title: Surgeon and Hospital Level Variation in the Costs of Robot-Assisted Radical Prostatectomy.
abstract: OBJECTIVE
  We assessed surgeon and hospital level variation in robot-assisted radical prostatectomy costs and predictors of high and low cost surgery.
  
  
  METHODS
  The study population consisted of a weighted sample of 291,015 men who underwent robot-assisted radical prostatectomy for prostate cancer by 667 surgeons at 197 U.S. hospitals from 2003 to 2013. We evaluated 90-day direct hospital costs (2014 USD) in the Premier Hospital Database. High costs per robot-assisted radical prostatectomy were those above the 90th percentile and low costs were those below the 10th percentile.
  
  
  RESULTS
  Mean hospital cost per robot-assisted radical prostatectomy was $11,878 (95% CI $11,804-$11,952). Mean cost was $2,837 (95% CI $2,805-$2,869) in the low cost group vs $25,906 (95% CI $24,702-$25,490) in the high cost group. Nearly a third of the variation in robot-assisted radical prostatectomy cost was attributable to hospital characteristics and more than a fifth was attributable to surgeon characteristics (R-squared 30.43% and 21.25%, respectively). High volume surgeons and hospitals (90th percentile or greater) had decreased odds of high cost surgery (surgeons: OR 0.24, 95% CI 0.11-0.54; hospitals: OR 0.105, 95% CI 0.02-0.46). The performance of robot-assisted radical prostatectomy at a high volume hospital was associated with increased odds of low cost robot-assisted radical prostatectomy (OR 839, 95% CI 122-greater than 999).
  
  
  CONCLUSIONS
  This study provides insight into the role of surgeons and hospitals in robot-assisted radical prostatectomy costs. Given the substantial variability, identifying and remedying the root cause of outlier costs may yield substantial benefits.
authors.affiliation: Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Alexander P
authors.initials: AP
authors.lastname: Cole
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Leow
authors.affiliation: Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Steven L
authors.initials: SL
authors.lastname: Chang
authors.affiliation: Department of Urology, Stanford University Medical Center, Stanford, California.
authors.forename: Benjamin I
authors.initials: BI
authors.lastname: Chung
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Christian P
authors.initials: CP
authors.lastname: Meyer
authors.affiliation: Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Adam S
authors.initials: AS
authors.lastname: Kibel
authors.affiliation: Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan.
authors.forename: Mani
authors.initials: M
authors.lastname: Menon
authors.affiliation: Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Nguyen
authors.affiliation: Lank Center for Genitourinary Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Toni K
authors.initials: TK
authors.lastname: Choueiri
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Gally
authors.initials: G
authors.lastname: Reznor
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Stuart R
authors.initials: SR
authors.lastname: Lipsitz
authors.affiliation: Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan.
authors.forename: Jesse D
authors.initials: JD
authors.lastname: Sammon
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Maxine
authors.initials: M
authors.lastname: Sun
authors.affiliation: Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address: trinh.qd@gmail.com.
authors.forename: Quoc-Dien
authors.initials: QD
authors.lastname: Trinh
mesh_terms: D000368:Aged; D017721:Hospital Costs / Q000639:trends*; D061847:Hospitals, High-Volume; D006801:Humans; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D011467:Prostate / Q000601:surgery*; D011468:Prostatectomy / Q000191:economics* / Q000379:methods; D011471:Prostatic Neoplasms / Q000175:diagnosis / Q000191:economics / Q000601:surgery*; D065287:Robotic Surgical Procedures / Q000191:economics* / Q000379:methods; D066231:Surgeons / Q000706:statistics & numerical data*; D014481:United States
keywords: health care costs; health services; prostatectomy; prostatic neoplasms; robotic surgical procedures