Trends in radical prostatectomy: centralization, robotics, and access to urologic cancer care

Abstract

Background: Robotic surgery has been widely adopted for radical prostatectomy. We hypothesized that this change is rapidly shifting procedures away from hospitals that do not offer robotics and consequently increasing patient travel.

Methods: A population-based observational study of all prostatectomies for cancer in New York, New Jersey, and Pennsylvania from 2000 to 2009 was performed using hospital discharge data. Hospital procedure volume was defined as the number of prostatectomies performed for cancer in a given year. Straight-line travel distance to the treating hospital was calculated for each case. Hospitals were contacted to determine the year of acquisition of the first robot.

Results: From 2000 to 2009, the total number of prostatectomies performed annually increased substantially. The increase occurred almost entirely at the very high-volume centers (≥ 106 prostatectomies/year). The number of hospitals performing prostatectomy fell 37% from 2000 to 2009. By 2009, the 9% (21/244) of hospitals that had very high volume performed 57% of all prostatectomies, and the 35% (86/244) of hospitals with a robot performed 85% of all prostatectomies. The median travel distance increased 54% from 2000 to 2009 (P<.001). The proportion of patients traveling ≥ 15 miles increased from 24% to 40% (P < .001).

Conclusions: Over the past decade, the number of radical prostatectomies performed has risen substantially. These procedures have been increasingly centralized at high-volume centers, leading to longer patient travel distances. Few prostatectomies are now performed at hospitals that do not offer robotic surgery.

Figure 1

Figure 1a. Total number of prostatectomies performed annually in NJ, NY, and PA, 2000–2009. Figure 1b. Total number of hospitals performing prostatectomy each year in NJ, NY, and PA, 2000–2009. During this time period, there were roughly 590–600 acute care hospitals in the study area.

Figure 1

Figure 1a. Total number of prostatectomies performed annually in NJ, NY, and PA, 2000–2009. Figure 1b. Total number of hospitals performing prostatectomy each year in NJ, NY, and PA, 2000–2009. During this time period, there were roughly 590–600 acute care hospitals in the study area.

Figure 2

Relationship between hospital prostatectomy volume and robot acquisition. Each dot represents a single hospital in a single year. Hospitals that acquired a robot during the study period are red. Those that never obtained a robot are blue. For the hospitals that acquired a robot, year 0 is the year that the robot was acquired. For the hospitals that never acquired a robot, year 2005 (midway through the study period) was designated as year 0. The fitted curves show the trends in prostatectomy volume.

Figure 3

Median distance traveled in miles from patient home to hospital where prostatectomy was performed.

Figure 4

Figure 4a. Geographic location, by zip code, of US hospitals with robots in 2010. (Not shown: There are two hospitals with robots in Alaska, both in the same zip code in Anchorage. There are two hospitals with robots in Hawaii, both in Honolulu but in different zip codes.) Figure 4b. Geographic location, by zip code of hospitals with robots in NJ, NY, and PA in 2010.

Figure 4

Figure 4a. Geographic location, by zip code, of US hospitals with robots in 2010. (Not shown: There are two hospitals with robots in Alaska, both in the same zip code in Anchorage. There are two hospitals with robots in Hawaii, both in Honolulu but in different zip codes.) Figure 4b. Geographic location, by zip code of hospitals with robots in NJ, NY, and PA in 2010.