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Sadri H, Fung-Kee-Fung M, Shayegan B, Garneau PY, Pezeshki P. A systematic review of full economic evaluations of robotic-assisted surgery in thoracic and abdominopelvic procedures. J Robot Surg 2023; 17:2671-2685. [PMID: 37843673 PMCID: PMC10678817 DOI: 10.1007/s11701-023-01731-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/24/2023] [Indexed: 10/17/2023]
Abstract
This study aims to conduct a systematic review of full economic analyses of robotic-assisted surgery (RAS) in adults' thoracic and abdominopelvic indications. Authors used Medline, EMBASE, and PubMed to conduct a systematic review following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 guidelines. Fully published economic articles in English were included. Methodology and reporting quality were assessed using standardized tools. Majority of studies (28/33) were on oncology procedures. Radical prostatectomy was the most reported procedure (16/33). Twenty-eight studies used quality-adjusted life years, and five used complication rates as outcomes. Nine used primary and 24 studies used secondary data. All studies used modeling. In 81% of studies (27/33), RAS was cost-effective or potentially cost-effective compared to comparator procedures, including radical prostatectomy, nephrectomy, and cystectomy. Societal perspective, longer-term time-horizon, and larger volumes favored RAS. Cost-drivers were length of stay and equipment cost. From societal and payer perspectives, robotic-assisted surgery is a cost-effective strategy for thoracic and abdominopelvic procedures.Clinical trial registration This study is a systematic review with no intervention, not a clinical trial.
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Affiliation(s)
- Hamid Sadri
- Department of Health Economic and Outcomes Research, Medtronic ULC, 99 Hereford St., Brampton, ON, L6Y 0R3, Canada.
| | - Michael Fung-Kee-Fung
- Champlain Regional Cancer Program Depts OB/GYN, Surgery, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - Bobby Shayegan
- Division of Urology, Department of Surgery, McMaster University, 50 Charlton Ave., Hamilton, ON, L8N 4A6, Canada
| | - Pierre Y Garneau
- Surgical Department, Hôpital du Sacré-Coeur de Montréal, 5400 Boul Gouin O, Montréal, QC, H4J 1C5, Canada
| | - Padina Pezeshki
- Department of Clinical Research, Medtronic ULC, 99 Hereford St., Brampton, ON, L6Y 0R3, Canada
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Song C, Cheng L, Li Y, Kreaden U, Snyder SR. Systematic literature review of cost-effectiveness analyses of robotic-assisted radical prostatectomy for localised prostate cancer. BMJ Open 2022; 12:e058394. [PMID: 36127082 PMCID: PMC9490571 DOI: 10.1136/bmjopen-2021-058394] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Review and assess cost-effectiveness studies of robotic-assisted radical prostatectomy (RARP) for localised prostate cancer compared with open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP). DESIGN Systematic review. SETTING PubMed, Embase, Scopus, International HTA database, the Centre for Reviews and Dissemination database and various HTA websites were searched (January 2005 to March 2021) to identify the eligible cost-effectiveness studies. PARTICIPANTS Cost-effectiveness, cost-utility, or cost-minimization analyses examining RARP versus ORP or LRP were included in this systematic review. INTERVENTIONS Different surgical approaches to treat localized prostate cancer: RARP compared with ORP and LRP. PRIMARY AND SECONDARY OUTCOME MEASURES A structured narrative synthesis was developed to summarize results of cost, effectiveness, and cost-effectiveness results (eg, incremental cost-effectiveness ratio [ICER]). Study quality was assessed using the Consensus on Health Economic Criteria Extended checklist. Application of medical device features were evaluated. RESULTS Twelve studies met inclusion criteria, 11 of which were cost-utility analyses. Higher quality-adjusted life-years and higher costs were observed with RARP compared with ORP or LRP in 11 studies (91%). Among four studies comparing RARP with LRP, three reported RARP was dominant or cost-effective. Among ten studies comparing RARP with ORP, RARP was more cost-effective in five, not cost-effective in two, and inconclusive in three studies. Studies with longer time horizons tended to report favorable cost-effectiveness results for RARP. Nine studies (75%) were rated of moderate or good quality. Recommended medical device features were addressed to varying degrees within the literature as follows: capital investment included in most studies, dynamic pricing considered in about half, and learning curve and incremental innovation were poorly addressed. CONCLUSIONS Despite study heterogeneity, RARP was more costly and effective compared with ORP and LRP in most studies and likely to be more cost-effective, particularly over a multiple year or lifetime time horizon. Further cost-effectiveness analyses for RARP that more thoroughly consider medical device features and use an appropriate time horizon are needed. PROSPERO REGISTRATION NUMBER CRD42021246811.
