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Determinants of the Adoption of Minimally Invasive Radical Prostatectomy in the United States
William D Ulmer1, Sandip Prasad2, Xiangmei Gu3, Stuart Lipsitz4, Jim C Hu5
1Harvard Medical School, Boston, MA;2University of Chicago Medical Center, Chicago, IL;3The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, Boston, MA;4The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA;5Division of Urologic Surgery, Brigham and Women's Hospital, Boston, MA

Minimally invasive radical prostatectomy (MIRP) with and without robotic-assistance has been rapidly adopted. However the relative influence of tumor, patient, surgeon, and hospital characteristics driving its use over conventional open radical prostatectomy (ORP) remains poorly characterized.
Materials & Methods:
Using Surveillance, Epidemiology and End Results-Medicare linked data, we identified 1,428 MIRP and 5,452 RRP during 2003-2005. We assessed the relative contribution of pathologic, demographic, surgeon and practice characteristics on utilization of MIRP vs. RRP.
In multilevel models for men undergoing prostatectomy, surgeon factors accounted for 87.9% of variance in the receipt of MIRP versus RRP. Hospital factors accounted for 77.9% of the variance. In partitioned multilevel models, unmeasured surgeon (78%) and patient (79.3%) factors explained largest amount of variance in the use of MIRP that was attributable to each. Surgeon age explained 15.4% of variance. Surgeons less than 40 vs. over 60 years of age were more likely to use MIRP (OR, 25.9; 95% CI, 3.2-209.8, p=0.002). Surgeon volume comprised only 0.07% of surgeon variance. Hospital bed size accounted for 10.9%. Demographics were the largest patient contributors to variance in MIRP use (6.1%) while tumor characteristics contributed very little.

While increased utilization of MIRP is primarily driven by surgeon and hospital factors rather than patient demographic or tumor characteristics, young surgeon age was a major contributor while surgeon volume contributed very little to use of MIRP, which is worrisome given that higher surgeon volume and experience are associated with better radical prostatectomy outcomes and lower costs.

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