Use of initial nephrectomy, radical prostatectomy, and pancreatectomy is higher in the United States and Australia compared with Canada and generally increases with neighborhood income, investigators reported in JAMA Network Open.
Investigators chose 3 representative areas in these countries for comparison — New York State, New South Wales, and Ontario, respectively — because of the large populations, racial and ethnic diversity, and close geopolitical ties.
New York had the highest use of nephrectomy at 28.93 procedures per 100,000 residents per year, followed by 23.03 and 21.40 per 100,000 residents per year in New South Wales and Ontario, respectively, Peter Cram, MD, MBA, of Toronto General Hospital in Toronto, Ontario, Canada, and colleagues reported. New South Wales had the highest use of pancreatectomy (6.94 vs 6.68 and 6.18 procedures per 100,000 residents per year in New York and Ontario, respectively) and radical prostatectomy (94.37 vs 54.01 and 49.24 procedures per 100,000 residents per year in New York and Ontario, respectively).
According to Dr Cram’s team, the differences in surgical utilization rates likely reflect differences in care among these countries, starting with cancer screening practices, supply of surgeons, hospital operating room capacity, and preferences for surgical and nonsurgical treatment of prostate cancer. Unlike the United States, both Canada and Australia have government-sponsored insurance programs that cover all residents. Supplemental private insurance is allowable in Australia, yielding a public-private hybrid in that country.
Importantly, the investigators found significantly higher utilization of all 3 surgical procedures among residents from the highest vs lowest income neighborhoods in all 3 countries (with the exception of nephrectomy in Ontario).
In New York, for example, the nephrectomy standardized utilization rate was 34.78 and 26.35 procedures per 100,000 residents per year in neighborhoods with the highest vs lowest 20% of income. Radical prostatectomy use was 70.26 and 50.56 procedures per 100,000 residents per year, respectively. Pancreatectomy use was 8.88 vs 5.83 procedures per 100,000 residents per year, respectively. Residents of New York neighborhoods with the highest 20% of income had 32%, 39%, and 52% greater use of nephrectomy, radical prostatectomy, and pancreatectomy, respectively, compared with residents of neighborhoods in the bottom 20% of income, the investigators reported.
“There are many reasons to interpret existing data as evidence of surgical underuse for patients with lower income, particularly in the US, where employer-based insurance is common,” Dr Cram and his collaborators wrote. “At the same time, there is growing concern that at least part of wealth-based differences in utilization may represent overuse of certain treatments that are at best unnecessary and at worst harmful.”
Pang HYM, Chalmers K, Landon B, et al. Utilization rates of pancreatectomy, radical prostatectomy, and nephrectomy in New York, Ontario, and New South Wales, 2011 to 2018. Published online April 19, 2021. JAMA Netw Open. doi:10.1001/jamanetworkopen.2021.5477