Dr. Dagenais and colleagues did a retrospective review of 11092 patients that underwent partial nephrectomy among 19 surgeons between the years of 2011 and 2016 within the Cleveland Clinic healthcare group. They looked at patient demographics (including clinicodemographics, tumor characteristics), as well as surgeon factors (such as surgeon approach, how many years they were in practice, being or on the learning curve [>25 cases] and their annual partial nephrectomy volume).
Multi-level regression models were built to determine variability using fixed and unmeasured patient and surgeon factors on posts-operative outcomes. Most important outcomes of note were estimated blood loss, ischemia time, excisional volume loss, GFR presentation at 3 to 12 months, positive margin, CKD upstaging and intraoperative complication rates.
The study team’s analysis found that after combining all patient and surgical differences into composite x-axis, that there was still significant differences amongst surgeon outcomes. This implies that basic demographic information is not the leading cause of differences between surgeon outcomes. Further analysis showed that volume loss, positive margins, and intraoperative complications, were impacted greatly by surgeon factors, whether explained or unexplained. OR time, estimated blood loss, and ischemia time were mostly impacted by patient demographics.
In conclusion, while the study team found no surgeon-level differences in short and intermediate term functional and oncologic outcomes, intraoperative outcomes were greatly affected by surgeon experience, technique, and placement on the learning curve. The study team believes that these are some of the main causes for surgeon variability – some of which is not explained by these variables. The study team would like to emphasize that “increasing reliance on value-based medicine and [attention to unknown] surgeon factors may produce more optimal outcomes.”
Presented by: Julien Dagenais, MD
Written by: Anthony Warner, AS, Department of Urology, University of California-Irvine at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA