An evaluation of radical prostatectomy at Veterans Affairs Medical Centers- Time trends and geographic variation in utilization and outcomes

OBJECTIVE. TO examine temporal trends and geographic variation in utilizati on of radical prostatectomy (RP) as well as 30-day mortality and complicati on rates. DESIGN. Administrative data-base study of radical prostatectomy (RP) using the Department of Veterans Affairs Patient Treatment File and Outpatient Cl inic File between 1986 to 1996. Logistic regression was used to estimate te mporal and geographic effects on the use of RP. SETTING. All Departments of Veterans Affairs Medical Centers (VAMC) in the contiguous United States. PATIENTS. Men aged 45 to 84 years who underwent RP at a VAMC (n = 13,368). MAIN OUTCOME MEASURES. Number and utilization of RP, rate of 30-day mortali ty, major cardiopulmonary or vascular complications, and colorectal injurie s requiring surgical repair within 30 days of RP. RESULTS, From 1986 to 1996, the annual number of RP at VAMCs (range, 695-1, 545 RP) more than doubled, and the rate of RP at VAMCs per male VA user inc reased by 40% (range, 48/100,000-66/100,000); After controlling for age and year,the utilization of RP in West North Central, Mountain, West South Cen tral, and Pacific census divisions was 70%, 14%, 10%, and: 8% higher, respe ctively, whereas the utilization of RP in New England East North Central,an d Mid-Atlantic divisions was 38%, 31%, and 25% lower, respectively, than th e rest of the nation (P < 0.001). Geographic variation in utilization decre ased during the period between 1986 and 1996, but a twofold difference in R P utilization in 1996 remained between high- and low-utilization divisions. Major cardiopulmonary complications, vascular complications, and colorecta l injuries occurred in 1.7%, 0.2%, and 1.8% of men, respectively. Thirty-da y mortality was 0.73%, declined from 1986 to 1996, and was associated with a history of diabetes and congestive heart failure. CONCLUSION. Utilization of RP at VAMCs increased over time and varied acros s geographic areas. Thirty-day mortality was less than 1% and decreased wit h time. Differences in utilization may be caused by uncertainty regarding t he effectiveness of early detection and treatment of prostate cancer.