Surgical Quality Is More Than Volume: The Association between Changing Urologists and Complications for Patients with Localized Prostate Cancer

Identifying factors associated with surgical quality is important for helping patients receive better care. Patients treated by higher volume surgeons have, on average, better surgical outcomes (Halm, Lee, and Chassin 2002; Hu et al. 2003; Wilt et al. 2008; Eastham 2009; Barocas et al. 2010). However, not all men receive their care from high-volume surgeons (Bianco et al. 2005; Putt et al. 2009; Pollack et al. 2011; Al-Refaie et al. 2012), and many patients seeing low-volume surgeons have good surgical outcomes. While surgical volume is one indicator of quality, it does not fully explain the variation in surgical outcomes. Previous studies of physician characteristics such as board certification and medical malpractice claims have reported weak or no association with quality of care and clinical outcomes (Chen et al. 2006; Reid et al. 2010). In this article, we seek to examine a process that may reflect surgical quality. In particular, we ask whether patients who have a different surgeon for their initial diagnosis and their definitive surgical procedure—patients who have changed surgeons—have lower rates of complications. Our underlying hypothesis is that changing surgeons is unlikely to be a random process and may instead be a “signal” about surgical quality. Previous work on patterns of care suggests that physician selection, and by extension surgeon changing, is a complex decision-process (Shortell 1973; Forrest et al. 2001, 2006; Kinchen et al. 2004; Mukamel, Weimer, and Mushlin 2006; Mehrotra, Forrest, and Lin 2011). Surgeon selection may rely upon a number of sources of information (including a referral from the primary care provider, other surgeons, patient or family, other patients) and types of evidence (e.g., surgical volume, “best” doctor lists, anecdotes, and other quality metrics). Existing work stresses the important role that referring physicians play in determining from whom patients receive care (Harris 2003; Mukamel, Weimer, and Mushlin 2006; Bouche et al. 2008; Barnett et al. 2012), although a small portion of patients will choose their physician primarily on the advice of friends or family or proximity to home (Harris 2003; Katz et al. 2007). The process of surgeon selection and changing remains poorly understood. We use prostate cancer as a case study for examining these care patterns. It is the second most common form of cancer among men, affecting an estimated 238,590 men in the United States during 2013 (Siegel, Naishadham, and Jemal 2013); radical prostatectomy is commonly performed for men with localized disease (Siegel et al. 2012); and complications—including 30-day surgical complications, late urinary complications, and long-term incontinence—occur in a large percentage of men and have been associated with surgical volume (Begg et al. 2002; Hu et al. 2003). Given a substantial proportion of men with localized prostate cancer have a different diagnosing and treating urologist (Pollack et al. 2011), we sought to examine whether changing urologists is associated with surgical complications following radical prostatectomy. Furthermore, because black men are significantly less likely to change urologists for radical prostatectomy than white men (Pollack et al. 2011) and with the large disparities that have been documented in prostate cancer outcomes (Peters and Armstrong 2005; Siegel et al. 2011), we then tested whether changing urologists is differently associated with surgical outcomes among black and white men.