatectomy was performed by very-high-volumesurgeons than when it was performed by low-volume surgeons (26percent vs. 32 percent, P<0.001). The rates of late urinarycomplications followed a similar pattern. Results for long-termpreservation of continence were less clear-cut. In a detailedanalysis of the 159 surgeons who had a high or very high volumeof procedures, wide surgeon-to-surgeon variations in these clinicaloutcomes were observed, and they were much greater than wouldbe predicted on the basis of chance or observed variations inthe case mix.
Conclusions In men undergoing prostatectomy, the rates of postoperativeand late urinary complications are significantly reduced ifthe procedure is performed in a high-volume hospital and bya surgeon who performs a high number of such procedures.
Source Information
From the Health Outcomes Research Group, Department of Epidemiology and Biostatistics (C.B.B., E.R.R., P.B.B., M.W.K., D.S.), and the Department of Urology (M.W.K., P.T.S.), Memorial Sloan-Kettering Cancer Center, New York; and the Applied Research Branch, National Cancer Institute, Bethesda, Md. (J.L.W.).
Address reprint requests to Dr. Begg at the Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Box 44, New York, NY 10021, or at beggc{at}mskcc.org.
Volume and Outcome
Barone J. E., Risucci D. A., Savino J. A., Nallamothu B. K., Saint S., Eagle K. A., Senkowski C. K., Kocs D. M., Rowe A. K., Deming M. S., Bohmer R., Edmondson A., Pisano G., Ghertner J. L., Babson W. W. Jr., Birkmeyer J. D., Finlayson E. V.A., Epstein A. M.
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N Engl J Med 2002;
347:693-696, Aug 29, 2002.
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