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Affiliation(s)
- Chao Song
- Global Health Economics and Outcome Research, Intuitive Surgical, Atlanta, GA, USA
| | - Lucia Cheng
- Global Health Economics and Outcome Research, Intuitive Surgical, Sunnyvale, CA, USA
| | - Yanli Li
- Global Health Economics and Outcome Research, Intuitive Surgical, Sunnyvale, CA, USA
| | - Usha Kreaden
- Biostatistics & Global Evidence Management, Intuitive Surgical, Sunnyvale, CA, USA
| | - Susan R Snyder
- Georgia State University School of Public Health, Atlanta, Georgia, USA
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Labban M, Dasgupta P, Song C, Becker R, Li Y, Kreaden US, Trinh QD. Cost-effectiveness of Robotic-Assisted Radical Prostatectomy for Localized Prostate Cancer in the UK. JAMA Netw Open 2022; 5:e225740. [PMID: 35377424 PMCID: PMC8980901 DOI: 10.1001/jamanetworkopen.2022.5740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The cost-effectiveness of different surgical techniques for radical prostatectomy remains a subject of debate. Emergence of recent critical clinical data and changes in surgical equipment costs due to their shared use by different clinical specialties necessitate an updated cost-effectiveness analysis in a centralized, largely government-funded health care system such as the UK National Health Service (NHS). OBJECTIVE To compare robotic-assisted radical prostatectomy (RARP) with open radical prostatectomy (ORP) and laparoscopic-assisted radical prostatectomy (LRP) using contemporary data on clinical outcomes, costs, and surgical volumes in the UK. DESIGN, SETTING, AND PARTICIPANTS This economic analysis used a Markov model developed to compare the cost-effectiveness of RARP, LRP, and ORP to treat localized prostate cancer. The model was constructed from the perspective of the UK NHS. The model simulated 65-year-old men who underwent radical prostatectomy for localized prostate cancer and were followed up for a 10-year period. Data were analyzed from May 1, 2020, to July 31, 2021. EXPOSURES Robotic-assisted radical prostatectomy, LRP, and ORP. MAIN OUTCOMES AND MEASURES Quality-adjusted life-years (QALYs), costs (direct medical costs and costs outside the NHS), and incremental cost-effectiveness ratios (ICERs). RESULTS Compared with LRP, RARP cost £1785 (US $2350) less and had 0.24 more QALYs gained; thus, RARP was a dominant option compared with LRP. Compared with ORP, RARP had 0.12 more QALYs gained but cost £526 (US $693) more during the 10-year time frame, resulting in an ICER of £4293 (US $5653)/QALY. Because the ICER was below the £30 000 (US $39 503) willingness-to-pay threshold, RARP was more cost-effective than ORP in the UK. The most sensitive variable influencing the cost-effectiveness of RARP was the lower risk of biochemical recurrence (BCR). Scenario analysis indicated RARP would remain more cost-effective than ORP as long as the BCR hazard ratios comparing RARP vs ORP were less than 0.99. CONCLUSIONS AND RELEVANCE These findings suggest that in the UK, RARP has an ICER lower than the willingness-to-pay threshold and thus is likely a cost-effective surgical treatment option for patients with localized prostate cancer compared with ORP and LRP. The results were mainly driven by the lower risk of BCR for RARP. These findings may differ in other health care settings where different thresholds and costs may apply.
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Affiliation(s)
- Muhieddine Labban
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Prokar Dasgupta
- MRC (Medical Research Council) Centre for Transplantation, Guy’s Hospital Campus, King’s College London, King’s Health Partners, London, United Kingdom
| | - Chao Song
- Global Health Economics and Outcome Research, Intuitive Surgical Inc, Atlanta, Georgia
| | | | - Yanli Li
- Global Health Economics and Outcome Research, Intuitive Surgical Inc, Sunnyvale, California
| | - Usha Seshadri Kreaden
- Biostatistics & Global Evidence Management, Intuitive Surgical Inc, Sunnyvale, California
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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de Oliveira RAR, Guimarães GC, Mourão TC, de Lima Favaretto R, Santana TBM, Lopes A, de Cassio Zequi S. Cost-effectiveness analysis of robotic-assisted versus retropubic radical prostatectomy: a single cancer center experience. J Robot Surg 2021; 15:859-868. [PMID: 33417155 DOI: 10.1007/s11701-020-01179-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
Prostate cancer (PCa) treatment has been greatly impacted by the robotic surgery. The economics literature about PCa is scarce. We aim to carry-out cost-effectiveness and cost-utility analyses of the robotic-assisted radical prostatectomy (RALP) using the "time-driven activity-based cost" methodology. Patients who underwent radical prostatectomy in 2013 were retrospectively analyzed in a cancer center over a 5-year period. Fifty-six patients underwent RALP and 149 patients underwent retropubic radical prostatectomy (RRP). The amounts were subject to a 5% discount as correction of monetary value considering time elapsed. Calculation of the Incremental Cost-Effectiveness Ratios (ICER) related to events avoided and the Incremental Cost-Utility Ratio (ICUR) related to "QALY saved" were performed. QALY was performed using values of utility and "disutility" weights from the "Cost-Effectiveness Analysis Registry". Hypothetical cohorts were simulated with 1000 patients in each group, based on the treatment outcomes. Total and average costs were R$1,903,671.93, and R$12,776.32 for the RRP group, and R$1,373,987.26, and R$24,535.49 for the RALP group, respectively. The costs to treat the hypothetical cohorts were R$10,010,582.35 for RRP, and R$19,224,195.90 for RALP. ICER calculation evidenced R$9,213,613.55 of difference between groups. ICUR was R$ 22,690.83 per QALY saved. Limitations were the lack of cost-effectiveness analyses related to re-hospitalization rates and complications, single center perspective, and currency-translation differences. Medical fees were not included. RALP showed advantages in cost-effectiveness and cost-utility over RRP in the long term. Despite the increased costs to the introduction of robotic technology, its adoption should be encouraged due to the gains.
