The Relationship Between Surgeon Technical Skill and Healthcare Costs in Partial Nephrectomy

Introduction: There has been increasing interest in assessing the surgical performance of practicing surgeons. There is a growing body of literature linking a surgeon’s technical skill to short-term post-operative complications. However, little research has been performed examining technical skill and patient safety, and no research has examined the relationship between technical performance and hospital cost. The primary purpose of this thesis is to determine the relationship between direct, 30-day hospital costs and surgeon technical skill in open and robotic partial nephrectomy. Methods: We performed four studies: a systematic review examining the literature on intraoperative adverse events and costs, a prospective, multicenter, multi-surgeon study examining the relationship between direct, 30-day hospital costs and surgeon technical skill, and a prospective, multicenter, multi-surgeon study comparing the rates of intraoperative events between open and robotic partial nephrectomy. Finally, we performed a cost utility analysis to compare the cost effectiveness of open partial nephrectomy to robotic partial nephrectomy. Results: Four research studies were completed. Our systematic review found that while the overall quality of the current literature was poor, intraoperative events increase the cost of abdominal surgery. For our surgical safety study, open partial nephrectomy has a greater number of severe intraoperative events than robotic partial nephrectomy. When comparing the costs between surgeons of differing skill levels, surgeons with higher levels of technical skill cost less than surgeons with lower levels of skill. Finally, at a Willingness to Pay (WTP) of $200,000/QALY, open partial nephrectomy is the most cost effective option, although robotic partial nephrectomy becomes cost effective when the fixed robotic costs are below$3,330 per case. Conclusion: We are the first to study the relationship between surgeon performance and short-term hospital costs. While future studies need to confirm our findings, our results highlight the possibility of financial benefit from improving surgeon performance. Furthermore, we conclude that the robotic platform may improve intraoperative patient safety and intraoperative event assessment may be useful in providing individualized feedback.Ph.D

The relationship between sperm viability and DNA fragmentation rates

Abstract Background In humans, sperm DNA fragmentation rates have been correlated with sperm viability rates. Reduced sperm viability is associated with high sperm DNA fragmentation, while conversely high sperm viability is associated with low rates of sperm DNA fragmentation. Both elevated DNA fragmentation rates and poor viability are correlated with impaired male fertility, with a DNA fragmentation rate of > 30% indicating subfertility. We postulated that in some men, the sperm viability assay could predict the sperm DNA fragmentation rates. This in turn could reduce the need for sperm DNA fragmentation assay testing, simplifying the infertility investigation and saving money for infertile couples. Methods All men having semen analyses with both viability and DNA fragmentation testing were identified via a prospectively collected database. Viability was measured by eosin-nigrosin assay. DNA fragmentation was measured using the sperm chromosome structure assay. The relationship between DNA fragmentation and viability was assessed using Pearson’s correlation coefficient. Results From 2008-2013, 3049 semen analyses had both viability and DNA fragmentation testing. A strong inverse relationship was seen between sperm viability and DNA fragmentation rates, with r = -0.83. If viability was ≤ 50% (n = 301) then DNA fragmentation was ≥ 30% for 95% of the samples. If viability was ≥ 75% (n = 1736), then the DNA fragmentation was ≤ 30% for 95% of the patients. Sperm viability correlates strongly with DNA fragmentation rates. Conclusions In men with high levels of sperm viability ≥ 75%, or low levels of sperm viability ≤ 30%, DFI testing may be not be routinely necessary. Given that DNA fragmentation testing is substantially more expensive than vitality testing, this may represent a valuable cost-saving measure for couples undergoing a fertility evaluation