Assessing Cost of Robotic Utilization in Partial Nephrectomy with Increasing Utilization.

PURPOSE: To evaluate trends in utilization of robotic assistance in partial nephrectomy (PN) and assess the association between cost and utilization. PATIENTS AND METHODS: Using the 2009-2012 Nationwide Inpatient Sample database, we identified all adult (>17 years) patients undergoing PN for localized primary renal malignancy. Coding for robotic assistance (17.4 × ) began in the final quarter of 2008. The primary outcome was total hospital cost exclusive of physician fees. A multiple linear regression model was used to adjust for patient and hospital characteristics. RESULTS: Between 2009 and 2012, there were 32,664 (58%) open, 3498 (6%) laparoscopic, and 20,350 (36%) robot-assisted partial nephrectomies performed in the United States. Between 2009 and 2012, the total number of partial nephrectomies semiannually increased by 93% (5114-9845) with robotic partial nephrectomies (RPNs) representing >80% of the increase. RPN increased from 1029 cases in the first half of 2009 to 4840 in the last half of 2012 and surpassed utilization of open nephrectomy. The proportion of all partial nephrectomies performed with robotic assistance increased from 20% to 49% during the same period. After adjusting for demographics, Charlson comorbidity index, and hospital region, RPN went from $1,464 (p = 0.009) more than open in 2009 to $456 (p = 0.28) less than open in 2012. CONCLUSIONS: Utilization of RPN surpassed open in 2012 in the United States. The difference in cost between the robotic and open approaches decreased during the study period and by 2011 was not statistically different.

Reducing Operating Room Costs Through Real-Time Cost Information Feedback: A Pilot Study.

PURPOSE: To create a protocol for providing real-time operating room (OR) cost feedback to surgeons. We hypothesize that this protocol will reduce costs in a responsible way without sacrificing quality of care. METHODS: All OR costs were obtained and recorded for robot-assisted partial nephrectomy and laparoscopic donor nephrectomy. Before the beginning of this project, costs pertaining to the 20 most recent cases were analyzed. Items were identified from previous cases as modifiable for replacement or omission. Timely feedback of total OR costs and cost of each item used was provided to the surgeon after each case, and costs were analyzed. RESULTS: A cost analysis of the robot-assisted partial nephrectomy before the washout period indicates expenditures of $5243.04 per case. Ten recommended modifiable items were found to have an average per case cost of $1229.33 representing 23.4% of the total cost. A postwashout period cost analysis found the total OR cost decreased by $899.67 (17.2%) because of changes directly related to the modifiable items. Therefore, 73.2% of the possible identified savings was realized. The same stepwise approach was applied to laparoscopic donor nephrectomies. The average total cost per case before the washout period was $3530.05 with $457.54 attributed to modifiable items. After the washout period, modifiable items costs were reduced by $289.73 (8.0%). No complications occurred in the donor nephrectomy cases while one postoperative complication occurred in the partial nephrectomy group. CONCLUSION: Providing surgeons with feedback related to OR costs may lead to a change in surgeon behavior and decreased overall costs. Further studies are needed to show equivalence in patient outcomes.

Changing USA national trends for adrenalectomy: the influence of surgeon and technique.

OBJECTIVE: To explain differences over time between operative approach and surgeon type for adrenal surgery in the USA. PATIENTS AND METHODS: A retrospective cohort analysis was performed on all patients undergoing adrenalectomy between 2002 and 2011 using the Nationwide Inpatient Sample. Patients undergoing concurrent nephrectomy were excluded. Surgeon specialty was only available for 2003-2009. Descriptive analyses and multivariable logistic regression models were used to assess variables associated with minimally invasive surgery (MIS) and urologist-performed procedures. RESULTS: In all, 58,948 adrenalectomies were identified. A MIS approach was used in 20% of these operations. There was a 4% increase in MIS throughout the study period (P < 0.001). Cases performed at teaching hospitals were more likely to be MIS (odds ratio [OR] 1.47, P < 0.001). We were able to identify surgical specialty in 23,746 cases, of which 60% were performed by urologists. Cases performed in the Midwest compared with Northeast were at increased adjusted odds of being performed by urologists (OR 1.38, P = 0.11). Despite most cases being performed by urologists, adrenalectomy by urologists showed a 15% annual decrease over the analysed period (P < 0.001). CONCLUSIONS: The use of a MIS technique to perform adrenalectomy is increasing at a slower rate compared with most other surgical extirpative procedures. Further investigation to explain the decreased performance of adrenalectomy by urologists is warranted.

