Utilization and quality outcomes of cT cT 1a, cT cT 1b and cT cT 2a partial nephrectomy: analysis of the national cancer database

摘要

Objective To describe the utilization and compare quality outcomes of partial nephrectomy ( PN ) for cT 1a, cT 1b and cT 2a renal masses using a large national database. Methods We conducted a retrospective analysis of patients from the US National Cancer Database who underwent PN for cT 1a/ cT 1b/T2a renal cell carcinoma between 2004 and 2013. We examined the use of PN over time and assessed quality indicators [positive surgical margin ( PSM ) and 30‐day postoperative readmission rates]. Multivariable analysis was conducted to determine predictors for outcome comparisons. Results A total of 43 749 patients underwent PN for cT 1a, cT 1b and cT 2a renal masses ( cT 1a, n = 34 796; cT 1b, n = 8 040; cT 2a, n = 913). The proportion of patients undergoing PN increased from 30.8% in 2004 to 56.7% in 2013 ( P 0.001), and this trend was apparent for all clinical stages. The PSM rate was 6.8%. Predictive factors for increased risk of PSM s included cT 1a stage ( P = 0.03), age [odds ratio ( OR ) 1.01; P 0.001] and later year of diagnosis ( OR : 1.05; P 0.001). The 30‐day readmission rate was 4.2%. Predictive factors for increased risk of readmission included cT 1b ( P 0.001), high Charlson comorbidity score ( OR : 1.32; P = 0.001) and lack of private insurance ( OR : 1.21–1.97; P 0.05); later year of diagnosis was associated with decreased odds of readmission ( OR : 0.96; P 0.001). Subset analysis of the 2010–2013 cohort showed increases in the proportion of minimally invasive PN for cT 1a (52.8–69.6%; P 0.001), cT 1b (39.9–59.6%; P 0.001) and cT 2a tumours (33.3–47.3%; P = 0.01). The PSM rate was also increased, at 7.3%. Predictive factors for PSM s included increasing age ( OR : 1.01; P 0.001), minimally invasive surgical approach ( OR : 1.52; P 0.001), and conversion to open surgery ( OR : 1.52; P = 0.01), but not clinical stage ( P = 0.75–0.99). The 30‐day readmission rate was 4.0%. Predictive factors for readmission included lack of private insurance ( P 0.001) and conversion to open surgery (OR: 1.63; P 0.001). Conclusion The use of PN has increased significantly over time for all clinical stage groups. PSM rates increased, while 30‐day readmission rates decreased. The PSM rate increase was driven by increasing use of minimally invasive approaches, and not by higher clinical stage. The 30‐day readmission rate was driven by patient comorbidities and socio‐economic factors. Rising PSM rates represent a quality‐of‐care concern.