Disparities in the receipt of robot-assisted radical prostatectomy: between-hospital and within-hospital analysis using 2009-2011 California inpatient data

Stereotactic Body Radiation Adoption Impacts Prostate Cancer Treatment Patterns

OBJECTIVE

To investigate stereotactic body radiation (SBRT) adoption for prostate cancer. As evidence supporting SBRT mounts, its utilization and impact relative to other prostate cancer treatments is unknown.

METHODS

We used SEER-Medicare to identify patients diagnosed with localized prostate cancer from 2008 to 2017. We then identified physician networks by identifying the primary treating physician of each patient based on primary treatment, then linking each physician to a practice. We examined trends in prostate cancer treatment between networks performing SBRT or not using chi-squared tests and logistic regression models.

RESULTS

There were 35,972 patients who received treatment for prostate cancer at 234 physician networks. Of these patients, 30,635 were treated in a non-SBRT network (n = 190), while 5337 received treatment in a SBRT network (n = 44). Patients who received care in an SBRT network were more likely to live in metropolitan areas ≥1 million (70% vs 46%, P <.001), have a higher median income >$60,000 (62% vs 42%, P <.001), and live in the northeast (35% vs 12%) or west (40% vs 38%, P <.001) compared to non-SBRT networks. In SBRT networks, more patients received IMRT (31% vs 23%), and fewer patients received prostatectomy (16% vs 23%) or active surveillance (15% vs 19%) compared to non-SBRT networks. Black men were 45% less likely to receive SBRT (OR=0.55, CI: 0.36-0.85) compared to White men.

CONCLUSION

SBRT utilization is increasing relative to other prostate cancer treatments. Prostate cancer treatment mix is different in networks that offer SBRT, and SBRT is less available to some patient groups, raising concern for novel treatment inequity.

Racial and ethnic disparities in robot-assisted radical prostatectomy: testing the physician-level segregated and differential treatment hypotheses

BACKGROUND

Mechanisms underlying racial and ethnic disparities in robot-assisted radical prostatectomy (RARP) vs open radical prostatectomy (ORP) are unclear. We sought to test 2 physician-level hypotheses: 1) Segregated Treatment and 2) Differential Treatment.

METHODS

This observational study used the New York State Cancer Registry linked to discharge records and included patients undergoing radical prostatectomy for localized prostate cancer from October 1, 2008 to December 31, 2018. For hypothesis 1, we examined the association between patient race and ethnicity and treating surgeon RARP use (high-use surgeons, low-use surgeons, and surgeons at non-RARP facilities). For hypothesis 2, we determined the association between patient race and ethnicity and receipt of RARP when matching on treating surgeon, age, year of procedure, and Gleason group. We explored the role of insurance in both analyses.

RESULTS

This study included 18 926 patients (8.0% Hispanic, 16.9% non-Hispanic Black, 75.1% non-Hispanic White), with a mean age of 60.4 ± 7.1 years. Compared with non-Hispanic White patients, Hispanic and non-Hispanic Black patients had higher odds of being treated by low-RARP-use surgeons (odds ratio [OR] = 2.16, 95% confidence interval [CI] = 1.20 to 3.88; OR = 1.76, 95% CI = 1.06 to 2.94, respectively) and by surgeons at non-RARP facilities (OR = 4.19, 95% CI = 2.18 to 8.07; OR = 4.60, 95% CI = 2.58 to 8.23, respectively). In the matched cohorts, Hispanic and non-Hispanic Black patients were less likely to receive RARP than non-Hispanic White patients (OR = 0.78, 95% CI = 0.62 to 0.98; OR = 0.75, 95% CI = 0.57 to 1.00, respectively). These associations were partially attenuated after accounting for insurance.

CONCLUSIONS

Racial and ethnic disparities in RARP use are related to patients being treated by different surgeons and treated differently by the same surgeons. Identifying and addressing multilevel barriers to equitable surgical treatment is needed to reduce disparities among prostate cancer patients.

