Variability in surgical management of kidney cancer between urban and rural hospitals in Queensland, Australia: a population-based analysis

Background: International guidelines recommend partial over radical nephrectomy for management of kidney tumours, due to perceived advantages of kidney function preservation. In Queensland, oncological nephrectomy is performed in both metropolitan and rural hospitals. Previous studies have shown that patients from rural areas with kidney tumours are less likely to undergo partial nephrectomy compared with those in major cities. The aim of this study was to investigate patterns of partial nephrectomy according to geographical area, and to identify patient- and health-service-level characteristics associated with partial nephrectomy. Methods: All 3,799 incident kidney cancer cases in Queensland (Jan 2009 to Dec 2014) were ascertained. Patients aged <18 yrs (n=47), who did not receive surgery (n=988), or had end-stage kidney disease (ESKD) before surgery (n=17) were excluded. The final sample included 2,747 patients. Data were analysed using multivariable logistic regression in order to identify associations with partial nephrectomy. Results: Of 2,747 patients, 637 (25%) underwent partial nephrectomy. The likelihood of undergoing partial nephrectomy increased with more recent year of surgery (P<0.001) and higher socioeconomic status (P<0.001). The likelihood of undergoing partial nephrectomy decreased for patients managed in lower-volume centres (P=0.004), with increasing age (P<0.001), and hospital location outside of a major city (P<0.001). Overall, the number of nephrectomies, and proportion/number of partial nephrectomies, performed in rural hospitals has increased over the study period. Conclusions: Our results suggest that, although patients who are managed in major cities are more likely to undergo partial nephrectomy, likelihood of undergoing partial nephrectomy in rural centres is increasing, consistent with international best practice.