Fee-for-service health care may lead to higher risks in robotic prostate surgery
NEW ORLEANS, LA—Hospitals that have invested in expensive technology for robotic surgery may be jeopardizing patients with prostate cancer who seek out the procedure, concluded a new study presented at the American Urological Association (AUA) 2015 Annual Meeting.
The study, which compared complication rates in hospitals with low volumes of robot-assisted radical prostatectomies (RARPs) to institutions with high volumes of the procedure, suggested that current fee-for-service health care models might be to blame.
"Patients pursue robotic surgery based on perceived benefit, including its minimally invasive nature and faster recovery time compared to conventional open surgery," said lead author Jesse Sammon, DO, a researcher at the Vattikuti Urology Institute of Henry Ford Hospital in Detroit, Michigan. "But they fail to take into account the importance of hospital and surgeon experience on outcomes."
Now the most common surgical method for treating prostate cancer in the United States, RARP allows a surgeon to remove the diseased prostate by manipulating robotic arms holding undersized instruments through tiny incisions in the patient's skin. Besides avoiding the higher risk of infection and blood loss posed by open surgery, successful RARP reduces patient hospital stay and recovery time.
Researchers at Henry Ford Hospital, a pioneer in robotic surgery that has now performed more than 10,000 RARPs, saw a rapid increase in US hospitals investing in the technology and performing the procedure during the past decade.
Building on earlier research that showed higher-volume hospitals had more success with the procedure than smaller institutions, the new study focused on all patients listed in the National Inpatient Sample (NIS) who underwent RARP between 2009 and 2011. The NIS collects and provides data on all patients discharged from a 20% sample of nonfederal hospitals in the United States.
The number of hospitals performing RARP remained stable over the study period, at 802 hospitals in 2009, 792 in 2010, and 808 in 2011.
The overall complication rate after surgery was significantly related to the volume of RARPs performed at a hospital. On average, 14.7% of patients treated at very-low volume institutions experienced complications, whereas the complication rate was 5.7% among those treated at very-high volume institutions. Patients treated at very-high volume hospitals were less than half as likely to experience a complication as those treated at very-low volume hospitals.
"But between 2000 and 2008," Sammon explained, "there was a 74% increase in the number of radical prostatectomies performed, and a 19% decrease in the number of hospitals performing radical prostatectomy.
"By 2009, the median hospital volume for open radical prostate surgery was 32 cases per year, compared to 137 cases per year using the robotic approach."
What this suggests, Sammon said, is that market forces behind the adoption of robotic surgery may have unintentionally had the salutary effect of centralizing prostate cancer care.
"This migration of patients away from very-high volume hospitals is likely the result of the current fee-for-service models in US health care," Sammon said. "For institutions that have invested millions in robotic technology, there is no incentive to refer patients to other, higher volume hospitals.
"This perverse disincentive is probably jeopardizing patients, and calls for a renewed focus on the benefits of centralized care at larger providers."