The impact of hospital volume on postoperative complications following robot-assisted partial nephrectomy.

PURPOSE: We sought to evaluate the relationship between hospital volume and postoperative complications following robot-assisted partial nephrectomy (RAPN) using the Nationwide Inpatient Sample. MATERIALS AND METHODS: We identified patients undergoing RAPN between 2009 and 2011. Hospitals were divided into volume-based tertiles for each year (high, medium, low). Descriptive analyses were performed using Pearson's chi-squared and Student's t-test. Multivariable logistic regression assessed the association between hospital volume and postoperative complications, adjusting for age, gender, hospital region, type of hospital, primary payer, comorbidities, and kidney cancer. RESULTS: We identified 17,583 cases from 323 hospitals, of which 112 were low volume, 112 medium volume, and 99 high volume. 13,645 (78%) cases were performed at high-volume institutions. Eleven percent of patients developed an in-hospital postoperative complication, with 15% at low-volume, 12% at medium-volume, and 10% at high-volume hospitals (p=0.071). In addition, blood transfusion was less common at high-volume hospitals (p=0.015). On multivariable logistic regression, high-volume hospitals had 42% decreased odds of postoperative in-hospital complications (95% confidence interval 0.37-0.90; p=0.016). Complications were associated with a $4500 increase in hospital costs. CONCLUSIONS: High-volume hospitals are associated with decreased blood transfusions and complications. With the recognition that high-volume RAPN hospitals are independently associated with improved clinical outcomes, further studies should be performed to determine the role of the hospital and surgeon volume thresholds in the performance of RAPN.

Does robotic assistance confer an economic benefit during laparoscopic radical nephrectomy?

PURPOSE: While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit. MATERIALS AND METHODS: From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique and those with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges. RESULTS: We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001). CONCLUSIONS: Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy.

Economic and utilization analysis of robot-assisted versus laparoscopic live donor nephrectomy.

BACKGROUND: Reports of robot-assisted live donor nephrectomies (LDNs) have been emerging in the literature. We sought to examine the national incidence of robot-assisted LDNs and to assess regional use and economic differences in robot-assisted versus laparoscopic LDN. METHODS: Data from the Nationwide Inpatient Sample (NIS) were used to identify patients who underwent either laparoscopic or robot-assisted LDN between 2009 and 2011. Descriptive analysis was performed to examine differences between the laparoscopic and robot-assisted groups. RESULTS: A total of 4,163 cases of LDN were performed using robot-assistance or pure laparoscopic surgery between 2009 and 2011. Of these, 142 were classified as robot-assisted nephrectomies; these cases were all from the western United States. There was no difference in the incidence of complications between the laparoscopic and robot-assisted groups (P=0.206). Median (interquartile range [IQR]) total charges for robot-assisted LDN were $48,639 ($42,380-$53,050) vs $37,019 ($28,715-$48,816) for laparoscopic cases (P<0.001). CONCLUSIONS: The role of robotic assistance in LDN remains to be determined; we identified no benefits to robotic assistance in our study.

Trends in robot-assisted laparoscopic pyeloplasty in pediatric patients.

OBJECTIVE: To evaluate the incidence of pediatric robotic-assisted laparoscopic pyeloplasties (RALPs) and to determine if there were regional or age-related trends associated with the performance of RALP. METHODS: Using 2005-2010 data from the Nationwide Inpatient Sample (NIS), the incidence of and trends in pyeloplasty in patients less than 18 years of age were assessed. This was broken down by open, laparoscopic, and robotic techniques when possible. Multiple logistic regression determined which characteristics were associated with increased performance of RALP. Population weighting was used to estimate national rates. RESULTS: A total of 15,498 pediatric pyeloplasties were performed between 2005 and 2010. Coding for robotics began at the end of 2008, and, since then, 750 of the 5557 pediatric pyeloplasties were robotic. The rate of RALP remained unchanged from 2008-2010 (odds ratio [OR] 0.93, P = .051); however, there was an overall increase in minimally invasively procedures (RALP or laparoscopic) since 2005 (OR 1.4, P <.001). Factors associated with increased performance of RALP were aged above 11 years (OR 50.3, P <.001) and living in the northeast (OR 3.0, P = .001), midwest (OR 2.9, P = .001), or west (OR 4.31, P <.001) compared with the south. CONCLUSION: An estimated 750 robotic pyeloplasties were performed in the United States between the end of 2008 and 2010. There was an increase in the total number of pyeloplasties performed using minimally invasive techniques since 2005. Older children are more likely and patients living in the south are less likely to be treated with robotic assistance.