When COVID-19 hit New York City, an acute shortage of inpatient hospital beds spurred physicians to think about how to eliminate hospital stays for certain procedures to lessen the burden on the healthcare system. Jim C. Hu, MD, MPH, a urologic oncologist and surgeon at the LeFrak Center for Robotic Surgery at NewYork-Presbyterian and Weill Cornell Medicine, saw an opportunity in robotic-assisted radical prostatectomies (RARP).
Robotics had already demonstrated a profound impact on shortening RARP stays. “Thirty years ago, when someone had an open radical prostatectomy, they’d stay in the hospital five to seven days,” he says. “Now with RARP, that’s decreased the length of stay down to typically an overnight stay.” But with more than 50,000 RARPs performed annually in the United States, Dr. Hu believed a same-day discharge (SDD) could further that impact.
“I thought SDD was feasible based on my own empiric observation of patients — they didn’t get any blood transfusions and they were relatively comfortable in the recovery room,” he says. “So, we said, ‘let’s start trying SDD.’”
I thought SDD was feasible based on my own empiric observation of patients — they didn’t get any blood transfusions and they were relatively comfortable in the recovery room. So, we said, ‘let’s start trying SDD.’
— Dr. Jim Hu
SDD Versus Inpatient RARP
Dr. Hu initiated a study to compare the impact and outcomes of same-day discharge versus an overnight stay that looked at 392 RARPs performed at two academic medical centers from February 2020 to November 2022, the results of which were published in the Journal of Urology. “We utilized propensity score analysis to assess the impact of SDD versus inpatient RARP on 30-day complications and hospital readmission,” he says. Researchers also applied a time-driven activity-based costing (TDABC) analysis, generally regarded as the most accurate method to capture true healthcare costs, to compare the total costs of RARP over its care phases.
The care phases for RARP included:
- Time of hospital arrival to time in preop
- Time in the operating room
- The beginning and end of anesthesia
- The beginning and end of case
- Time in the post-anesthesia care unit (PACU)
- Time on the inpatient floor/observation unit before discharge
Additionally, the researchers calculated the average time spent in each phase and determined the capacity cost rate for every resource involved in the process. They also calculated the cost of each process in the pathway, factoring in personnel, medications, surgical instruments and equipment, and the surgical robot. Those calculations yielded the total average cost of care for SDD and inpatient RARP.
The clinicians also modified a validated Patient Satisfaction Outcome Questionnaire and administered it starting in February 2021, within 30 days post-surgery, to compare satisfaction and pain between the inpatient and outpatient procedures. The questionnaire focused on patient perceptions of the effectiveness of pain control, medication side effects, and overall satisfaction with the surgery and recovery process. Responses were scored from 0-100, with higher scores representing better outcomes in terms of drug effectiveness, and lower scores representing better outcomes regarding side effect severity.
Key Findings
Of the surgeries performed, 206 were SDD and 186 were admitted as inpatients. “What we found was there was no difference in complications and no difference in patient satisfaction,” says Dr. Hu. “And there was an almost 20% decrease in the cost of health care rendered with SDD. That increases the value of care, given that outcomes are similar, and costs are lower.”
Additional key findings included:
- 89% of patients preferred SDD to inpatient RARP.
- SDD after RARP lowered healthcare costs by nearly 20% without affecting 30-day complications or patient satisfaction.
- In the propensity score analysis, complication rates were similar for SDD versus inpatient RARP.
- The only statistically significant factor associated with complications was body mass index (BMI), which was similar between groups.
What we found was there was no difference in complications and no difference in patient satisfaction. And there was an almost 20% decrease in the cost of health care rendered with SDD. That increases the value of care, given that outcomes are similar, and costs are lower.
— Dr. Jim Hu
Dr. Hu notes that the similar complication rate for both inpatient and SDD is especially notable. “In the 1990s, when you had a radical prostatectomy, half of men needed a blood transfusion,” he says. “The surgery has become more refined and blood loss is minimal because of robotics. I’ve done enough of these procedures to know that if everything looks good at the end of the case, they’re not going to bleed. You have to have that conviction and experience before you send patients home the same day.”
Future Implications
Dr. Hu is exploring SDD for other conditions, including robotic partial and radical nephrectomy for certain kidney cancer patients. He recently published results from this study in Urology, which showed similar results to RARP: an 18%-25% cost savings and no difference in complications for SDD robotic partial and radical nephrectomy.
In New York City, Dr. Hu says NewYork-Presbyterian and Weill Cornell Medicine is the only hospital offering SDD RARP. While he is hopeful that same-day discharge will eventually be offered at more locations, it may take time. “Surgeons are creatures of habit,” he says. “However, necessity is the mother of invention and I do think that we will see movement toward value-based care given the positive results we’ve seen.”
