title: The interplay between hospital and surgeon factors and the use of sentinel lymph node biopsy for breast cancer.
abstract: BACKGROUND
  Several surgeon characteristics are associated with the use of sentinel lymph node biopsy (SLNB) for breast cancer. No studies have systematically examined the relative contribution of both surgeon and hospital factors on receipt of SLNB.
  
  
  OBJECTIVE
  To evaluate the relationship between surgeon and hospital characteristics, including a novel claims-based classification of hospital commitment to cancer care (HC), and receipt of SLNB for breast cancer, a marker of quality care.
  
  
  METHODS
  Observational prospective survey study was performed in a population-based cohort of Medicare beneficiaries who underwent incident invasive breast cancer surgery, linked to Medicare claims, state tumor registries, American Hospital Association Annual Survey Database, and American Medical Association Physician Masterfile. Multiple logistic regression models determined surgeon and hospital characteristics that were predictors of SLNB.
  
  
  RESULTS
  Of the 1703 women treated at 471 different hospitals by 947 different surgeons, 65% underwent an initial SLNB. Eleven percent of hospitals were high-volume and 58% had a high commitment to cancer care. In separate adjusted models, both high HC (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.12-2.10) and high hospital volume (HV, OR 1.90, 95% CI 1.28-2.79) were associated with SLNB. Adding surgeon factors to a model including both HV and HC minimally modified the effect of high HC (OR 1.34, 95% CI 0.95-1.88) but significantly weakened the effect of high HV (OR 1.25, 95% CI 0.82-1.90). Surgeon characteristics (higher volume and percentage of breast cancer cases) remained strong independent predictors of SLNB, even when controlling for various hospital characteristics.
  
  
  CONCLUSIONS
  Hospital factors are associated with receipt of SLNB but surgeon factors have a stronger association. Since regionalization of breast cancer care in the U.S. is unlikely to occur, efforts to improve the surgical care and outcomes of breast cancer patients must focus on optimizing patient access to SLNB by ensuring hospitals have the necessary resources and training to perform SLNB, staffing hospitals with surgeons who specialize/focus in breast cancer and referring patients who do not have access to SLNB to an experienced center.
authors: Department of Surgery, Division of Surgical Oncology Division of Biostatistics Department of Medicine Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA.
authors: Tina W F
authors: TWF
authors: Yen
authors: Jianing
authors: J
authors: Li
authors: Rodney A
authors: RA
authors: Sparapani
authors: Purushuttom W
authors: PW
authors: Laud
authors: Ann B
authors: AB
authors: Nattinger
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D001943:Breast Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D002983:Clinical Competence; D005260:Female; D006761:Hospitals; D006801:Humans; D033183:Interdisciplinary Communication; D008875:Middle Aged; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D018570:Risk Assessment; D000071036:Sentinel Lymph Node / Q000473:pathology; D021701:Sentinel Lymph Node Biopsy / Q000706:statistics & numerical data*; D013043:Specialties, Surgical / Q000639:trends; D011795:Surveys and Questionnaires; D017741:Survivors; D014481:United States