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Affiliation(s)
- Renato Almeida Rosa de Oliveira
- Department of Uro-Oncology, BP-A Beneficência Portuguesa de São Paulo, Rua Martiniano de Carvalho, 965, São Paulo, SP, 01323-030, Brazil.,ACCamargo Cancer Center, Urology Division, São Paulo, Brazil
| | | | - Thiago Camelo Mourão
- Department of Uro-Oncology, BP-A Beneficência Portuguesa de São Paulo, Rua Martiniano de Carvalho, 965, São Paulo, SP, 01323-030, Brazil.
| | - Ricardo de Lima Favaretto
- Department of Uro-Oncology, BP-A Beneficência Portuguesa de São Paulo, Rua Martiniano de Carvalho, 965, São Paulo, SP, 01323-030, Brazil
| | - Thiago Borges Marques Santana
- Department of Uro-Oncology, BP-A Beneficência Portuguesa de São Paulo, Rua Martiniano de Carvalho, 965, São Paulo, SP, 01323-030, Brazil.,ACCamargo Cancer Center, Urology Division, São Paulo, Brazil
| | - Ademar Lopes
- Head of Pelvic Surgery Department, ACCamargo Cancer Center, São Paulo, Brazil
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Parackal A, Tarride JE, Xie F, Blackhouse G, Hoogenes J, Hylton D, Hanna W, Adili A, Matsumoto ED, Shayegan B. Economic evaluation of robot-assisted radical prostatectomy compared to open radical prostatectomy for prostate cancer treatment in Ontario, Canada. Can Urol Assoc J 2020; 14:E350-E357. [PMID: 32379598 DOI: 10.5489/cuaj.6376] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Recent health technology assessments (HTAs) of robot-assisted radical prostatectomy (RARP) in Ontario and Alberta, Canada, resulted in opposite recommendations, calling into question whether benefits of RARP offset the upfront investment. Therefore, the study objectives were to conduct a cost-utility analysis from a Canadian public payer perspective to determine the cost-effectiveness of RARP. METHODS Using a 10-year time horizon, a five-state Markov model was developed to compare RARP to open radical prostatectomy (ORP). Clinical parameters were derived from Canadian observational studies and a recently published systematic review. Costs, resource utilization, and utility values from recent Canadian sources were used to populate the model. Results were presented in terms of increment costs per quality-adjusted life years (QALYs) gained. A probabilistic analysis was conducted, and uncertainty was represented using cost-effectiveness acceptability curves (CEACs). One-way sensitivity analyses were also conducted. Future costs and QALYs were discounted at 1.5%. RESULTS Total cost of RARP and ORP were $47 033 and $45 332, respectively. Total estimated QALYs were 7.2047 and 7.1385 for RARP and ORP, respectively. The estimated incremental cost-utility ratio (ICUR) was $25 704 in the base-case analysis. At a willingness-to-pay threshold of $50 000 and $100 000 per QALY gained, the probability of RARP being cost-effective was 0.65 and 0.85, respectively. The model was most sensitive to the time horizon. CONCLUSIONS The results of this analysis suggest that RARP is likely to be cost-effective in this Canadian patient population. The results are consistent with Alberta's HTA recommendation and other economic evaluations, but challenges Ontario's reimbursement decision.