Racial and Ethnic Disparities in the Use of Robot-Assisted Surgery and Minimally Invasive Surgery in Pelvic Cancer Treatment: A Systematic Review

Surgical innovations for cancer treatment may penetrate differentially across racial and ethnic groups and contribute to disparities in health and health care quality. We summarized the current evidence of racial and ethnic disparities in robot-assisted surgery (RAS) and minimally invasive surgery (MIS) use in four major pelvic cancer treatments. We identified studies related to racial and ethnic disparities in RAS and/or MIS use in the treatment of prostate, endometrial, bladder, and rectal cancers during 2001 to 2022 from PubMed, EMBASE, and the Cochrane database. Twenty-eight studies were selected (prostate = 7, endometrial = 14, bladder = 1, rectal = 5, multiple cancers = 1) and all were retrospective. Thirteen and 23 studies examined racial and ethnic differences in individual patients' receipt of RAS and MIS, respectively. Black patients were less likely to receive RAS/MIS than White patients in most studies. Hispanic patients were less likely to receive RAS/MIS than White patients in just over half of the studies. Studies of Asian patients were few and reported mixed results. Three studies examined disparities on the center level and found that racial and ethnic minority prostate cancer patients were less likely to be treated at RAS-performing or high-technology facilities. More work is needed to improve understanding of the mechanisms underlying racial and ethnic disparities in RAS and MIS use and their impact on disparities in health outcomes.

Disparities in access to robotic technology and perioperative outcomes among patients treated with radical prostatectomy

BACKGROUND

Most radical prostatectomies are completed with robotic assistance. While studies have previously evaluated perioperative outcomes of robot-assisted radical prostatectomy (RARP), this study investigates disparities in access and clinical outcomes of RARP.

STUDY DESIGN

The National Cancer Database (NCDB) was used to identify patients who received radical prostatectomy for cancer between 2010 and 2017 with outcomes through 2018. RARP was compared to open radical prostatectomy (ORP). Odds of receiving RARP were evaluated while adjusting for covariates. Overall survival was evaluated using a propensity-score matched cohort.

RESULTS

Overall, 354 752 patients were included with 297 676 (83.9%) receiving RARP. Patients who were non-Hispanic Black (82.8%) or Hispanic (81.3%) had lower rates of RARP than non-Hispanic White (84.0%) or Asian patients (87.7%, p < 0.001). Medicaid or uninsured patients were less likely to receive RARP (75.5%) compared to patients with Medicare or private insurance (84.4%, p < 0.001). Medicaid or uninsured status was associated with decreased odds of RARP in adjusted multivariable analysis (OR 0.61, 95% CI 0.49-0.76). RARP was associated with decreased perioperative mortality and improved overall survival compared to ORP.

CONCLUSION

Patients who were underinsured were less likely to receive RARP. Improved access to RARP may lead to decreased disparities in perioperative outcomes for prostate cancer.

Insurance Disparities in Access to Robotic Surgery for Colorectal Cancer

BACKGROUND

The use of the robotic approach is increasing for colorectal cancer operations, but the added cost of the platform has the potential to introduce challenges in its dissemination. We hypothesized that adoption of the robot is introducing new disparities in access to minimally invasive surgery (MIS) for colorectal cancer, especially across patient insurance groups.

METHODS

This cross-sectional study analyzed surgical cases of stage I-III colorectal cancer from the National Cancer Database (NCDB) between 2010 and 2019. The primary outcome was surgical approach (robotic, laparoscopic, or the composite "MIS"). The predictor was a patient's primary payor. Potential confounders included sociodemographics, tumor characteristics, and the facility. Hierarchical multivariable models were generated, and sensitivity analyses were performed.

RESULTS

For colorectal cancer operations, the MIS approach increased from 39% in 2010 to 73% in 2019, driven predominantly by an increase in the robotic approach from 2 to 24%. For laparoscopy, the size of the disparity between patients with Private insurance and Medicaid shrank from 11% (2010) to 4% (2019), whereas this disparity increased for the robotic approach from 1% (2010) to 5% (2019). On adjusted analysis, patients with Medicaid (odds ratio [OR] 0.86 [CI 0.79-0.95]) and the Uninsured (OR 0.67 [CI 0.56-0.79]) had lower odds of receiving a robotic operation than those with Private insurance in 2019. This disparity remained consistent across five sensitivity analyses.

