The impact of fellowship training on pathological outcomes following radical prostatectomy: a population based analysis

The National Provider Identifier Taxonomy: Does it Align With a Surgeon's Actual Clinical Practice?

INTRODUCTION

The taxonomy code(s) associated with each National Provider Identifier (NPI) entry should characterize the provider's role (e.g., physician) and any specialization (e.g., orthopedic surgery). While the intent of the taxonomy system was to monitor medical appropriateness and the expertise of care provided, this system is now being used by researchers to identify providers and their practices. It is unknown how accurate the taxonomy codes are in describing a provider's true specialization.

METHODS

Department websites of orthopedic surgery and general surgery from three large academic institutions were queried for practicing surgeons. The surgeon's specialty and subspeciality information listed was compared to the provider's taxonomy code(s) listed on the National Plan and Provider Enumeration System (NPPES). The match rate between these data sources was evaluated based on the specialty, subspecialty, and institution.

RESULTS

There were 295 surgeons (205 general surgery and 90 orthopedic surgery) and 24 relevant taxonomies (8 orthopedic and 16 general or plastic) for analysis. Of these, 294 surgeons (99%) selected their general specialty taxonomy correctly, while only 189 (64%) correctly chose an appropriate subspecialty. General surgeons correctly chose a subspecialty more often than orthopedic surgeons (70 versus 51%, P = 0.002). The institution did not affect either match rate, however there were some differences noted in subspecialty match rates inside individual departments.

CONCLUSIONS

In these institutions, the NPI taxonomy is not accurate for describing a surgeon's subspecialty or actual practice. Caution should be taken when utilizing this variable to describe a surgeon's subspecialization as our findings might apply in other groups.

A Systematic Review of the Impact of Surgeon and Hospital Caseload Volume on Oncological and Nononcological Outcomes After Radical Prostatectomy for Nonmetastatic Prostate Cancer

CONTEXT

The impact of surgeon and hospital volume on outcomes after radical prostatectomy (RP) for localised prostate cancer (PCa) remains unknown.

OBJECTIVE

To perform a systematic review on the association between surgeon or hospital volume and oncological and nononcological outcomes following RP for PCa.

EVIDENCE ACQUISITION

Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. All comparative studies for nonmetastatic PCa patients treated with RP published between January 1990 and May 2020 were included. For inclusion, studies had to compare hospital or surgeon volume, defined as caseload per unit time. Main outcomes included oncological (including prostate-specific antigen persistence, positive surgical margin [PSM], biochemical recurrence, local and distant recurrence, and cancer-specific and overall survival) and nononcological (perioperative complications including need for blood transfusion, conversion to open procedure and within 90-d death, and continence and erectile function) outcomes. Risk of bias (RoB) and confounding assessments were undertaken. Both a narrative and a quantitative synthesis were planned if the data allowed.

EVIDENCE SYNTHESIS

Sixty retrospective comparative studies were included. Generally, increasing surgeon and hospital volumes were associated with lower rates of mortality, PSM, adjuvant or salvage therapies, and perioperative complications. Combining group size cut-offs as used in the included studies, the median threshold for hospital volume at which outcomes start to diverge is 86 (interquartile range [IQR] 35-100) cases per year. In addition, above this threshold, the higher the caseload, the better the outcomes, especially for PSM. RoB and confounding were high for most domains.

CONCLUSIONS

Higher surgeon and hospital volumes for RP are associated with lower rates of PSMs, adjuvant or salvage therapies, and perioperative complications. This association becomes apparent from a caseload of >86 (IQR 35-100) per year and may further improve hereafter. Both high- and low-volume centres should measure their outcomes, make them publicly available, and improve their quality of care if needed.

PATIENT SUMMARY

We reviewed the literature to determine whether the number of prostate cancer operations (radical prostatectomy) performed in a hospital affects the outcomes of surgery. We found that, overall, hospitals with a higher number of operations per year have better outcomes in terms of cancer recurrence and complications during or after hospitalisation. However, it must be noted that surgeons working in hospitals with lower annual operations can still achieve similar or even better outcomes. Therefore, making hospital's outcome data publicly available should be promoted internationally, so that patients can make an informed decision where they want to be treated.

Current status of uro-oncology training during urology residency and the need for fellowship programs: An international questionnaire study

OBJECTIVE

This study aimed to evaluate the opinions of urologists from different countries about uro-oncology education, fellowship programs, and approaches to different urological malignancies at different stages using a questionnaire.

MATERIAL AND METHODS

A total of 207 urologists from 22 countries were sent a questionnaire containing 18 items by email. The questions were related to urologic oncology training provided during residency, acceptance of uro-oncology as a sub-branch, the necessity of certification for treatment and follow-up, fellowship program preferences, adequateness of the programs, and approach differences to the different stages of urological malignancies among the urologists from different countries.