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Affiliation(s)
- Anna Parackal
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada.,McMaster Chair in Health Technology Management, McMaster University, Hamilton, ON, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada.,Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, ON, Canada
| | - Gord Blackhouse
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada.,Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Jen Hoogenes
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Danielle Hylton
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Wael Hanna
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Anthony Adili
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Bobby Shayegan
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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6
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Prostatectomies for localized prostate cancer: a mixed comparison network and cumulative meta-analysis. J Robot Surg 2018; 12:633-639. [PMID: 29476324 DOI: 10.1007/s11701-018-0791-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/12/2018] [Indexed: 10/18/2022]
Abstract
No consensus has been attained regarding the utility of open retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALRP) for localized prostate cancer (PCa). We carried out a network meta-analysis and cumulative meta-analysis comparing RRP, LRP and RALRP on peri-operative and functional outcome measures. Electronic databases were searched for either randomized clinical trials or cohort studies comparing RALRP either with LRP or RRP in patients with localized PCa. Outcome measures were as follows: overall, pT2 and pT3-positive surgical margins (PSMs); biochemical recurrence (BCR); complication rates; estimated blood loss; blood transfusion rate; continence and potency rates; duration of catheterization and hospital stay. Publication bias, risk of bias and inconsistency were assessed. Inverse heterogeneity model was used for analysis. A total of 45 studies were included for the final analysis. We observed that RALRP and LRP did not differ significantly from RRP with regard to the following outcomes: overall PSM; pT2 and pT3 PSMs; OT; complication rate; continence and potency rates; total blood loss and hospital stay. Duration of catheterization was significantly shorter in RALRP than LRP and RRP while significant reductions in the need for blood transfusion and BCR were observed for both RALRP and LRP in comparison with RRP. To conclude, similar functional, operative and oncologic outcomes were observed for both RALRP and LRP compared to RRP.
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Glaser SM, Kalash R, Bongiorni DR, Roberts MS, Balasubramani GK, Jacobs BL, Beriwal S, Heron DE, Greenberger JS. Challenges in the Analysis of Outcomes for Surgical Compared to Radiotherapy Treatment of Prostate Cancer. In Vivo 2018; 32:113-120. [PMID: 29275307 PMCID: PMC5892645 DOI: 10.21873/invivo.11212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/19/2017] [Accepted: 11/29/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Prostate cancer can be treated with radical prostatectomy (RP), external-beam radiotherapy (EBRT), or brachytherapy (BT). These modalities have similar cancer-related outcomes. We used an innovative method to analyze the cost of such treatment. MATERIALS AND METHODS We queried our Institution's Insurance Division [University of Pittsburgh Medical Center (UPMC) Health Plan] beneficiaries from 2003-2008, who were diagnosed with prostate cancer and also queried the UPMC tumor registry for all patients with prostate cancer treated at our Institution. In a de-identified manner, data from the Health Plan and Tumor Registry were merged. RESULTS A total of 354 patients with non-metastatic disease with treatment initiated within 9 months of diagnosis were included (RP=236, EBRT=55, and BT=63). Radiotherapy-treated patients tended to be older, higher-risk, and have more comorbidities. Unadjusted median total health care expenditures during the first year after diagnosis were: RP: $16,743, EBRT: $47,256, and BT: $23,237 (p<0.0005). A propensity score-matched model comparing RP and EBRT demonstrated median total health care expenditures during year one: RP: $8,189, EBRT: $10,081; p=0.48. In a propensity-matched model comparing RP and BT, the median total health care expenditures during year one were: RP: $18,143, BT: $26,531; p=0.015 and per year during years 2 through 5 from diagnosis were: RP: $5,913, BT: $6,110; p=0.68. CONCLUSION This pilot study demonstrates the feasibility of combining healthcare costs from the payer's perspective with clinical data from a Tumor Registry within an IDFS and represents a novel approach to investigating the economic impact of cancer treatment.
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Affiliation(s)
- Scott M Glaser
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Ronny Kalash
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Dante R Bongiorni
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, U.S.A
| | - Mark S Roberts
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, PA, U.S.A
| | - Goundappa K Balasubramani
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, U.S.A
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A
| | - Joel S Greenberger
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, U.S.A.