CONCLUSIONS

As the field of colorectal cancer surgery shifts away from laparoscopy and toward robotics, new inequities across patient insurance are emerging. Proactive efforts are needed to ensure all patients benefit from a minimally invasive approach.

Population-Based Assessment of Determining Predictors for Discharge Disposition in Patients with Bladder Cancer Undergoing Radical Cystectomy

Objective: To assess predictors of discharge disposition—either home or to a CRF—after undergoing RC for bladder cancer in the United States. Methods: In this retrospective, cohort study, patients were divided into two cohorts: those discharged home and those discharged to CRF. We examined patient, surgical, and hospital characteristics. Multivariable logistic regression models were used to control for selected variables. All statistical tests were two-sided. Patients were derived from the Premier Healthcare Database. International classification of disease (ICD)-9 (<2014), ICD-10 (≥2015), and Current Procedural Terminology (CPT) codes were used to identify patient diagnoses and encounters. The population consisted of 138,151 patients who underwent RC for bladder cancer between 1 January 2000 and 31 December 2019. Results: Of 138,151 patients, 24,922 (18.0%) were admitted to CRFs. Multivariate analysis revealed that older age, single/widowed marital status, female gender, increased Charlson Comorbidity Index, Medicaid, and Medicare insurance are associated with CRF discharge. Rural hospital location, self-pay status, increased annual surgeon case, and robotic surgical approach are associated with home discharge. Conclusions: Several specific patient, surgical, and facility characteristics were identified that may significantly impact discharge disposition after RC for bladder cancer.

Socioeconomic disparities in the utilization of primary robotic hernia repair

OBJECTIVE

This study aimed to examine socioeconomic disparities in the utilization of primary robotic hernia repair (RHR), utilizing statewide population-level data. It was funded by the SAGES Robotic Surgery Research Grant.

METHODS AND PROCEDURES

The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database was used to identify adult patients who underwent primary open, laparoscopic, and robotic hernia repair (inguinal, femoral, umbilical, ventral) from 2010 through 2016. Utilization trends were compared between the surgical approaches, assessing for difference in age, sex, race, insurance status, and socioeconomic status (as defined by median income for zip code). Multivariable regression models were used with statistical significance set at 0.05.

RESULTS

A total of 280,064 patients underwent primary hernia repair: n = 216,892 (77.4%) open, n = 61,037 (21.8%) laparoscopic, and n = 2,135 (0.8%) robotic. After adjusting for confounding variables, senior age (OR 1.01, p = 0.002), male sex (OR 1.35, p < 0.001), and non-Hispanic race (OR 1.3-1.54, p < 0.001) were significantly associated with the use of robotic compared to open or laparoscopic surgery. Additionally, patients with commercial insurance were more likely to undergo RHR compared to those with Medicare (OR 1.32) or Medicaid (OR 1.54) (p < 0.0001). Income was significantly correlated with RHR such that every $10,000 increase in income would increase the odds of having RHR by 6% (OR 1.06, p < 0.0001). Academic facilities were also associated with a significantly higher likelihood of utilizing RHR (OR 1.88, p < 0.0001).

CONCLUSION

There are significant socioeconomic disparities in the utilization of robotic compared to laparoscopic or open hernia repair. While the robotic approach is overall increasing in popularity, adoption of new technology should not be limited to specific socioeconomic cohorts of the population. Recognizing these disparities is a necessary first step in providing equal and consistent care.

Are there disparities in access to robot-assisted laparoscopic surgery among pediatric urology patients? US institutional experience

Objective

Literature suggests access to robotic surgery varies by race and payer status. We seek to investigate whether disparities exist in robot‐assisted laparoscopic surgery among the pediatric urology population at our tertiary academic medical center and, if so, to find plausible reasons why.

