Diffusion of surgical innovation among patients with kidney cancer

Authors

  • David C. Miller MD, MPH,

    1. Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California
    2. Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California
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  • Christopher S. Saigal MD, MPH,

    1. Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California
    2. Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California
    3. RAND Corporation, Santa Monica, California
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  • Mousumi Banerjee PhD,

    1. Department of Biostatistics, University of Michigan School of Public Health, Michigan
    2. University of Michigan Comprehensive Cancer Center
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  • Jan Hanley MS,

    1. RAND Corporation, Santa Monica, California
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  • Mark S. Litwin MD, MPH

    Corresponding author
    1. Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California
    2. Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California
    3. RAND Corporation, Santa Monica, California
    4. Department of Health Services, School of Public Health, University of California, Los Angeles, California
    • Department of Urology, David Geffen School of Medicine, University of California, Los Angeles. Box 951738, Los Angeles, CA 90095-1738
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    • Fax: (310) 206-5343


  • See referenced original article on pages 1646-9, this issue.

  • This study made use of the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, National Cancer Institute; the Office of Research, Development and Information, Centers for Medicare and Medicaid Services; Information Management Services, Inc.; and the SEER Program tumor registries in the creation of the SEER-Medicare database.

Abstract

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. Cancer 2008. © 2008 American Cancer Society.

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