title: Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy.
abstract: OBJECTIVE
  Surgical innovations disseminate in the absence of coordinated systems to ensure their safe integration into clinical practice, potentially exposing patients to increased risk for medical error.
  
  
  OBJECTIVE
  To investigate associations of patient safety with the diffusion of minimally invasive radical prostatectomy (MIRP) resulting from the development of the da Vinci robot.
  
  
  METHODS
  A cohort study of 401 325 patients in the Nationwide Inpatient Sample who underwent radical prostatectomy during MIRP diffusion between January 1, 2003, and December 31, 2009.
  
  
  METHODS
  We used Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs), which measure processes of care and surgical provider performance. We estimated the prevalence of MIRP among all prostatectomies and compared PSI incidence between MIRP and open radical prostatectomy in each year during the study. We also collected estimates of MIRP incidence attributed to the manufacturer of the da Vinci robot.
  
  
  RESULTS
  Patients who underwent MIRP were more likely to be white (P = .004), have fewer comorbidities (P = .02), and have undergone surgery in higher-income areas (P = .005). The incidence of MIRP was substantially lower than da Vinci manufacturer estimates. Rapid diffusion onset occurred in 2006, when MIRP accounted for 10.4% (95% CI, 10.2-10.7) of all radical prostatectomies in the United States. In 2005, MIRP was associated with an increased adjusted risk for any PSI (adjusted odds ratio, 2.0; 95% CI, 1.1-3.7; P = .02) vs open radical prostatectomy. Stratification by hospital status demonstrated similar patterns: rapid diffusion onset among teaching hospitals occurred in 2006 (11.7%; 95% CI, 11.3-12.0), with an increased risk for PSI for MIRP in 2005 (adjusted odds ratio, 2.7; 95% CI, 1.4-5.3; P = .004), and onset among nonteaching hospitals occurred in 2008 (27.1%; 95% CI, 26.6-27.7), with an increased but nonsignificant risk for PSI in 2007 (adjusted odds ratio, 2.0; 95% CI, 0.8-5.2; P = .14).
  
  
  CONCLUSIONS
  During its initial national diffusion, MIRP was associated with diminished perioperative patient safety. To promote safety and protect patients, the processes by which surgical innovations disseminate into clinical practice require refinement.
authors.affiliation: Department of Urology, University of California, San Diego Health System2Urologic Cancer Unit, University of California, San Diego Moores Cancer Center, La Jolla3Section of Surgery, VA San Diego Healthcare System, San Diego, California.
authors.forename: J Kellogg
authors.initials: JK
authors.lastname: Parsons
authors.affiliation: Division of Biostatistics, University of California, San Diego Moores Cancer Center, La Jolla5Department of Family and Preventive Medicine, University of California, San Diego School of Medicine, La Jolla.
authors.forename: Karen
authors.initials: K
authors.lastname: Messer
authors.affiliation: Department of Urology, University of California, San Diego Health System2Urologic Cancer Unit, University of California, San Diego Moores Cancer Center, La Jolla.
authors.forename: Kerrin
authors.initials: K
authors.lastname: Palazzi
authors.affiliation: Naval Medical Center San Diego, Urologic Oncology, San Diego, California.
authors.forename: Sean P
authors.initials: SP
authors.lastname: Stroup
authors.affiliation: Department of Surgery, University of California, San Diego Health System.
authors.forename: David
authors.initials: D
authors.lastname: Chang
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004059:Diffusion of Innovation; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D061214:Patient Safety; D011468:Prostatectomy / Q000009:adverse effects / Q000295:instrumentation* / Q000706:statistics & numerical data; D011471:Prostatic Neoplasms / Q000601:surgery*; D012371:Robotics; D012959:Socioeconomic Factors