title: Urologist density and county-level urologic cancer mortality.
abstract: OBJECTIVE
  The surgical work force distribution at the county level varies widely across the United States, and the impact of differential access on cancer outcomes is unclear. We used urologists as a test case because they are the first care providers for urologic cancers, can easily be identified from available data sources, and are unevenly distributed throughout the country. The goal of this study was to determine the effect of increasing urologist density on local prostate, bladder, and kidney cancer mortality.
  
  
  METHODS
  Using county-level data from the Area Resource File, US Census, National Cancer Institute, and Centers for Disease Control, regression models were built for prostate, bladder, and kidney cancer mortality, controlling for categorized urologist density, county demographics, socioeconomic factors, and preexisting health care infrastructure.
  
  
  RESULTS
  For each of the three cancers, there was a statistically significant cancer-specific mortality reduction associated with counties that had more than zero urologists (16% to 22% reduction for prostate cancer, 17% to 20% reduction for bladder cancer, and 8% to 14% reduction for kidney cancer with increasing urologist density) relative to zero urologists. However, increasing density greater than two urologists per 100,000 people had no statistically significant impact on mortality for any of the tumors studied.
  
  
  CONCLUSIONS
  The presence of a urologist is associated with lower mortality for urologic cancers in that county, but increasing urologist density does not yield further improvements. Therefore, a nuanced and geographically aware policy toward the size and distribution of the future work force is most likely to provide the greatest population-level improvement in cancer mortality outcomes.
authors.affiliation: Department of Urology, University of California, San Francisco, San Francisco, CA 94143-1695, USA. anobel.odisho@ucsf.edu
authors.forename: Anobel Y
authors.initials: AY
authors.lastname: Odisho
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Cooperberg
authors.forename: Vincent
authors.initials: V
authors.lastname: Fradet
authors.forename: Ardalan E
authors.initials: AE
authors.lastname: Ahmad
authors.forename: Peter R
authors.initials: PR
authors.lastname: Carroll
mesh_terms: D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D015994:Incidence; D007680:Kidney Neoplasms / Q000401:mortality; D008297:Male; D010820:Physicians / Q000706:statistics & numerical data*; D011471:Prostatic Neoplasms / Q000401:mortality; D014481:United States / Q000453:epidemiology; D001749:Urinary Bladder Neoplasms / Q000401:mortality; D014571:Urologic Neoplasms / Q000401:mortality*; D014572:Urology; D000078329:Workforce
references.citation: Health Aff (Millwood). 2005 Jan-Jun;Suppl Web Exclusives:W5-111-W5-114
references.pmid: 15769798
references.citation: Urology. 1997 Mar;49(3):335-42
references.pmid: 9123694
references.citation: Prostate Cancer Prostatic Dis. 2008;11(3):247-51
references.pmid: 18268527
references.citation: J Urol. 2009 Feb;181(2):760-5; discussion 765-6
references.pmid: 19091334
references.citation: JAMA. 2008 Jan 23;299(3):335-7
references.pmid: 18212319
references.citation: J Urol. 1987 Sep;138(3):473-6
references.pmid: 3625843
references.citation: Cancer Epidemiol Biomarkers Prev. 2005 Mar;14(3):590-5
references.pmid: 15767335
references.citation: Bull Am Coll Surg. 2008 Mar;93(3):11-8
references.pmid: 18390225
references.citation: Health Serv Res. 2007 Dec;42(6 Pt 1):2233-51; discussion 2294-323
references.pmid: 17995563
references.citation: J Urol. 1978 Sep;120(3):267-8
references.pmid: 682240
references.citation: N Engl J Med. 2002 May 16;346(20):1538-44
references.pmid: 12015393
references.citation: Int J Cancer. 2002 Sep 10;101(2):168-74
references.pmid: 12209994
references.citation: Int J Health Serv. 2007;37(1):111-26
references.pmid: 17436988
references.citation: J Am Acad Dermatol. 2009 Jan;60(1):51-8
references.pmid: 18937998
references.citation: Cancer. 2008 Feb 15;112(4):909-18
references.pmid: 18189295
references.citation: Health Serv Res. 1996 Jun;31(2):191-211
references.pmid: 8675439
references.citation: Nat Clin Pract Rheumatol. 2008 Jul;4(7):333
references.pmid: 18587429
references.citation: J Am Board Fam Pract. 2000 Nov-Dec;13(6):408-14
references.pmid: 11117337
references.citation: Health Aff (Millwood). 2005 Jan-Jun;Suppl Web Exclusives:W5-97-W5-107
references.pmid: 15769797
references.citation: J Fam Pract. 1999 Nov;48(11):850-8
references.pmid: 10907621