Methods

Retrospective analysis identified patients who underwent open or robot‐assisted laparoscopic surgery by a single surgeon at a tertiary care center between 2008 and 2019. Univariate and multivariate analyses determined the relationship of patient demographic and socioeconomic factors to procedure approach.

Results

Among 356 patients, race, age, American Society of Anesthesiologists status, and year of surgery were significant by univariate analysis. Insurance status was not significant (P = 0.066). Multivariate analysis indicated that age, American Society of Anesthesiologists status, and year of surgery were statistically significant (P < 0.001, P = 0.005, P < 0.001). By multivariate logistic regression, Black and Hispanic patient race were not significant with an odds ratio of 0.60 (0.35–1.02) (P = 0.061). In 60.2% of open cases, open approach selection was attributable to complex pathology, limitations of robotic approach, and surgeon's robot‐assisted laparoscopic learning curve.

Conclusions

Optimal procedure approach was determined by case complexity and surgeon's robot‐assisted laparoscopic learning curve and was independent of patient race and payer status. This study did not find racial or socioeconomic disparities in robotic surgery within pediatric urology at our tertiary medical center, inconsistent with previous literature.

Robotic Prostatectomy and Prostate Cancer-Related Medicaid Spending: Evidence from New York State

BACKGROUND

Robotic prostatectomy is a costly new technology, but the costs may be offset by changes in treatment patterns. The net effect of this technology on Medicaid spending has not been assessed.

OBJECTIVE

To identify the association of the local availability of robotic surgical technology with choice of initial treatment for prostate cancer and total prostate cancer-related treatment costs.

DESIGN AND PARTICIPANTS

This cohort study used New York State Medicaid data to examine the experience of 9564 Medicaid beneficiaries 40-64 years old who received a prostate biopsy between 2008 and 2017 and were diagnosed with prostate cancer. The local availability of robotic surgical technology was measured as distance from zip code centroids of patient's residence to the nearest hospital with a robot and the annual number of robotic prostatectomies performed in the Hospital Referral Region.

MAIN MEASURES

Multivariate linear models were used to relate regional access to robots to the choice of initial therapy and prostate cancer treatment costs during the year after diagnosis.

KEY RESULTS

The mean age of the sample of 9564 men was 58 years; 30% of the sample were White, 26% were Black, and 22% were Hispanic. Doubling the distance to the nearest hospital with a robot was associated with a reduction in robotic surgery rates of 3.7 percentage points and an increase in the rate of use of radiation therapy of 5.2 percentage points. Increasing the annual number of robotic surgeries performed in a region by 10 was associated with a decrease in the probability of undergoing radiation therapy of 0.6 percentage point and a $434 reduction in total prostate cancer-related costs per Medicaid patient.

CONCLUSIONS

A full accounting of the costs of a new technology will depend on when it is used and the payment rate for its use relative to payment rates for substitutes.

Population demographics in geographic proximity to hospitals with robotic platforms do not correlate with disparities in access to robotic surgery

BACKGROUND

Disparities in access to robotic surgery have been shown on the local, regional, and national level. This study aims to see if the location of hospitals with robotic platforms (HWR) correlates with population trends to explain the disparity in access to robotic surgery.

METHODS

Hospitals with da Vinci surgical systems were identified by compiling data from the publicly available da Vinci surgeon locator website. Demographic, and economic data were compiled. Multivariate logistic regression and place-based analysis were used to determine population characteristics associated with geographic proximity to HWR.

RESULTS

The United States has 1971 HWR (5.93 hospitals with robots per 1 million people). The states with the most HWR are Texas (203), California (175), and Florida (162). Multivariate logistic regression analysis of Texas counties determined population (OR 1.97, 95% CI 1.40-3.38) education level (OR 1.64, 95% CI 1.07-3.21), and urban designation (OR 1.15, 95% CI 1.05-1.31) remained significantly associated with HWR. When applied to a national level, population remained associated with higher numbers of HWR (R = 0.945), however level of education and urbanization were not.

