title: The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy.
abstract: BACKGROUND
  The rapid diffusion of the surgical robot has been controversial because of the technology's high costs and its disputed marginal benefit. Some, however, have suggested that adoption of the robot may have improved care for patients with renal malignancy by facilitating partial nephrectomy, an underutilized, technically challenging procedure believed to be less morbid than radical nephrectomy. We sought to determine whether institutional acquisition of the robot was associated with increased utilization of partial nephrectomy.
  
  
  METHODS
  We used all payer data from 7 states to identify 21,569 nephrectomies. These patient-level records were aggregated to the hospital-level then merged with the American Hospital Association Annual Survey and publicly available data on timing of robot acquisition. We used a multivariable difference-in-difference model to assess at the hospital-level whether robot acquisition was associated with an increase in the proportion of partial nephrectomy, adjusting for hospital nephrectomy volume, year of surgery, and several additional hospital-level factors.
  
  
  RESULTS
  In the multivariable-adjusted differences-in-differences model, hospitals acquiring a robot between 2001 and 2004 performed a greater proportion of partial nephrectomy in both 2005 (29.9% increase) and 2008 (34.9% increase). Hospitals acquiring a robot between 2005 and 2008 also demonstrated a greater proportion of partial nephrectomy in 2008 (15.5% increase). In addition, hospital nephrectomy volume and urban location were also significantly associated with increased proportion of partial nephrectomy.
  
  
  CONCLUSIONS
  Hospital acquisition of the surgical robot is associated with greater proportion of partial nephrectomy, an underutilized, guideline-encouraged procedure. This is one of the few studies to suggest robot acquisition is associated with improvement in quality of patient care.
authors.affiliation: *Department of Urology, New York University Langone Medical Center, New York, NY †Cleveland Clinic, Cleveland, OH ‡Yale School of Medicine, New Haven, CT §Department of Veteran Affairs, New York Harbor Healthcare System ∥Department of Public Healthy, New York University Langone Medical Center ¶New York University Cancer Institute #Robert F. Wagner Graduate School of Public Service, New York, NY.
authors.forename: Ganesh
authors.initials: G
authors.lastname: Sivarajan
authors.forename: Glen B
authors.initials: GB
authors.lastname: Taksler
authors.forename: Dawn
authors.initials: D
authors.lastname: Walter
authors.forename: Cary P
authors.initials: CP
authors.lastname: Gross
authors.forename: Raul E
authors.initials: RE
authors.lastname: Sosa
authors.forename: Danil V
authors.initials: DV
authors.lastname: Makarov
mesh_terms: D000328:Adult; D000368:Aged; D004059:Diffusion of Innovation; D005260:Female; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data; D006786:Hospitals, Urban / Q000706:statistics & numerical data; D006801:Humans; D007345:Insurance Claim Review / Q000706:statistics & numerical data; D007680:Kidney Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods* / Q000706:statistics & numerical data*; D065287:Robotic Surgical Procedures / Q000379:methods* / Q000706:statistics & numerical data*; D014481:United States