RESULTS

In total, 111 (53.62%) urologists who completed the questionnaire were enrolled in the study, and 40.54% of the urologists reported that the uro-oncology training during the residency period was not sufficient. Furthermore, 79.27% of the urologists reported opinions about acceptance of uro-oncology as a sub-branch. The ratio of urologists who undertake the treatment of patients with muscle-invasive bladder cancer (radical surgery and urinary diversion) and prostate cancer (radical prostatectomy, definitive radiation therapy, experimental local treatment, and hormonal therapy) is 27.92% and 37.83%, respectively. The urologists reported that they perform nephron-sparing surgery (NSS), radical nephrectomy (RN), and laparoscopic NSS/RN treatments in patients with localized renal cancer at the rates of 61.26%, 47.74%, and 25.22%, respectively.

CONCLUSION

Uro-oncology training during the residency period seems to be inadequate in most of the countries, and a high number of the urologists tend to avoid high-volume operations and systemic treatments of uro-oncologic malignancies.

Fellowship and Subspecialization in Urology: An Analysis of Robotic-assisted Partial Nephrectomy

OBJECTIVE

To evaluate the impact of a urologic fellowship on physician case-volume and immediate patient outcomes, and to assess predictors of undergoing a robotic-assisted partial nephrectomy by a fellowship-trained (FT) urologist.

METHODS

We retrospectively reviewed all robotic (ICD-9 17.4) partial nephrectomies (PN; ICD-9 55.4) reported in the Statewide Planning and Research Cooperative Systems (SPARCS) database of New York State (NYS) from 2009 to 2014. Perioperative outcomes assessed included length of stay, 30-day readmission rates, 90-day readmission rates, and complication rates. Pearson chi-square tests were used to compare categorical variables, and unpaired Student t tests were used to assess continuous variables.

RESULTS

FT urologists performed 2199 (56%) RAPN during the study period, and nonfellowship trained (NFT) urologists completed 1700 (44%) RAPN. FT urologists performed more RAPN in teaching hospitals than NFT urologists (23% vs 7%). The average surgical volume per year for a FT urologist conducting RAPN was 9.6 ± 2.2 cases/y. NFT urologists had an average surgical volume of 7.2 ± 1.5 cases/y (P = <.0001). No significant difference was found in length of stay, 30- or 90-day readmission rate, or complication rate between the groups. RAPN conducted at teaching hospitals were more likely to be conducted by FT urologists. Patients who were self-payers were less likely to have a RAPN by FT urologists.

CONCLUSION

There were no differences for RAPN perioperative outcomes between FT urologists and their NFT peers. FT urologists perform a higher case-volume of RAPN in NYS, and this trend is increasing.

Decreased Rate of Complications in Carpal Tunnel Release with Hand Fellowship Training

Purpose

In many procedures, both high case volumes and fellowship training have been shown to improve outcomes. One of the most common procedures performed by hand surgeons, the carpal tunnel release (CTR) is also performed by several other specialties without specialty training in a hand fellowship. This study analyzed the effect that hand fellowship training has on outcomes of CTRs.

Materials and Methods

Using the American Board of Orthopedic Surgeons (ABOS) Part II candidates' case list submissions, a database was created for all open and endoscopic CTRs. Surgeon training, demographics, technique, and complications were recorded. Complications were then categorized and broken down by technique. Results were then analyzed for statistical significance.

Results

A total of 29,916 cases were identified. Hand fellowship-trained surgeons performed six times more CTRs at 31 cases per surgeon compared with five for non-hand fellowship-trained surgeons. They also improved outcomes in rates of infection, wound dehiscence, and overall complications. Rates of nerve injury or recurrence showed no statistical difference. This held true for the open release subset. Endoscopically, fellowship-trained surgeons had only improved rates of overall complications.

Conclusion

Surgeons undergoing additional hand fellowship training may show improved outcomes in the surgical treatment of carpal tunnel syndrome. However, no effect was seen on nerve injury or recurrence of symptoms.

Trends in Inpatient Urological Surgery Practice Patterns

INTRODUCTION

As the nation's population ages and the number of practicing urologists per capita declines, characterization of practice patterns is essential to understand the current state of the urological workforce and anticipate future needs. Accordingly, we examined trends in adult inpatient urological surgery practice patterns over a five-year period.