CONCLUSIONS

Based on this study of population-level data, disparities in access to robotic surgery seen in prior literature cannot be explained exclusively by sociodemographic factors related to the geographic proximity of HWR. This suggests other biases are involved in the lack of robotic procedures performed among minority and underprivileged populations.

Trends in the diffusion of robotic surgery in prostate, uterus, and colorectal procedures: a retrospective population-based study

This study aimed to propose quantifiable metrics on the adoption lifecycle of robotic-assisted surgery (RAS) within and across prostate, hysterectomy, and colorectal procedures. This was a retrospective population-based cohort study of commonly performed RAS procedures in the US conducted from July 2001 to July 2015. The patients were identified from the Premier Hospital Database using International Classification of Diseases, 9th revision, Clinical Modification codes denoting prostate, uterus, and colorectal procedures. The Diffusion of Innovations theory was applied to percent RAS utilization to determine discrete eras of technology adoption. Overall and by-era patient baseline characteristics were compared between robotic and non-robotic groups. This study included a total of 2,098,440 RAS procedures comprising prostate (n = 155,342), uterus (n = 1,300,046), and colorectal (n = 643,052) procedures. Prostate (76.7%) and uterus (28.9%) procedures had the highest robotic utilization by the end of the study period and appear to be in the last adoption era (Laggard). However, robotic utilization in colorectal procedures (7.5%) was low and remained in the first era (Innovator) for a longer time (15 vs 60 vs 135 months). Whites, privately insured, patients with fewer comorbidities, and those admitted in large teaching hospitals were more likely to undergo RAS in the early study period. AS-associated patient and hospital profiles changed over time, suggesting that selected patient cohorts should be contextualized by overall adoption of a novel medical technology. The time-discretized analysis may also inform patient selection criteria and appropriate timing for clinical study stages proposed by the Idea, Development, Exploration, Assessment, Long-term study-Devices framework.

Ethnicity and insurance status predict metastatic disease presentation in prostate, breast, and non-small cell lung cancer

Background

Ethnicity and insurance status have been shown to impact odds of presenting with metastatic cancer, however, the interaction of these two predictors is not well understood. We evaluate the difference in odds of presenting with metastatic disease in minorities compared to white patients despite access to the same insurance across three common cancer types.

Methods

Using the National Cancer Database, a multilevel logistic regression model that estimated the odds of metastatic disease was fit, adjusting for covariates including year of diagnosis, ethnicity, insurance, income, and region. We included adults diagnosed with metastatic prostate, non–small cell lung cancer (NSCLC), and breast cancer from 2004 to 2015.

Results

The study cohort consisted of 1 191 241 prostate cancer (PCa), 1 310 986 breast cancer (BCa), and 1 183 029 NSCLC patients. Private insurance was the most protective factor against metastatic presentation. Odds of presenting with metastatic disease were 0.190 [95% CI, 0.182‐0.198], 0.616 [95% CI, 0.602‐0.630], and 0.270 [95% CI, 0.260‐0.279] for PCa, NSCLC, and BCa compared to uninsured patients, respectively. Private insurance provided the most significant benefit to non‐Hispanic White PCa patients with 81% reduction in odds of metastatic presentation and conferred the least benefit to African‐American NSCLC patients at 30.4% reduction in odds of metastatic presentation.

Conclusions

Insurance status provided the single most protective effect against metastatic presentation. This benefit varied for minorities despite similar insurance. Reducing metastatic disease presentation rates requires addressing social barriers to care independent of insurance.

Waiting times and treatment following cancer diagnosis: comparison between immigrants and the Norwegian host population

