AUA 2018: "Superusers" of Post-Prostatectomy Care: Identifying Drivers of Extreme Healthcare Costs

San Francisco, CA (UroToday.com) Based on different hospital jurisdiction policies and cultural norms, globally there is a wide variation of post-operative care for patients undergoing radical prostatectomy. For instance, in Italy, some centers will wait until the patient is ready to have their catheter removed prior to discharge since many patients travel from great distances to have their operation. Alternatively, patients in the United States and Canada undergoing robotic radical prostatectomy are frequently discharged on the first post-operative day with their Foley catheter in situ. In the United States, hospitalization post-operatively is a major cost of healthcare expenditure, and a small percentage of patients drive the majority of healthcare spending through these mechanisms. As such, Chirag Doshi, MD, and colleagues aimed to identify and characterize “superusers” of postoperative care in a radical prostatectomy surgical population in the United States.

For this study, the authors used The Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery Database for the state of California from 2007 to 2011 to identify 48,825 patients undergoing radical prostatectomy. These patients were identified using ICD-9-CM for radical prostatectomy. The authors identified superusers defined as patients with a postoperative length of stay (LOS) in the top 1% of radical prostatectomy patients. Superusers were compared to non-superusers to determine baseline differences in demographics, comorbidities, and clinical characteristics. Multivariable logistic regression models were performed to identify independent risk factors for classification as a superuser.

Among the 48,825 patients meeting inclusion criteria, 493 men were identified as superusers. The mean age for superusers was 69.4 years (SD 11.0) compared to 62.9 years (SD 8.1) for non-superusers. The mean LOS was 17.3 days (SD 10.9) for superusers vs 2.1 days (SD 1.4) for non-superusers. Superusers were more likely to be African-American (OR 1.93, 95%CI 1.37-2.71), have Medicare (OR1.57, 95%CI 1.19-2.07) or Medicaid insurance (OR 4.06, 95%CI 2.63-6.25). Additionally, superusers were more likely to be readmitted to the hospital within 30 days (OR 2.8; 95%CI 2.08-3.72) following their radical prostatectomy, and had a higher inpatient mortality rate compared to non-superusers (2.64% vs 0.04%, p<0.01). With regards to 90-day complication rates (which likely accounts for the prolonged length of stay and subsequently increased cost) include:

Superusers of Post Prostatectomy Care

The strength of the current study is the unique study design to identify patients that are the strongest drivers of post-operative care at the population-level. To my knowledge, this is the first such study of its type. A possible limitation is the retrospective analysis and the inherent limitations associated with such analyses. Doshi concluded with several take-home messages:

Certain characteristics place patients at risk for prolonged utilization of inpatient care following radical prostatectomy, thus conferring a disproportionate cost burden on the healthcare system
Patients at an increased risk of becoming a superuser must be identified preoperatively in an effort to optimize their inpatient care and discharge. This may include incorporation of social workers and case managers to assist with post-operative care in an attempt to obviate the need for prolonged hospitalization secondary to post-operative care placement issues
Further work is needed to identify perioperative factors and preventative measures that may assist the urologist in making clinical decisions

Presented by: Chirag Doshi, MD, Loyola University Medical Center, Maywood, IL
Co-Authors: Eric Kirshenbaum, Alex Gorbonos, Marcus Quek, Gopal Gupta, Anai Kothari, Grace Delos Santos, Maywood, IL

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA

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