Results in lower healthcare costs than open surgery after a year

Robotic-surgery appears to be a cost-effective option for performing radical prostatectomy. A retrospective cohort study showed that while at the time of hospitalization the costs associated with patients who underwent robotic-assisted radical prostatectomy were higher than those of patients who underwent open radical prostatectomy, those higher costs were offset by lower post-discharge health care use after the robot-assisted procedure.

The study, from Kennedy E. Okhawere, MD, MPH, Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, was published in JAMA Network Open.

“The long-term benefits of the robotic-assisted approach may offset the cost implication in the use of robotic surgery compared with the open approach if the cost of postoperative health care is properly evaluated (eg, prolonged hospital stay and cost of readmissions, management of postoperative complications, and the care setting),” wrote Okhawere and colleagues.

While open surgery is still commonly used in the treatment of prostate cancer, robotic-assisted prostatectomy has become the most frequently used approach in the U.S., with more than 70% of radical prostatectomy surgeries performed with robotic assistance since 2012. Previous studies have shown that the robotic approach to prostatectomy compared with open surgery reduces blood loss, results in shorter lengths of hospital stay, fewer intraoperative and postoperative complications, and better functional outcomes. However, these advantages come with higher financial costs.

In their study, Okhawere and colleagues compared long-term costs and health care use after surgery between robotic-assisted radical prostatectomy (RARP) and an open radical prostatectomy (ORP). They used the IBM MarketScan Commercial Claims and Encounter Database from January 1, 2013, to December 31, 2018. They identified 11,457 men, ages 18 to 64 years, who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after the surgery.

The study authors investigated 3 outcomes within 1 year after the inpatient prostatectomy: total health care costs, including reimbursement paid by insurers and out of pocket by patients; health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and estimated days missed from work due to health care use.

Of the 11,457 men in the study, 1,604 men (14.0%) underwent ORP and 9,853 (86.0%) underwent RARP. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (($26,504; 95% CI, $26,284-$26,726 versus $24,137; 95% CI, $23,642-$24,642), with a cost difference of $2,367 per prostatectomy.

Over time that cost difference narrowed, and became nonsignificant at 180 days (mean difference, $397; 95% CI, −$582 to $1,375) and ultimately favored RARP at 365 days (−$383; 95% CI, −$1,802 to $1,037).

In addition, patients who underwent RARP had fewer mean emergency department visits (−0.09; 95% CI, −0.11 to −0.07), fewer mean hospital outpatient visits (−1.5; 95% CI, −1.63 to −1.36;), and fewer office visits (−0.22; 95% CI, −0.41 to −0.03).

The reduction in health care use among patients in the RARP group translated into additional savings of $2,929 (95% CI, $1,600-$4, 257), with the greatest cost reduction seen in outpatient therapeutic radiologic expenditures (approximately $2,000 less in expenditures during the postsurgery period with RARP). RARP was also associated with 1.69 fewer days of missed work. “[C]ost analysis of RARP versus ORP should account for long-term savings instead of only initial up-front costs,” wrote Okhawere and colleagues. “These findings suggest that lower post-discharge health care use after robotic-assisted prostatectomy may offset the higher costs during the index hospitalization.”

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In a commentary accompanying the study, Bogdana Schmidt, MD, MPH, and John T. Leppert, MD, MS, both of Stanford University Medical School, Stanford, California, agreed that measuring the true cost of care requires calculating the cost of healthcare services over time and across locations.

“Okhawere et al present reassuring data that the adoption of robotic-assisted radical prostatectomy has not placed undue financial burdens on the system,” they wrote. “As urologists, we have the unique opportunity to innovate and improve care for our patients, and as clinicians, we have a responsibility to act as cost arbiters for the health care system.” And while they acknowledged that short-term costs must be considered, a “wide lens” must be maintained to improve value in surgical care.

Limitations of Okhawere and colleague’s study include its retrospective design, and the results “may not be generalizable to older, Medicare, Medicaid, or uninsured patients.”

  1. Robotic-assisted radical prostatectomy may be more costly at the time of surgery compared to open radical prostectomy, but that is offset by cost savings accrued in the post-surgery period.

  2. Radical prostatectomy was associated with much higher costs during the index hospitalization, but the cost difference was nonsignificant at 180 days after discharge and actually favored the robotic approach at 365 days.

Michael Bassett, Contributing Writer, BreakingMED™

None of the authors disclosed any relevant relationships.

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