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Schroeck FR, Jacobs BL, Bhayani SB, Nguyen PL, Penson D, Hu J. Cost of New Technologies in Prostate Cancer Treatment: Systematic Review of Costs and Cost Effectiveness of Robotic-assisted Laparoscopic Prostatectomy, Intensity-modulated Radiotherapy, and Proton Beam Therapy. Eur Urol 2017; 72:712-735. [PMID: 28366513 PMCID: PMC5623181 DOI: 10.1016/j.eururo.2017.03.028] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/17/2017] [Indexed: 02/02/2023]
Abstract
CONTEXT Some of the high costs of robot-assisted radical prostatectomy (RARP), intensity-modulated radiotherapy (IMRT), and proton beam therapy may be offset by better outcomes or less resource use during the treatment episode. OBJECTIVE To systematically review the literature to identify the key economic trade-offs implicit in a particular treatment choice for prostate cancer. EVIDENCE ACQUISITION We systematically reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement and protocol. We searched Medline, Embase, and Web of Science for articles published between January 2001 and July 2016, which compared the treatment costs of RARP, IMRT, or proton beam therapy to the standard treatment. We identified 37, nine, and three studies, respectively. EVIDENCE SYNTHESIS RARP is costlier than radical retropubic prostatectomy for hospitals and payers. However, RARP has the potential for a moderate cost advantage for payers and society over a longer time horizon when optimal cancer and quality-of-life outcomes are achieved. IMRT is more expensive from a payer's perspective compared with three-dimensional conformal radiotherapy, but also more cost effective when defined by an incremental cost effectiveness ratio <$50 000 per quality-adjusted life year. Proton beam therapy is costlier than IMRT and its cost effectiveness remains unclear given the limited comparative data on outcomes. Using the Grades of Recommendation, Assessment, Development and Evaluation approach, the quality of evidence was low for RARP and IMRT, and very low for proton beam therapy. CONCLUSIONS Treatment with new versus traditional technologies is costlier. However, given the low quality of evidence and the inconsistencies across studies, the precise difference in costs remains unclear. Attempts to estimate whether this increased cost is worth the expense are hampered by the uncertainty surrounding improvements in outcomes, such as cancer control and side effects of treatment. If the new technologies can consistently achieve better outcomes, then they may be cost effective. PATIENT SUMMARY We review the cost and cost effectiveness of robot-assisted radical prostatectomy, intensity-modulated radiotherapy, and proton beam therapy in prostate cancer treatment. These technologies are costlier than their traditional counterparts. It remains unclear whether their use is associated with improved cure and reduced morbidity, and whether the increased cost is worth the expense.
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Affiliation(s)
- Florian Rudolf Schroeck
- White River Junction VA Medical Center, White River Junction, VT, USA; Section of Urology and Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA.
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sam B Bhayani
- Division of Urology, Washington University School of Medicine, St Louis, MO, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - David Penson
- Department of Urologic Surgery, Vanderbilt University, Nashville, TN, USA; VA Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - Jim Hu
- Department of Urology, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY, USA
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9
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Redmond EJ, Dolbec KS, Fawaz AS, Flood HD, Giri SK. Hospital burden of long-term genitourinary and gastrointestinal toxicity after radical radiotherapy for prostate cancer. Surgeon 2017; 16:171-175. [PMID: 28988618 DOI: 10.1016/j.surge.2017.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 08/06/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Treatment options for prostate cancer (PCa) include radical radiotherapy (RT) and radical prostatectomy, both of which have comparable oncological outcomes. The aim of this study was to investigate the hospital burden of long-term genitourinary and gastrointestinal toxicity among patients with PCa who were treated with radiotherapy at our institution. METHODS The radiotherapy department database was used retrospectively to identify all patients who underwent radiotherapy for PCa from January 2006 to January 2008. The patient administration system from each public hospital in the region was interrogated and all patient points of contact were recorded. Minimum follow up was 5 years. Individual patient charts were reviewed and factors that might influence outcomes were documented. RESULTS We identified 112 patients. The mean age at diagnosis was 66 (44-76) and the median PSA was 12.1 (3.2-38). The mean duration of follow-up was 7.8 yrs. Twenty-three patients (20%) presented to the Emergency Department (ED) with late onset toxicity. Nine patients had more than 2 ED attendances. Twenty-five patients (22%) were investigated for genitourinary toxicity. Forty-seven patients (42%) underwent investigation for gastrointestinal side-effects and 45% of these required argon therapy (21/47). CONCLUSION We found a significant hospital burden related to the management of gastrointestinal and genitourinary toxicity post radical radiotherapy for prostate cancer. As health care reforms gain momentum, policy makers must take into account the considerable longitudinal health care cost related to radiotherapy. It is also important that patients are counselled carefully in relation to potential long-term side-effects.
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Affiliation(s)
- Elaine J Redmond
- Department of Urology, University Hospital of Limerick, Limerick, Ireland.
