Variations in Stress Incontinence and Prolapse Management by Surgeon Specialty Jennifer T. Anger,* Mark S. Litwin, Qin Wang, Chris L. Pashos and Larissa V. Rodríguez From the Departments of Urology (JTA, MSL, LVR) and Health Services (MSL), David Geffen School of Medicine and School of Public Health, University of California-Los Angeles, Los Angeles, California, and Abt Associates, Inc. (QW, CLP), Cambridge, Massachusetts Purpose: Numerous studies have documented a relationship between provider specialty and outcomes for surgical proce- dures. In this study we sought to determine the effect of surgeon specialty on outcomes of sling surgery for women with stress urinary incontinence. Materials and Methods: We analyzed the 1999 to 2001 Medicare claims data from a 5% national random sample of Medicare beneficiaries. Women 65 years or older who underwent a sling procedure between July 1, 1999 and December 31, 2000 were identified on the basis of CPT-4 codes and tracked for 12 months. Key complications were identified using CPT-4 and ICD-9 revision codes for relevant procedures and diagnoses. Outcomes were compared between urologists and gynecol- ogists. Results: A total of 1,356 sling procedures were performed. Of them 1,063 (78.4%) were performed by urologists, while 246 (18.1%) were performed by gynecologists. Urologists performed concomitant prolapse repairs in 29.1% of cases, and gyne- cologists performed prolapse repairs in 55.7% (p 0.0001). In the 12 months following sling surgery, urologists were more likely than gynecologists to perform a repeat incontinence procedure (9.3% vs 4.9%, p = 0.024) and prolapse repair (26.0% vs 12.2%, p 0.0001). The 2 surgical specialties did not differ in postoperative outlet obstruction, urological complications, or nonurological complications. Conclusions: Early prolapse management by gynecologists corresponded to fewer prolapse repairs in the year following the sling. Our findings suggest that gynecologists are more likely to identify and manage prolapse at the time of the evaluation of urinary incontinence, a strategy that appears to avoid the morbidity and cost of repeat surgery. Key Words: urinary incontinence, stress; prolapse; female; outcome assessment, health care; specialties, medical U rinary incontinence among women is commonly as- sociated with pelvic organ prolapse, and it is esti- mated that 1 of 10 women undergoes surgical treatment in their lifetime for these disorders. 1 In addi- tion, 1 of 3 women treated surgically for incontinence or prolapse require at least 1 additional surgery for recur- rence of the problem. 1 The surgical approach chosen to treat these disorders is varied. Although slings, along with the Burch procedure, are considered by many to be the gold standard in the surgical management of stress urinary incontinence, data on complication rates after sling surgery have historically been derived from retro- spective studies of clinical subjects with a large focus on continence outcomes and surgical complications. 2,3 Few rigorous health services research studies have evaluated patient outcomes after sling surgery and other procedures for stress urinary incontinence. 4,5 To date, little is known about the effect of provider or physician characteristics on patient outcomes. Numerous studies have documented a relationship be- tween provider specialty and outcomes for surgical proce- dures. 6–8 Patients with cutaneous melanoma treated by dermatologists have significantly better survival than those treated by general or plastic surgeons. 8 In addition, patients with ovarian cancer treated by gynecologic oncologists have been shown to have marginally better outcomes than those treated by general gynecologists and clearly superior out- comes than patients treated by general surgeons. 9 In addi- tion to specialty, fellowship training in surgical subspecial- ties has also been shown to impact patient outcomes in high risk surgery. 6,7,10 Vascular surgeons have lower in hospital mortality rates than neurosurgeons or general surgeons af- ter carotid endarterectomy. 10 At least part of the impact of surgeon specialty on outcomes may be explained by surgeon volume, since subspecialists are more likely to perform a large number of such procedures, and thereby develop more effective skills, ie the so-called practice makes perfect phe- nomenon. 11,12 To our knowledge the influence of provider specialty on the decision to perform prolapse repair at the time of sling procedure has not been established. Since stress urinary incontinence frequently occurs in conjunction with pelvic organ prolapse, slings may be performed in combination with 1 or more prolapse procedures. Although patients with Submitted for publication February 28, 2007. Supported by an American Urological Association Foundation, Inc. Health Policy Award, National Institute of Diabetes and Diges- tive and Kidney Diseases Individual National Research Service Award 1 F32 DK072874-01 and a fellowship grant from the Kidney and Urology Foundation of America, Inc. * Correspondence: Department of Urology, University of Califor- nia-Los Angeles, 1260 15th St., Suite 1200, Santa Monica, Califor- nia 90404 (telephone: 310-451-8751; FAX: 310-394-5302; e-mail: janger@mednet.ucla.edu). Outcomes/Epidemiology/Socioeconomics 0022-5347/07/1784-1411/0 Vol. 178, 1411-1417, October 2007 THE JOURNAL OF UROLOGY ® Printed in U.S.A. Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2007.05.149 1411