title: National trends in the utilization of partial nephrectomy before and after the establishment of AUA guidelines for the management of renal masses.
abstract: OBJECTIVE
  To assess the impact of the American Urological Association (AUA) guidelines advocating partial nephrectomy for T1 tumors guidelines on the likelihood of undergoing partial nephrectomy.
  
  
  METHODS
  We analyzed the Nationwide Inpatient Sample (NIS), a dataset encompassing 20% of all United States inpatient hospitalizations, from 2007 through 2010. Our dependent variable was receipt of radical vs partial nephrectomy (55.50, 55.51, 55.52, and 55.54 vs 55.4) for a renal mass (International Classification of Disease, 9th Revision [ICD-9] code 189.0). The independent variable of interest was time of surgery (before or after the establishment of AUA guidelines); covariates included a diagnosis of chronic kidney disease (CKD), overall comorbidity, age, race, gender, geographic region, income, and hospital characteristics. Bivariate and multivariable adjusted logistic regression was used to determine the association between receipt of partial nephrectomy and time of guideline establishment.
  
  
  RESULTS
  We identified 26,165 patients with renal tumors who underwent surgery. Before the guidelines, 4031 patients (27%) underwent partial nephrectomy compared to 3559 (32%) after. On multivariable analysis, undergoing surgery after the establishment of guidelines (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.08-1.32, P <.01) was an independent predictor of partial nephrectomy. Other factors associated with partial nephrectomy were urban location, surgery at a teaching hospital, large hospital bed size, Northeast location, and Black race. Female gender and CKD were not associated with partial nephrectomy.
  
  
  CONCLUSIONS
  Although adoption of partial nephrectomy increased after establishment of new guidelines on renal masses, partial nephrectomy remains an underutilized procedure. Future research must focus on barriers to adoption of partial nephrectomy and how to overcome them.
authors.affiliation: Division of Urologic Oncology, Department of Urology, New York University Langone Medical Center, New York, NY. Electronic address: marc.bjurlin@nyumc.org.
authors.forename: Marc A
authors.initials: MA
authors.lastname: Bjurlin
authors.forename: Dawn
authors.initials: D
authors.lastname: Walter
authors.forename: Glen B
authors.initials: GB
authors.lastname: Taksler
authors.forename: William C
authors.initials: WC
authors.lastname: Huang
authors.forename: James S
authors.initials: JS
authors.lastname: Wysock
authors.forename: Ganesh
authors.initials: G
authors.lastname: Sivarajan
authors.forename: Stacy
authors.initials: S
authors.lastname: Loeb
authors.forename: Samir S
authors.initials: SS
authors.lastname: Taneja
authors.forename: Danil V
authors.initials: DV
authors.lastname: Makarov
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009392:Nephrectomy / Q000379:methods / Q000706:statistics & numerical data* / Q000639:trends; D017410:Practice Guidelines as Topic; D012955:Societies, Medical; D014481:United States; D055815:Young Adult