Surgeon and Hospital Level Variation in the Costs of Robot-Assisted Radical Prostatectomy

PURPOSE: We assessed surgeon and hospital level variation in robot-assisted radical prostatectomy costs and predictors of high and low cost surgery. MATERIALS AND 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.