Background: There are concerns about timely access to appropriate cancer treatment for the growing immigrant population in Norway. This study aims to compare waiting times between cancer diagnosis and start of cancer treatment, as well as treatment patterns between immigrants in Norway and the host population.Material and methods: We performed a nationwide, registry-based study with individual-level data, including 213,320 Norwegians and 8324 immigrants diagnosed with breast, colorectal, lung or prostate cancer in 1990-2014. Differences in time from diagnosis to treatment and in treatment patterns were described for the selected cancer sites. The Cox and logistic regressions were used to adjust for patient and tumour characteristics.Results: After adjustment for covariates, hazard ratios for time from diagnosis to treatment for non-Western immigrants compared to Norwegians were 0.88 (95% confidence interval (CI): 0.82-0.95) for breast cancer and 0.84 (95% CI: 0.75-0.95) for lung cancer, indicating longer waiting times. Treatment patterns in the four major cancer sites were similar among immigrants and the Norwegian host population, except for breast cancer, where women from East and South Asia received less breast-conserving surgery than the Norwegian host population (adjusted odds ratios 0.65 (95% CI: 0.46-0.93) for East Asians and 0.75 (95% CI: 0.50-1.13) for South Asians).Conclusions: The present study reports delayed treatment for lung and breast cancer among immigrants from non-Western countries in Norway. Systematic differences in cancer treatment were not detected. However, less breast-conserving surgery among breast cancer patients from Asia compared to Norwegians was observed.

Robotic proctectomy for rectal cancer in the US: a skewed population

BACKGROUND

Socioeconomic and racial differences have been associated with disparities in cancer care within the US, including disparate access to minimally invasive surgery for rectal cancer. We hypothesized that robotic approach to rectal cancer may be associated with similar disparities.

METHODS

The National Cancer Database (NCDB) was used to identify patients over 18 years old with clinical stage I-III rectal adenocarcinoma who underwent a proctectomy between 2010 and 2014. Demographic and hospital factors were analyzed for association with robotic approach. Factors identified on bivariate analyses informed multivariate analysis.

RESULTS

We identified 33,503 patients who met inclusion criteria; 3702 (11.1%) underwent robotic surgery with 7.8% conversion rate. Patients who received robotic surgery were more likely to be male, white, privately insured and with stage III cancer. They were also more likely to live in a metropolitan area, more than 25 miles away from the hospital and with a higher high school graduation rate. The treating hospital was more likely to be academic and high volume.

CONCLUSIONS

Robotic surgery is performed rarely and access to it is limited for patients who are female, black, older, non-privately insured and unable to travel to high-volume teaching institutions. The advantages of robotic surgery may not be available to all patients given disparate access to the robot. This inherent bias in access to robot may skew study populations, preventing generalizability of robotic surgery research.

Facility-level analysis of robot utilization across disciplines in the National Cancer Database

To evaluate trends in contemporary robotic surgery across multiple organ sites as they relate to robotic prostatectomy volume. We queried the National Cancer Database for patients who underwent surgery from 2010 to 2013 for prostate, kidney, bladder, corpus uteri, uterus, cervix, colon, sigmoid, rectum, lung and bronchus. The trend between volumes of robotic surgery for each organ site was analyzed using the Cochran-Armitage test. Multivariable models were then created to determine independent predictors of robotic surgery within each organ site by calculating the odds ratio with 95% CI. Among the 566,399 surgical cases analyzed, 35.1% were performed using robot assistance. Institutions whose robotic prostatectomy volume was in the top 75 percentile compared to the bottom 25 percentile performed a larger percentage of robotic surgery on the following sites: kidney 32.6 vs. 28.8%, bladder 23.6 vs. 18.6%, uterus 52.5 vs. 47.7%, cervix 43.5 vs. 39.2%, colon 3.2 vs. 2.9%, rectum 10.7 vs. 8.9%, and lung 7.3 vs. 6.8% (all p < 0.0001). It appears that increased trends toward robotic surgery in urology have lead to increased robotic utilization within other surgical fields. Future analysis in benign utilizations of robotic surgery as well as outcome data comparing robotic to open approaches are needed to better understand the ever-evolving nature of minimally invasive surgery within the United States.

Trends in Utilization of Robotic and Open Partial Nephrectomy for Management of cT1 Renal Masses

BACKGROUND

Partial nephrectomy is widely used for surgical management of small renal masses. Use of robotic (RPN) versus open partial nephrectomy (OPN) among various populations is not well characterized.

OBJECTIVE

To analyze trends in utilization of RPN and disparities that may be associated with this procedure for management of cT1 renal masses in the USA.

