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Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Dr. Ruchika Talwar, and I'm a urologic oncologist in Nashville, Tennessee. Today, I'm really excited to be joined by Dr. Brian Lane, who will be sharing some recently published work out of the MUSIC collaborative exploring same-day discharges for radical prostatectomy patients. Thanks so much, Dr. Lane, for spending some time with us.

Brian Lane: Thanks for having me. Look forward to this discussion.

So we were looking at the uptake of same-day discharge for patients undergoing robot-assisted radical prostatectomy in the state of Michigan. And MUSIC, as a collaborative, we're able to kind of look at practice patterns in all the participating practices that we have in Michigan. This work was spearheaded by one of our fellows at the University of Michigan, Goleana Moncaleano-Fernandez, and was recently published.

I'll review some of the results with you. So post-operative length of stay is a modifiable aspect of care for any condition. So radical prostatectomy used to be a one-, two-, or longer-day hospital stay when it was an open operation, and with robotics, for the most part, patients go home after an overnight stay. But if we can reduce hospital length of stay further, we can decrease costs to patients and to the health system, minimize the chance of hospital-acquired conditions, and really improve resource allocation, like beds and nursing care, to patients who may better benefit from this. So we really evaluated the uptake and safety of same-day discharge after our robotic prostatectomy across our collaborative.

So we classified patients during the years of 2018 to 2022 as having undergone a discharge without any hospitalization, so same day, or a one-night stay or two-night stay in the hospital. We use this timeframe because before 2018, there were very few patients who had undergone same-day discharge. And we looked at practice and surgeon-level variation, and our primary outcome was 30-day readmission.

So during this timeframe, only 2.8% of patients had a same-day discharge. The vast majority, so 80% of patients, only had a one-day hospital stay. And we did see a rise from 0.6% up to 4.4%. We had presented at MUSIC in 2018, this is an opportunity, and we had an expert come in and talk to us and try to address barriers that might exist in practices. So we expected that the uptake would have been much higher, but this is really what we observed. We saw 52 of 138 urologists had at least one of their patients go home on the same day, and similarly, about 64% of our practices had at least one patient doing it. But overall, again, the percentage was pretty low. And this was, of course, spurred on during the COVID years when there was really an interest in keeping patients out of the hospital. You can see 58% of our patients were during that timeframe.

Well, looking at our primary outcome of readmission, we really saw no difference; there's no statistically significant difference between patients that had gone home the same day versus had a one-day length of stay. The readmission rate was 5.2% versus 3.5%, so a little bit higher, but again, not statistically significant. And in multivariable analysis, again, it did not reach the pre-specified cut point of 0.05.

So what did we learn? Same-day discharge is safe. It's feasible. Readmission rates are comparable to those with a one-day hospital stay. We feel that the approach can really align patient preferences for home recovery with reduction in healthcare costs. But interestingly, implementation across Michigan remained very low, less than 5%, suggesting some hesitancy or barriers to broader use. We think future efforts should focus on refining patient selection criteria and establishing perioperative pathways to support adoption of same-day discharge at urology practices.

Ruchika Talwar: Really interesting data you presented, Dr. Lane. So I'm curious, what do you think the reason for the sluggish uptake of same-day discharge was?

Brian Lane: I think it's a few things. Without good planning upfront, it can be difficult... If your patients are used to going to the urology floor and get instructed up there, the same-day nurses may not really have the same level of understanding or be used to advising patients on catheter care, and switching a night bag from a leg bag—that just may not be a task that they're used to doing. I think for providers, if you're concerned that you're going to get calls on that first night or the second day about catheter issues or pain issues, you might be reluctant to send home patients. Importantly, in our study, we didn't see any readmissions within 48 hours after same-day discharge. Maybe there were some phone calls, but certainly none of the patients had medical issues that required readmission.

Ruchika Talwar: I think that's a really interesting point because I think we have an opportunity here to standardize and really optimize our pathway for same-day discharges. The health system's moving towards bundled payments for a single episode of care, and so I can certainly see a world in which eventually robotic surgery for prostate cancer ends up being a single episode. So I think we are going to be highly incentivized to, as you mentioned, free up resources inpatient for patients who truly need an inpatient stay.

Hearing some of those barriers you cite, it tells me that there's a big opportunity for us to do significant education preoperatively and build upon prior work from our nursing allies in care and ensure that we have really good pathways for patient education post-operatively. Curious on your thoughts on that, if potentially... especially about preoperative expectation-setting from the patient perspective.

Brian Lane: Yeah. So for my patients, and then it's now extended to all of my partners, because they were initially skeptical as well, I simply say to them at the visit, "Historically, folks spend a night in the hospital, but you'll have the opportunity after your operation, if you're feeling well enough to go home, then we'll offer that to you. And so long as you and your caregiver are comfortable with that, that's probably the best thing for you." And I think starting the conversation there is essential because, again, if they've talked to friends or family members who've had the operation, they're expecting to stay in the hospital; if they're looking at certain materials on the internet, that might be an expectation as well. But I think with some simple education and redirection, the patients love it. This is not a physician-directed kicking them out of the hospital. This is patients being really thankful that it's a safe option for them and that they can go back and sleep in their own bed.

Ruchika Talwar: Yeah, I think that's really important. A lot of times we've even minimized labs, for example, that we get after prostatectomy, and so what is the reason for us keeping them in the hospital? It's hard to think about what good there is or what we're getting out of it other than just monitoring. So if they are reliable, they have low baseline comorbidities, and are overall low-risk, then absolutely it makes sense for them to be in their own beds, eating the normal home food they're used to as opposed to our hospital food, and importantly ambulating, walking around, getting back to that baseline activity level. Really interesting.

So as we wrap up here, what is your advice for the urologic community with regards to same-day discharge after a radical prostatectomy?

Brian Lane: I would reconsider if you've had a previous thought about this process and were hesitant and think about how to implement it. It can be for prostatectomy; it can also be for other robotic surgeries as well, like kidney surgery. I think setting up a process is essential, by which I mean perioperative nursing needs to be aware, anesthesia needs to be aware, if there's urology trainees or APPs involved. Everyone on the team needs to understand this is a priority and have their concerns addressed. And once you set up a process that works, I think you'll find that your patient satisfaction will be high and a really significant proportion of your patients will thank you for having this option.

Ruchika Talwar: Great. Well, thanks for sharing some of your work with the UroToday community. We really appreciate it.

Brian Lane: Thanks for having me. I hope this does have some significant impacts.

Ruchika Talwar: Absolutely. And to our audience, thanks again for tuning in. We'll see you next time.