| | | | - Aisling S Fawaz
- Graduate Entry Medical School, University of Limerick, Ireland
| | - Hugh D Flood
- Department of Urology, University Hospital of Limerick, Limerick, Ireland
| | - Subhasis K Giri
- Department of Urology, University Hospital of Limerick, Limerick, Ireland
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Hyldgård VB, Laursen KR, Poulsen J, Søgaard R. Robot-assisted surgery in a broader healthcare perspective: a difference-in-difference-based cost analysis of a national prostatectomy cohort. BMJ Open 2017; 7:e015580. [PMID: 28733299 PMCID: PMC5642660 DOI: 10.1136/bmjopen-2016-015580] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To estimate costs attributable to robot-assisted laparoscopic prostatectomy (RALP) as compared with open prostatectomy (OP) and laparoscopic prostatectomies (LP) in a National Health Service perspective. PATIENTS AND METHODS Register-based cohort study of 4309 consecutive patients who underwent prostatectomy from 2006 to 2013 (2241 RALP, 1818 OP and 250 LP). Patients were followed from 12 months before to 12 months after prostatectomy with respect to service use in primary care (general practitioners, therapists, specialists etc) and hospitals (inpatient and outpatient activity related to prostatectomy and comorbidity). Tariffs of the activity-based remuneration system for primary care and the Diagnosis-Related Grouping case-mix system for hospital-based care were used to value service use. Costs attributable to RALP were estimated using a difference-in-difference analytical approach and adjusted for patient-level and hospital-level risk selection using multilevel regression. RESULTS No significant effect of RALP on resource-use was observed except for a marginally lower use of primary care and fewer bed days as compared with OP (not LP). The overall cost consequence of RALP was estimated at an additional €2459 (95% CI 1377 to 3540, p=0.003) as compared with OP and an additional €3860 (95% CI 559 to 7160, p=0.031) as compared with LP, mainly due to higher cost intensity during the index admissions. CONCLUSIONS In this study from the Danish context, the use of RALP generates a factor 1.3 additional cost when compared with OP and a factor 1.6 additional cost when compared with LP, on average, based on 12 months follow-up. The policy interpretation is that the use of robots for prostatectomy should be driven by clinical superiority and that formal effectiveness analysis is required to determine whether the current and eventual new purchasing of robot capacity is best used for prostatectomy.
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Affiliation(s)
- Vibe Bolvig Hyldgård
- Health Economics, DEFACTUM, Central Denmark Region, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - Johan Poulsen
- Department of Urology, Aalborg University Hospital, Aalborg, Denmark
- Department of Urology, King’s College Hospital, London, UK
| | - Rikke Søgaard
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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11
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Becerra V, Ávila M, Jimenez J, Cortes-Sanabria L, Pardo Y, Garin O, Pont A, Alonso J, Cots F, Ferrer M. Economic evaluation of treatments for patients with localized prostate cancer in Europe: a systematic review. BMC Health Serv Res 2016; 16:541. [PMID: 27716267 PMCID: PMC5048403 DOI: 10.1186/s12913-016-1781-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 09/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Our objective was to assess the efficiency of treatments in patients with localized prostate cancer, by synthesizing available evidence from European economic evaluations through systematic review. METHODS Articles published 2000-2015 were searched in MEDLINE, EMBASE and NHS EED (Prospero protocol CRD42015022063). Two authors independently selected studies for inclusion and extracted the data. A third reviewer resolved discrepancies. We included European economic evaluations or cost comparison studies, of any modality of surgery or radiotherapy treatments, regardless the comparator/s. Drummond's Checklist was used for quality assessment. RESULTS After reviewing 8,789 titles, 13 European eligible studies were included: eight cost-utility, two cost-effectiveness, one cost-minimization, and two cost-comparison analyses. Of them, five compared interventions with expectant management, four contrasted robotic with non robotic-assisted surgery, three assessed new modalities of radiotherapy, and three compared radical prostatectomy with brachytherapy. All but two studies scored ≥8 in the quality checklist. Considering scenario and comparator, three interventions were qualified as dominant strategies (active surveillance, robotic-assisted surgery and IMRT), and six were cost-effective (radical prostatectomy, robotic-assisted surgery, IMRT, proton therapy, brachytherapy, and 3DCRT). However, QALY gains in most of them were small. For interventions considered as dominant strategies, QALY gain was 0.013 for active surveillance over radical prostatectomy; and 0.007 for robotic-assisted over non-robotic techniques. The highest QALY gains were 0.57-0.86 for radical prostatectomy vs watchful waiting, and 0.72 for brachytherapy vs conventional radiotherapy. CONCLUSIONS Currently, relevant treatment alternatives for localized prostate cancer are scarcely evaluated in Europe. Very limited available evidence supports the cost-effectiveness of radical prostatectomy over watchful waiting, brachytherapy over radical prostatectomy, and new treatment modalities over traditional procedures. Relevant disparities were detected among studies, mainly based on effectiveness. These apparently contradictory results may be reflecting the difficulty of interpreting small differences between treatments regarding QALY gains.
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Affiliation(s)
- Virginia Becerra
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain
| | - Mónica Ávila
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Jorge Jimenez
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Laura Cortes-Sanabria
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, IMSS, Guadalajara, México
| | - Yolanda Pardo
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Olatz Garin
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Angels Pont
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Jordi Alonso
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain.,CIBER en Epidemiología y Salud Pública, CIBERESP, Madrid, Spain
| | - Francesc Cots
- Epidemiology and Evaluation Department, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Health Services Research on Chronic Patients Network (Red de Investigación en Servicios de Salud en Enfermedades Crónicas [REDISSEC]), Barcelona, Spain
| | - Montse Ferrer
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain. .,Universitat Pompeu Fabra, Barcelona, Spain. .,Universitat Autònoma de Barcelona, Bellaterra, Spain.
