Examining and Understanding Value: The Impact of Preoperative Characteristics, Intraoperative Variables, and Postoperative Complications on Cost of Robot-Assisted Laparoscopic Radical Prostatectomy.

Introduction and Objective: Quality-based reimbursement continues to gain popularity as value-based care becomes more prominent. Our goal is to describe the impact of preoperative characteristics, intraoperative variables, and postoperative complications on the cost of robot-assisted laparoscopic radical prostatectomy (RALP). Materials and Methods: Using our institution's National Surgical Quality Improvement Program (NSQIP) data, we identified minimally invasive prostatectomies performed from January 2012 to March 2017. A retrospective chart review was done to collect perioperative data; financial data were collected from the business office. Results: Two hundred seventy-five patients were identified during this time period. Median total cost was $16,600 (interquartile range $15,100-$18,300), and median direct cost (DC) was $11,200 ($10,100-$12,400). Among preoperative characteristics, body mass index (BMI) ≥30 kg/m2, diabetes, hypertension, and blood urea nitrogen >21 were associated with increased DCs of $500, $500, $200, and $600, respectively (p < 0.05). American Society of Anesthesiologists (ASA) class III was associated with increased DC of $200 compared with ASA classes I-II (p < 0.05). Considering intraoperative characteristics, increasing operative times and estimated blood loss (EBL) were associated with increased DC (p < 0.001, p < 0.05, respectively). Occurrence of any postoperative complication was associated with increased DC of $1400 (p < 0.05). On multivariable analysis, a 1-U increase in BMI was associated with a $129 increase in DC (p < 0.001), a length of stay (LOS) greater than 3 days was associated with a $4099 increase in DC (p < 0.001), a 30-minute increase in operating room duration was associated with a $410 increase in DC (p < 0.05), any postoperative complication was associated with a $5397 increase in DC (p < 0.01), and treatment for diabetes was associated with a $1860 increase in DC (p < 0.05). Conclusion: BMI, diabetes, operative duration, EBL, LOS, and postoperative complications were associated with significantly increased DC of RALP. Understanding perioperative factors affecting cost contributes to understanding value in prostatectomy and improving quality in urologic care.

Examining and Understanding Value: The Cost of Preoperative Characteristics, Intraoperative Variables and Postoperative Complications of Minimally Invasive Partial Nephrectomy.

INTRODUCTION: As value based health care gains favor and reimbursement models move toward quality rather than quantity of care, a better understanding of cost and its predictors becomes increasingly important. We identified how preoperative characteristics, intraoperative variables and postoperative complications impact the cost of partial nephrectomy. METHODS: Our institution's ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Program) database was accessed for minimally invasive partial nephrectomy performed from January 2012 to March 2017. Perioperative and financial data were collected through retrospective chart review. Total cost and direct cost were analyzed relative to clinical variables. RESULTS: A total of 215 minimally invasive partial nephrectomies were included in the study. Median total cost was $17,000 and median direct cost was $11,500. Among preoperative characteristics age 56 to 65 years and diabetes were associated with an increased median direct cost of $2,000 and $800, respectively. ASA® (American Society of Anesthesiologists®) class III was associated with an increased direct cost of $1,400 compared to ASA class I-II. Among intraoperative variables increased operative duration was associated with increased direct cost. Robot-assisted cases increased direct cost by $3,000. Estimated blood loss greater than 250 cc was associated with an increased direct cost of $800. R.E.N.A.L. score did not affect cost parameters. Patients who experienced any postoperative complications had an increased direct cost compared to those who did not. Blood transfusions were associated with an increased direct cost of $3,700 and unplanned reintubation $14,500. On multivariable analysis age, operative duration, robot use and complications retained significance. CONCLUSIONS: Age, diabetes, ASA class, operative duration, estimated blood loss, robot use and postoperative complications are associated with increased cost. Increased understanding of cost predictors can be used to optimize perioperative care and value, and contribute to improved alternative reimbursement models.