The Role of Provider Volume on Outcomes After Sling Surgery for Stress Urinary Incontinence
Published in: The Journal of Urology, v. 177, no. 4, Apr. 2007, p. 1457-1462
Posted on RAND.org on December 31, 2006
PURPOSE: Studies of various surgical procedures have documented a relationship between provider volume and outcomes, suggesting that providers who perform a high volume of procedures provide better quality of care. The authors ascertained whether this relationship held in sling surgery for urinary incontinence. MATERIALS AND METHODS: The authors analyzed the 1999 to 2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services for a 5% national random sample of beneficiaries. Women undergoing pubovaginal sling procedures between July 1, 1999 and December 31, 2000 (the index period) were identified and followed for 12 months. The number of slings performed was stratified empirically by cumulative surgeon volume. Main outcomes measures included postoperative complications, concomitant or delayed prolapse repair, outlet obstruction and repeat incontinence surgery. RESULTS: Among the 5% of Medicare beneficiaries analyzed during the index period 1,356 sling procedures were performed. This extrapolates to 27,120 slings in the entire Medicare population. High volume providers (upper 24th percentile) performed significantly more prolapse repairs at the time of sling surgery than did low volume providers (40.8% vs 32.4%, p <0.006). Subsequently low volume providers performed almost twice the number of prolapse repairs during the first postoperative year following the index sling procedure (p <0.0001). There was no significant difference in complication rates or repeat anti-incontinence procedures between high and low volume providers. CONCLUSIONS: High volume surgeons were more likely to perform concomitant prolapse surgery at the time of sling surgery, whereas low volume providers had higher reoperation rates to correct prolapse during the first postoperative year. This suggests that high volume providers are more likely to diagnose and manage prolapse at the time of the sling, obviating the need for a second operation.