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12
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Seo HJ, Lee NR, Son SK, Kim DK, Rha KH, Lee SH. Comparison of Robot-Assisted Radical Prostatectomy and Open Radical Prostatectomy Outcomes: A Systematic Review and Meta-Analysis. Yonsei Med J 2016; 57:1165-77. [PMID: 27401648 PMCID: PMC4960383 DOI: 10.3349/ymj.2016.57.5.1165] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 04/08/2016] [Accepted: 07/08/2016] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To systematically update evidence on the clinical efficacy and safety of robot-assisted radical prostatectomy (RARP) versus retropubic radical prostatectomy (RRP) in patients with prostate cancer. MATERIALS AND METHODS Electronic databases, including ovidMEDLINE, ovidEMBASE, the Cochrane Library, KoreaMed, KMbase, and others, were searched, collecting data from January 1980 to August 2013. The quality of selected systematic reviews was assessed using the revised assessment of multiple systematic reviews and the modified Cochrane Risk of Bias tool for non-randomized studies. RESULTS A total of 61 studies were included, including 38 from two previous systematic reviews rated as best available evidence and 23 additional studies that were more recent. There were no randomized controlled trials. Regarding safety, the risk of complications was lower for RARP than for RRP. Among functional outcomes, the risk of urinary incontinence was lower and potency rate was significantly higher for RARP than for RRP. Regarding oncologic outcomes, positive margin rates were comparable between groups, and although biochemical recurrence (BCR) rates were lower for RARP than for RRP, recurrence-free survival was similar after long-term follow up. CONCLUSION RARP might be favorable to RRP in regards to post-operative complications, peri-operative outcomes, and functional outcomes. Positive margin and BCR rates were comparable between the two procedures. As most of studies were of low quality, the results presented should be interpreted with caution, and further high quality studies controlling for selection, confounding, and selective reporting biases with longer-term follow-up are needed to determine the clinical efficacy and safety of RARP.
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Affiliation(s)
- Hyun Ju Seo
- Department of Nursing, College of Medicine, Chosun University, Gwangju, Korea
- Department of Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Na Rae Lee
- Department of Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
- Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University, Seoul, Korea
| | - Soo Kyung Son
- Department of Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
- Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University, Seoul, Korea
| | - Dae Keun Kim
- Department of Urology, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Koon Ho Rha
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
| | - Seon Heui Lee
- Department of Nursing Science, College of Nursing, Gachon University, Incheon, Korea.
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13
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Sham JG, Richards MK, Seo YD, Pillarisetty VG, Yeung RS, Park JO. Efficacy and cost of robotic hepatectomy: is the robot cost-prohibitive? J Robot Surg 2016; 10:307-313. [PMID: 27153838 DOI: 10.1007/s11701-016-0598-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/26/2016] [Indexed: 12/11/2022]
Abstract
Robotic technology is being utilized in multiple hepatobiliary procedures, including hepatic resections. The benefits of minimally invasive surgical approaches have been well documented; however, there is some concern that robotic liver surgery may be prohibitively costly and therefore should be limited on this basis. A single-institution, retrospective cohort study was performed of robotic and open liver resections performed for benign and malignant pathologies. Clinical and cost outcomes were analyzed using adjusted generalized linear regression models. Clinical and cost data for 71 robotic (RH) and 88 open (OH) hepatectomies were analyzed. Operative time was significantly longer in the RH group (303 vs. 253 min; p = 0.004). Length of stay was more than 2 days shorter in the RH group (4.2 vs. 6.5 days; p < 0.001). RH perioperative costs were higher ($6026 vs. $5479; p = 0.047); however, postoperative costs were significantly lower, resulting in lower total hospital direct costs compared with OH controls ($14,754 vs. $18,998; p = 0.001). Robotic assistance is safe and effective while performing major and minor liver resections. Despite increased perioperative costs, overall RH direct costs are not greater than OH, the current standard of care.
