In Reply We appreciate both responses to our Original Investigation,1 as well as the fact that they are from urological surgeons in Canada and the United Kingdom. We hope all surgeons will agree with the need for more conservative, risk-based strategies for small renal masses.
At the same time, we recognize there are real barriers to such strategies. In the United States and Canada, fee-for-service remains the dominant payment system, and nephrectomies (as well as ablations) produce more revenue than surveillance. Even salaried surgeons may face strong incentives to perform surgery because they are constantly reminded that the hospitals they work for are rewarded for increased volumes.
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Welch HG, Schroeck FR. Uncoupling Diagnosis and Treatment of Incidentally Imaged Renal Masses—Reply. JAMA Intern Med. 2018;178(5):729. doi:10.1001/jamainternmed.2018.1183
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