Hospital Characteristics and Use of Innovative Surgical Therapies Among Patients With Kidney Cancer

BACKGROUND: Despite their potential benefits to patients, the adoption of partial nephrectomy and laparoscopic kidney cancer surgery has been both gradual and concentrated in select hospitals. OBJECTIVE: We assessed the degree to which adjusting for hospital structural characteristics modifies the association between hospital nephrectomy volume and patient receipt of partial nephrectomy and/or laparoscopic kidney cancer surgery. RESEARCH DESIGN AND SUBJECTS: From the Nationwide Inpatient Sample, we identified an unweighted sample of 4943 patients who underwent kidney cancer surgery in 2003. MAIN OUTCOME MEASURE: Our primary outcomes were patient receipt of (1) partial nephrectomy and/or (2) laparoscopic kidney cancer surgery. RESULTS: Our weighted analytic cohort comprised 34,045 cases. Overall, 16% of patients received a partial nephrectomy, and 17% underwent laparoscopic surgery; at high-nephrectomy-volume hospitals the proportions increased to 22% and 26%, respectively. Hospital structural characteristics varied across nephrectomy-case volume strata. In unadjusted models, patients treated at hospitals in the highest-nephrectomy-volume tercile were more likely than those treated at low-volume facilities to receive a partial nephrectomy [Risk RatioPN (RRPN) 2.2; 95% confidence interval (CI), 1.6-2.8] or laparoscopic surgery (RRlap 2.9; 95% CI, 2.0-4.0). Adjusting for differences in hospital structure attenuated the association between hospital nephrectomy volume and use of partial nephrectomy or laparoscopy by 60% (adjusted RRPN 1.4; 95% CI, 0.9-2.2) and 12% (adjusted RRlap 2.5; 95% CI, 1.4-4.1), respectively. CONCLUSIONS: Changes to the hospital environment may facilitate greater use of partial nephrectomy at hospitals that infrequently perform kidney cancer surgery. Efforts to increase the uptake of laparoscopy are probably best directed at surgeon-specific adoption barriers.