Variability in Partial Nephrectomy Outcomes: Does Your Surgeon Matter?

Eur Urol. 2019 Apr;75(4):628-634. doi: 10.1016/j.eururo.2018.10.046. Epub 2018 Nov 2.

Abstract

Background: Understanding physician-level discrepancies is increasingly a target of US healthcare reform for the delivery of quality-focused patient care.

Objective: To estimate the relative contributions of patient and surgeon characteristics to the variability in key outcomes after partial nephrectomy (PN).

Design, setting, and participants: Retrospective review of 1461 patients undergoing PN performed by 19 surgeons between 2011 and 2016 at a tertiary care referral center.

Intervention: PN for a renal mass.

Outcomes measurements and statistical analysis: Hierarchical linear and logistic regression models were built to determine the percentage variability contributed by fixed patient and surgeon factors on peri- and postoperative outcomes. Residual between- and within-surgeon variability was calculated while adjusting for fixed factors.

Results and limitations: On null hierarchical models, there was significant between-surgeon variability in operative time, estimated blood loss (EBL), ischemia time, excisional volume loss, length of stay, positive margins, Clavien complications, and 30-d readmission rate (all p<0.001), but not chronic kidney disease upstaging (p=0.47) or percentage preservation of glomerular filtration rate (p=0.49). Patient factors explained 82% of the variability in excisional volume loss and 0-32% of the variability in the remainder of outcomes. Quantifiable surgeon factors explained modest amounts (10-40%) of variability in intraoperative outcomes, and noteworthy amounts of variability (90-100%) in margin rates and patient morbidity outcomes. Immeasurable surgeon factors explained the residual variability in operative time (27%), EBL (6%), and ischemia time (31%).

Conclusions: There is significant between-surgeon variability in outcomes after PN, even after adjusting for patient characteristics. While renal functional outcomes are consistent across surgeons, measured and unmeasured surgeon factors account for 18-100% of variability of the remaining peri- and postoperative variables. With the increasing utilization of value-based medicine, this has important implications for the goal of optimizing patient care.

Patient summary: We reviewed our institutional database on partial nephrectomy performed for renal cancer. We found significant variability between surgeons for key outcomes after the intervention, even after adjusting for patient characteristics.

Keywords: Complications; Nephron sparing; Outcomes; Partial nephrectomy; Renal neoplasm; Surgeon.

MeSH terms

  • Carcinoma, Renal Cell / pathology
  • Carcinoma, Renal Cell / surgery*
  • Clinical Competence
  • Databases, Factual
  • Humans
  • Kidney Neoplasms / pathology
  • Kidney Neoplasms / surgery*
  • Learning Curve
  • Nephrectomy / adverse effects
  • Nephrectomy / trends*
  • Outcome and Process Assessment, Health Care / trends*
  • Postoperative Complications / etiology
  • Practice Patterns, Physicians' / trends*
  • Quality Indicators, Health Care / trends*
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Robotic Surgical Procedures / adverse effects
  • Robotic Surgical Procedures / trends*
  • Surgeons / trends*
  • Treatment Outcome