METHODS

We used the Nationwide Inpatient Sample (NIS) data from 2005 through 2009 to identify both surgeons and urological surgeries. We classified the latter into 1 of 7 clinical domains (Endourology & Stone Disease, Incontinence, Urogenital Reconstruction, Urologic Oncology, Benign Prostate, Renal Transplant, and Other Urological Procedures). For each urological surgeon, three parameters were determined for each year: 1) Case-diversity (the number of distinct urological clinical domains in which they performed ≥2 procedures/year); 2) Subspecialty (the predominant clinical domain of cases that each surgeon performed); and 3) Subspecialty-focus (the proportion of a surgeon's total urological cases/year that belonged to their assigned clinical domain). We examined trends in these metrics over a five-year period, and compared results between urban and rural practice settings.

RESULTS

We analyzed data for 2,237 individual surgeons performing 144,138 inpatient surgeries. Over time, urologist's practice patterns evolved toward lower case-diversity (p<0.001) and greater subspecialty-focus (p<0.001). These trends were more pronounced for surgeons practicing in urban versus rural practice settings (p-values <0.05).

CONCLUSIONS

At a national level, urologists' inpatient surgical practice patterns are narrowing, with less case-diversity and higher subspecialty-focus. These trends are even more prominent among urologists in urban, compared with rural, practice settings.

Effect of radical prostatectomy surgeon volume on complication rates from a large population-based cohort

INTRODUCTION

Surgical volume can affect several outcomes following radical prostatectomy (RP). We examined if surgical volume was associated with novel categories of treatment-related complications following RP.

METHODS

We examined a population-based cohort of men treated with RP in Ontario, Canada between 2002 and 2009. We used Cox proportional hazard modeling to examine the effect of physician, hospital and patient demographic factors on rates of treatment-related hospital admissions, urologic procedures, and open surgeries.

RESULTS

Over the study interval, 15 870 men were treated with RP. A total of 196 surgeons performed a median of 15 cases per year (range: 1-131). Patients treated by surgeons in the highest quartile of annual case volume (>39/year) had a lower risk of hospital admission (hazard ratio [HR]=0.54, 95% CI 0.47-0.61) and urologic procedures (HR=0.69, 95% CI 0.64-0.75), but not open surgeries (HR=0.83, 95% CI 0.47-1.45) than patients treated by surgeons in the lowest quartile (<15/year). Treatment at an academic hospital was associated with a decreased risk of hospitalization (HR=0.75, 95% CI 0.67-0.83), but not of urologic procedures (HR=0.94, 95% CI 0.88-1.01) or open surgeries (HR=0.87, 95% CI 0.54-1.39). There was no significant trend in any of the outcomes by population density.

CONCLUSIONS

The annual case volume of the treating surgeon significantly affects a patient's risk of requiring hospitalization or urologic procedures (excluding open surgeries) to manage treatment-related complications.

Unplanned Hospital Return for Infection following Ureteroscopy-Can We Identify Modifiable Risk Factors?

PURPOSE

Genitourinary infection after ureteroscopy with laser lithotripsy is a clinically significant event that may lead to expensive and morbid return to the hospital. We evaluate factors associated with infection after ureteroscopy with laser lithotripsy leading to unplanned hospital return.

MATERIALS AND METHODS

We performed a retrospective chart review evaluating all ureteroscopy with laser lithotripsy performed at a single academic institution from April 2011 to August 2014. Data were extracted including patient demographics, comorbidities, surgical encounter characteristics, preoperative urine culture status, antibiotic type/duration and compliance with the AUA Best Practice Statement for antibiotic prophylaxis. Bivariate and multivariate analyses were performed to determine factors associated with unplanned return to the hospital.

RESULTS

Among 550 patients undergoing ureteroscopy with laser lithotripsy 45% (248) were female with an average age of 56.8 (± 14.8) years. Overall 3.4% (19 patients) had an unplanned return for genitourinary infection, with most (78.9%, 15 of 19) requiring inpatient readmission. Overall compliance with AUA Best Practice Statement for antibiotic prophylaxis was 48.7% (268 of 550). Rates of infection related returns were higher in patients undergoing preoperative stenting (84.2% vs 58.6%, p=0.025), those with an operative time greater than 120 minutes (89.5% vs 32.6% p <0.001) and those for whom there was AUA Best Practice Statement compliance for antibiotic prophylaxis (78.9% vs 47.6%, p=0.007). These factors remained significant on multivariate analysis (p <0.05).

CONCLUSIONS

Preoperative stenting and longer operative time were associated with a greater likelihood of serious genitourinary infection after ureteroscopy with laser lithotripsy. These patients may warrant additional antibiotic prophylaxis but further research is needed to answer this question more definitively. Interestingly the AUA Best Practice Statement compliance for antibiotic prophylaxis was also associated with a higher risk of infection, underscoring the need for locally appropriate prophylaxis strategies and further study of optimal prophylaxis regimens.