DESIGN, SETTING, AND PARTICIPANTS

Patients who underwent RPN or OPN for clinical stage T1N0M0 renal masses in the USA from 2010 to 2013 were identified in the National Cancer Data Base. A total of 23 154 patients fulfilled the inclusion criteria.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Univariable and multivariable logistic regression analyses were performed to evaluate differences in receiving RPN or OPN across various patient groups.

RESULTS AND LIMITATIONS

Utilization of RPN increased from 41% in 2010 to 63% in 2013. Black patients (adjusted odds ratio [aOR] 0.91, 95% confidence interval [CI] 0.84-0.98) and Hispanic patients (aOR 0.85, 95% CI 0.77-0.95) were less likely to undergo RPN. RPN was less likely to be performed in rural counties (aOR 0.80, 95% CI 0.66-0.98) and in patients with no insurance (aOR 0.52, 95% CI 0.44-0.61) or patients covered by Medicaid (aOR 0.81, 95% CI 0.73-0.90). There was no significant difference in RPN utilization between academic and non-academic facilities. Patients with higher clinical stage (aOR 0.58, 95% CI 0.55-0.62) and comorbidities (aOR 0.79, 95% CI 0.71-0.88) were also less likely to undergo RPN.

CONCLUSIONS

Utilization of RPN has continued to increase over time; however, there are significant disparities in its utilization according to race and socioeconomic status. Black and Hispanic patients and patients in rural communities and with limited insurance were more likely to be treated with OPN instead of RPN.

PATIENT SUMMARY

The use of robotic surgery in partial nephrectomy for management of small renal masses has increased over time. We found a significant disparity across different racial and socioeconomic groups in use of robotic partial nephrectomy compared to open surgery. Patients living in rural areas, with limited insurance, and multiple medical comorbidities were more likely to undergo open than robotic partial nephrectomy.

Trends and the utilization of transoral robotic surgery with neck dissection in New York State

OBJECTIVES

The timing of neck dissection (ND) in relation to transoral robotic surgery (TORS) is controversial. This study identifies local practice patterns and economic and social access disparities during adoption of TORS.

STUDY DESIGN

We analyzed utilization patterns of TORS and ND using the New York Statewide Planning and Research Cooperative System all-payer administrative database. Statewide head and neck cancer incidence from the Centers for Disease Control and Prevention (Bethesda, MD) was used to control for overall cancer incidence.

METHODS

Patient demographic, insurer, and institutional information of patients aged ≥ 18 (n = 225) years from 2008 to 2012 were evaluated. Temporal trends were analyzed with Poisson regression models for counts.

RESULTS

Transoral robotic surgery was used in 386 procedures, and 58.3% involved ND (n = 225). Concurrent ND was most frequent (n = 173), followed by staged TORS then ND (n = 44) and staged ND preceding TORS (n = 8). Caucasians were more likely than Blacks/Hispanics to undergo TORS (P = 0.03). Medicare (26.2%) and Medicaid (2.7%) payers comprised a minority of patients compared to those commercially insured (70.2%). Only 20% of patients received care outside a major urban center, and these patients were more likely to undergo staged procedures, P = 0.02. Staged procedures resulted in higher mean hospital charges (P = 0.02).

CONCLUSION

Concurrent TORS + ND, the most common practice in New York, is more cost-effective. Patients without commercial insurance, patients in racial minorities, or patients residing outside major urban centers may be targeted to improve care access disparities with respect to minimally invasive TORS technology.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:1571-1576, 2017.

Comparison of Robot-Assisted Radical Prostatectomy and Open Radical Prostatectomy Outcomes: A Systematic Review and Meta-Analysis

PURPOSE

To systematically update evidence on the clinical efficacy and safety of robot-assisted radical prostatectomy (RARP) versus retropubic radical prostatectomy (RRP) in patients with prostate cancer.

MATERIALS AND METHODS

Electronic databases, including ovidMEDLINE, ovidEMBASE, the Cochrane Library, KoreaMed, KMbase, and others, were searched, collecting data from January 1980 to August 2013. The quality of selected systematic reviews was assessed using the revised assessment of multiple systematic reviews and the modified Cochrane Risk of Bias tool for non-randomized studies.

