Propensity-matched comparison of morbidity and costs of open and robot-assisted radical cystectomies: a contemporary population-based analysis in the United States.
BACKGROUND
Radical cystectomy (RC) is a morbid procedure associated with high costs. Limited population-based data exist on the complication profile and costs of robot-assisted RC (RARC) compared with open RC (ORC).


OBJECTIVE
To evaluate morbidity and cost differences between ORC and RARC.


METHODS
We conducted a population-based, retrospective cohort study of patients who underwent RC at 279 hospitals across the United States between 2004 and 2010.


METHODS
Multivariable logistic and median regression was performed to evaluate 90-d mortality, postoperative complications (Clavien classification), readmission rates, length of stay (LOS), and direct costs. To reduce selection bias, we used propensity weighting with survey weighting to obtain nationally representative estimates.


CONCLUSIONS
The final weighted cohort included 34 672 ORC and 2101 RARC patients. RARC use increased from 0.6% in 2004 to 12.8% in 2010. Major complication rates (Clavien grade ≥ 3; 17.0% vs 19.8%, p = 0.2) were similar between ORC and RARC (odds ratio [OR]: 1.32; p = 0.42). RARC had 46% decreased odds of minor complications (Clavien grade 1-2; OR: 0.54; p = 0.03). RARC had $4326 higher adjusted 90-d median direct costs (p = 0.004). Although RARC had a significantly shorter LOS (11.8 d vs 10.2 d; p = 0.008), no significant differences in room and board costs existed (p = 0.20). Supply costs for RARC were significantly higher ($6041 vs $3638; p < 0.0001). Morbidity and cost differences were not present among the highest-volume surgeons (≥ 7 cases per year) and hospitals (≥ 19 cases per year). Limitations include use of an administrative database and lack of oncologic characteristics.


CONCLUSIONS
The use of RARC has increased between 2004 and 2010. Compared with ORC, RARC was associated with decreased odds of minor but not major complications and with increased expenditures attributed primarily to higher supply costs. Centralization of ORC and RARC to high-volume providers may minimize these morbidity and cost differences.


RESULTS
Using a US population-based cohort, we found that robotic surgery for bladder cancer decreased minor complications, had no impact on major complications and was more costly than open surgery.
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Jeffrey J
JJ
Leow
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Stephen W
SW
Reese
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Wei
W
Jiang
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Stuart R
SR
Lipsitz
Dana-Farber/Brigham and Women's Hospital Cancer Center, Harvard Medical School, Boston, MA, USA.
Joaquim
J
Bellmunt
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Dana-Farber/Brigham and Women's Hospital Cancer Center, Harvard Medical School, Boston, MA, USA.
Quoc-Dien
QD
Trinh
Department of Urology, Stanford University Medical Center, Stanford, CA, USA.
Benjamin I
BI
Chung
Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Dana-Farber/Brigham and Women's Hospital Cancer Center, Harvard Medical School, Boston, MA, USA.
Adam S
AS
Kibel
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Dana-Farber/Brigham and Women's Hospital Cancer Center, Harvard Medical School, Boston, MA, USA. Electronic address: slchang@bics.bwh.harvard.edu.
Steven L
SL
Chang
D000368:Aged; D015653:Cystectomy / Q000009:adverse effects* / Q000191:economics* / Q000379:methods / Q000639:trends; D004180:Direct Service Costs / Q000706:statistics & numerical data; D004865:Equipment and Supplies, Hospital / Q000191:economics; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects* / Q000191:economics* / Q000639:trends; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D057216:Propensity Score; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000009:adverse effects* / Q000191:economics* / Q000639:trends; D014481:United States; D001749:Urinary Bladder Neoplasms / Q000191:economics / Q000601:surgery*
Bladder cancer; Comparative effectiveness research; Complications; Costs; Radical cystectomy; Robot-assisted