PURPOSE: Regional and local variation in radical prostatectomy (RP) rates contribute to overtreatment of low-risk (LR) prostate cancer.
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We hypothesized individual practice variability would be minimal between urologists practicing in a high-volume academic center.
MATERIALS AND METHODS: Percentage of LR patients treated with RP in a given year (LR%) and comorbidity-adjusted life expectancy were assessed in an institutional database accounting for temporal trends and disease characteristics. Multivariable linear, spline, and logistic models were applied with a hierarchical random effects model to estimate proportion of variance due to surgeon and temporal effects.
RESULTS: Of 20,655 men included, 11,873 (57.5%) had LR disease. Gleason score leading to RP increased over time. Overall LR% increased 3.49% yearly (1991-2001) and then decreased by 1.73% yearly (2001-2013). Greater surgeon experience was associated with higher LR% from 1991-2001 (+0.46% per year experience). High-volume (>1000 total RPs) surgeons operated on a slightly greater percentage of LR patients (+3.54%). Substantial practice variation existed between surgeons with OR range 3.15 (95%CI 1.62-6.11) for operating on LR men ≥65 years and similar variation in operating on older patients with life expectancy < 15 years. Surgeon-level and temporal effects explained 24% and 70% of the LR% variance, respectively.
CONCLUSION: Within a high-volume academic center, substantial practice variation exists between surgeons in selecting prostate cancer patients to undergo RP based on risk and life expectancy even among older patients. In addition to patient decision support tools, public reporting of individual practice at the provider-level could reduce overtreatment of LR prostate cancer.
Patel HD, Humphreys E, Trock BJ, Han M, Carter HB. Are you the author?
James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD; Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD.
Reference: J Urol. 2014 Sep 4. pii: S0022-5347(14)04356-0.