title: High volume is the key for improving in-hospital outcomes after radical prostatectomy: a total population analysis in Germany from 2006 to 2013.
abstract: OBJECTIVE
  Outcomes of radical prostatectomy are prone to publication bias, because most of the data originated from highly specialized centers. We assessed in-hospital outcomes of all radical prostatectomies in Germany from 2006 to 2013 focusing on caseload volume, surgical approach, and certification status.
  
  
  METHODS
  We analyzed the nationwide German hospital billing data covering 221,331 radical prostatectomies from 2006 to 2013. Outcomes were in-hospital mortality, surgical revision, and transfusion rates and the length of stay. Multivariate models described the impact of these factors.
  
  
  RESULTS
  The yearly number of radical prostatectomies declined from 28,374 to 21,850. While shares of all other approaches decreased, shares for robot-assisted prostatectomy increased from 0.6 to 25.2%. Hospitals with ≥100 cases a year reported lower in-hospital mortality with 0.08 versus 0.17% for hospitals with <50 cases a year. On multivariate analysis, the odds for an individual death were doubled in hospitals with <50 cases a year. All other factors showed no significant impact on mortality. Concerning blood transfusion, the surgical approach was the strongest predictor with minimally invasive surgery (26% of the odds of conventional surgery) followed by caseload volume. Surgical revision was frequent in hospitals with lower rates of minimally invasive approaches (OR 1.6) and smaller caseloads (OR 1.4). Length of stay was reduced by 3 days for caseloads ≥200 a year, 2 days with minimally invasive approaches, and 1 day in certified prostate cancer centers. Lacking clinical information is a major limitation.
  
  
  CONCLUSIONS
  Annual caseload volume of hospitals is the most important factor for improved in-hospital outcomes.
authors.affiliation: Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany. christer.groeben@uniklinikum-dresden.de.
authors.forename: Christer
authors.initials: C
authors.lastname: Groeben
authors.affiliation: Department of Medical Statistics and Biometry, Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany.
authors.forename: Rainer
authors.initials: R
authors.lastname: Koch
authors.affiliation: Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Baunacke
authors.affiliation: Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
authors.forename: Manfred P
authors.initials: MP
authors.lastname: Wirth
authors.affiliation: Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
authors.forename: Johannes
authors.initials: J
authors.lastname: Huber
mesh_terms: D000368:Aged; D005858:Germany / Q000453:epidemiology; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology / Q000628:therapy; D011467:Prostate / Q000473:pathology / Q000601:surgery*; D011468:Prostatectomy / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D011471:Prostatic Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures
keywords: Caseload; Health services research; Prostate cancer; Prostatectomy; Robotics