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.