title: Variations in morbidity after radical prostatectomy.
abstract: BACKGROUND
  Recent studies of surgery for cancer have demonstrated variations in outcomes among hospitals and among surgeons. We sought to examine variations in morbidity after radical prostatectomy for prostate cancer.
  
  
  METHODS
  We used the Surveillance, Epidemiology, and End Results-Medicare linked data base to evaluate health-related outcomes after radical prostatectomy. The rates of postoperative complications, late urinary complications (strictures or fistulas 31 to 365 days after the procedure), and long-term incontinence (more than 1 year after the procedure) were inferred from the Medicare claims records of 11,522 patients who underwent prostatectomy between 1992 and 1996. These rates were analyzed in relation to hospital volume and surgeon volume (the number of procedures performed at individual hospitals and by individual surgeons, respectively).
  
  
  RESULTS
  Neither hospital volume nor surgeon volume was significantly associated with surgery-related death. Significant trends in the relation between volume and outcome were observed with respect to postoperative complications and late urinary complications. Postoperative morbidity was lower in very-high-volume hospitals than in low-volume hospitals (27 percent vs. 32 percent, P=0.03) and was also lower when the prostatectomy was performed by very-high-volume surgeons than when it was performed by low-volume surgeons (26 percent vs. 32 percent, P<0.001). The rates of late urinary complications followed a similar pattern. Results for long-term preservation of continence were less clear-cut. In a detailed analysis of the 159 surgeons who had a high or very high volume of procedures, wide surgeon-to-surgeon variations in these clinical outcomes were observed, and they were much greater than would be predicted on the basis of chance or observed variations in the case mix.
  
  
  CONCLUSIONS
  In men undergoing prostatectomy, the rates of postoperative and late urinary complications are significantly reduced if the procedure is performed in a high-volume hospital and by a surgeon who performs a high number of such procedures.
authors.affiliation: Health Outcomes Research Group, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York 10021, USA. beggc@mskcc.org
authors.forename: Colin B
authors.initials: CB
authors.lastname: Begg
authors.forename: Elyn R
authors.initials: ER
authors.lastname: Riedel
authors.forename: Peter B
authors.initials: PB
authors.lastname: Bach
authors.forename: Michael W
authors.initials: MW
authors.lastname: Kattan
authors.forename: Deborah
authors.initials: D
authors.lastname: Schrag
authors.forename: Joan L
authors.initials: JL
authors.lastname: Warren
authors.forename: Peter T
authors.initials: PT
authors.lastname: Scardino
mesh_terms: D000368:Aged; D013502:General Surgery / Q000706:statistics & numerical data; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D006278:Medicare; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology* / Q000401:mortality; D011468:Prostatectomy / Q000009:adverse effects / Q000401:mortality* / Q000706:statistics & numerical data*; D011471:Prostatic Neoplasms / Q000601:surgery; D018426:SEER Program; D014481:United States / Q000453:epidemiology; D014549:Urinary Incontinence / Q000453:epidemiology / Q000209:etiology; D014570:Urologic Diseases / Q000453:epidemiology / Q000209:etiology; D000078329:Workforce