RESULTS

A total of 61 studies were included, including 38 from two previous systematic reviews rated as best available evidence and 23 additional studies that were more recent. There were no randomized controlled trials. Regarding safety, the risk of complications was lower for RARP than for RRP. Among functional outcomes, the risk of urinary incontinence was lower and potency rate was significantly higher for RARP than for RRP. Regarding oncologic outcomes, positive margin rates were comparable between groups, and although biochemical recurrence (BCR) rates were lower for RARP than for RRP, recurrence-free survival was similar after long-term follow up.

CONCLUSION

RARP might be favorable to RRP in regards to post-operative complications, peri-operative outcomes, and functional outcomes. Positive margin and BCR rates were comparable between the two procedures. As most of studies were of low quality, the results presented should be interpreted with caution, and further high quality studies controlling for selection, confounding, and selective reporting biases with longer-term follow-up are needed to determine the clinical efficacy and safety of RARP.

Medicaid beneficiaries undergoing complex surgery at quality care centers: insights into the Affordable Care Act

BACKGROUND

Medicaid beneficiaries do not have equal access to high-volume centers for complex surgical procedures. We hypothesize there is a large Medicaid Gap between those receiving emergency general vs complex surgery at the same hospital.

METHODS

Using the Nationwide Inpatient Sample, 1998 to 2010, we identified high-volume pancreatectomy hospitals. We then compared the percentage of Medicaid patients receiving appendectomies vs pancreatectomies at these hospitals. Hospital characteristics associated with increased Medicaid Gap were evaluated using generalized estimating equation models.

RESULTS

A total of 602 hospital-years of data from 289 high-volume pancreatectomy hospitals were included. Median percentages of Medicaid appendectomies and pancreatectomies were 12.1% (interquartile range: 5.8% to 19.8%) and 6.7% (interquartile range: 0% to 15.4%), respectively. Hospitals that performed greater than or equal to 40 pancreatic resections per year had higher odds of having significant Medicaid Gap (odds ratio 2.3, 95% confidence interval 1.1 to 5.0).

CONCLUSIONS

Gaps exist between the percentages of Medicaid patients receiving emergency general surgery vs more complex surgical care at the same hospital and may be exaggerated in hospitals with very high volume of complex elective surgeries.

Local coverage determination policy and the use of stereotactic body radiation therapy for prostate cancer

INTRODUCTION

Local coverage determinations (LCDs) are local decisions that regulate healthcare coverage. We evaluated the impact of LCDs as well as patient, tumor, and market characteristics on the adoption of stereotactic body radiation therapy (SBRT) for prostate cancer.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare, we identified men treated with SBRT, intensity-modulated radiotherapy (IMRT), and robotic prostatectomy. We compared demographics, clinical characteristics, and market factors among these three treatments. Our primary exposure was LCD policy; using the Medicare Coverage Database, we categorized LCDs as favorable (SBRT covered), neutral (SBRT covered in the context of a clinical trial or registry), unfavorable (SBRT not covered), or absent (i.e., SBRT not governed by an LCD at the time of treatment). We fit a multivariable multinomial logistic regression model and generated predicted probabilities to examine the relation between LCDs and SBRT.

RESULTS

During this early period of SBRT adoption, IMRT was the most common of the three treatments followed by robotic prostatectomy and then SBRT. SBRT use was high when governed by favorable and neutral LCDs and lowest when governed by unfavorable LCDs. Compared with favorable LCDs, areas where LCDs were absent were associated with higher SBRT use compared with IMRT (odds ratio [OR] 1.56; 95%CI, 1.07-2.25) and robotic prostatectomy (OR 1.84; 95%CI, 1.25-2.69).

CONCLUSIONS

When present, LCDs appear to regulate early SBRT adoption, but, when absent, are associated with increased SBRT use. Although SBRT use was uncommon, it varied across a wide range of patient, tumor, and market characteristics.