Is surgical volume an indicator of patient outcomes in robotic surgery?

This blog follows up on the one I posted looking at the evolution of the surgical approach to prostatectomies in the UK leveraging the British Association of Urological Surgeons (BAUS) annual surveys

If you dig into the data a little bit deeper a number of interesting factors still stand out,

A small number of high volume surgeons do significantly more than others

On average the highest volume quartile of surgeons are doing just over 50% of the surgeries. The lowest volume quartile is only doing 6% of the surgeries. The difference means on average that surgeons in the top group will be doing around 132 procedures a year which is around 2.5 a week. At the other end, the surgeons will be doing 16 a year which is a little over one a month. 

It is interesting to note that the number of active surgeons increased between 2014 and 2016 then decreased in 2017 and 2018.  There are currently 147 active surgeons compared to a peak of 159 though the number of total procedures has increased during that period. During the same period, the number of surgeries carried out by the highest volume surgeon has increased from 152 to 368.

The number of surgeries will vary by surgical approach 

The table below shows that the concentration does vary by surgical approach.

Table showing percentage of total procedures carried out by the top quartiles by surgical approach 

As you can see that the volume is concentrated in fewer hands in the surgical approaches that have seen their market share decrease. This makes complete sense as high volume surgeons who are getting good results with one approach will often be the last to be willing to convert to a new technique. Newer surgeons are more likely to adopt the market-leading approach, in the case of robotics.

The table below shows that the number of procedures that the average surgeon will do in both the top and bottom quartile in 2018.

Also to help explain the numbers 109 surgeons only did one approach while 2 surgeons did all three and the remaining 36 did two of the approaches. If a surgeon for example only did 1 open procedure, he/she may have done 15 of another approach.

There have been a number of recent studies done that have looked at the impact on patients of differences in surgical skill. Most recently work being carried out by Andrew Hung from USC who has started to look at the relationship between APM’s (automated performance algorithms) and clinical outcomes. In a number of studies using this approach, he has been able to predict the amount of time patients will stay in the hospital and if there is a relationship between surgical technique and time to regain urinary continence.

While volume is not an indicator of surgical skill it is often accepted that higher volume surgeons are more likely to get better outcomes. Research is beginning to challenge this. The UK is an interesting position that has been capturing surgeon performance and outcome data for a number of years and it would be easier than other markets to see what is really driving patient outcomes and the role that volume may play?