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Affiliation(s)
- Jonathan G Sham
- Department of Surgery, Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, 1959 Pacific St NE, Seattle, WA, 98195, USA.
| | - Morgan K Richards
- Department of Surgery, Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, 1959 Pacific St NE, Seattle, WA, 98195, USA
| | - Y David Seo
- Department of Surgery, Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, 1959 Pacific St NE, Seattle, WA, 98195, USA
| | - Venu G Pillarisetty
- Department of Surgery, Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, 1959 Pacific St NE, Seattle, WA, 98195, USA
| | - Raymond S Yeung
- Department of Surgery, Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, 1959 Pacific St NE, Seattle, WA, 98195, USA
| | - James O Park
- Department of Surgery, Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, 1959 Pacific St NE, Seattle, WA, 98195, USA
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14
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O'Neil B, Koyama T, Alvarez J, Conwill RM, Albertsen PC, Cooperberg MR, Goodman M, Greenfield S, Hamilton AS, Hoffman KE, Hoffman RM, Kaplan SH, Stanford JL, Stroup AM, Paddock LE, Wu XC, Stephenson RA, Resnick MJ, Barocas DA, Penson DF. The Comparative Harms of Open and Robotic Prostatectomy in Population Based Samples. J Urol 2016; 195:321-9. [PMID: 26343985 PMCID: PMC4916911 DOI: 10.1016/j.juro.2015.08.092] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Robotic assisted radical prostatectomy has largely replaced open radical prostatectomy for the surgical management of prostate cancer despite conflicting evidence of superiority with respect to disease control or functional sequelae. Using population cohort data, in this study we examined sexual and urinary function in men undergoing open radical prostatectomy vs those undergoing robotic assisted radical prostatectomy. MATERIALS AND METHODS Subjects surgically treated for prostate cancer were selected from 2 large population based prospective cohort studies, the Prostate Cancer Outcomes Study (enrolled 1994 to 1995) and the Comparative Effectiveness Analysis of Surgery and Radiation (enrolled 2011 to 2012). Subjects completed baseline, 6-month and 12-month standardized patient reported outcome measures. Main outcomes were between-group differences in functional outcome scores at 6 and 12 months using linear regression, and adjusting for baseline function, sociodemographic and clinical characteristics. Sensitivity analyses were used to evaluate outcomes between patients undergoing open radical prostatectomy and robotic assisted radical prostatectomy within and across CEASAR and PCOS. RESULTS The combined cohort consisted of 2,438 men, 1,505 of whom underwent open radical prostatectomy and 933 of whom underwent robotic assisted radical prostatectomy. Men treated with robotic assisted radical prostatectomy reported better urinary function at 6 months (mean difference 3.77 points, 95% CI 1.09-6.44) but not at 12 months (1.19, -1.32-3.71). Subjects treated with robotic assisted radical prostatectomy also reported superior sexual function at 6 months (8.31, 6.02-10.56) and at 12 months (7.64, 5.25-10.03). Sensitivity analyses largely supported the sexual function findings with inconsistent support for urinary function results. CONCLUSIONS This population based study reveals that men undergoing robotic assisted radical prostatectomy likely experience less decline in early urinary continence and sexual function than those undergoing open radical prostatectomy. The clinical meaning of these differences is uncertain and longer followup will be required to establish whether these benefits are durable.
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Affiliation(s)
- Brock O'Neil
- Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee.
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - JoAnn Alvarez
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | | | - Peter C Albertsen
- Division of Urology, University of Connecticut Health Center, Farmington, Connecticut
| | | | - Michael Goodman
- Department of Epidemiology, Emory University, Atlanta, Georgia
| | | | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Karen E Hoffman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard M Hoffman
- Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Sherrie H Kaplan
- Department of Medicine, University of California, Irvine, Irvine
| | - Janet L Stanford
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Xiao-Cheng Wu
- Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Robert A Stephenson
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Matthew J Resnick
- Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee; Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Daniel A Barocas
- Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee; Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee
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15
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Perlbarg J, Rabetrano H, Soulié M, Salomon L, Durand-Zaleski I. [Economic evaluation of the treatments of non-metastatic prostate cancer]. Prog Urol 2015; 25:1108-15. [PMID: 26519969 DOI: 10.1016/j.purol.2015.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 07/29/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Prostate cancer is the most frequent cancer and the third leading cause of cancer death in men in France. The development of treatment for prostate cancer is fast and sometimes relies on costly innovations. Medico-economic studies are however rare in this area. This literature review aims to summarize available medico-economic data on the initial management of localized prostate cancer and discuss the quality and usability of existing economic studies on the subject. MATERIALS AND METHOD Literature review was done using PubMed and Cochrane databases. Studies and articles were selected based on several criteria: population with initial treatment for localized prostate cancer (without metastasis), comparative studies with surgery as control treatment, studies in countries members of the OECD, articles in English or French published between 2004 and 2014. RESULTS The surgical robot, one of the newest innovations, is more expensive than conventional open surgery or no robotic laparoscopy, even if it is associated with a reduction of the original period of stay. Radiation therapy seems more expensive than surgery as initial therapy of localized prostate cancer. CONCLUSION Conclusions remain limited because of the rarity of reliable health economic studies on the subject.
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Affiliation(s)
- J Perlbarg
- URC-Eco (unité de recherche clinique spécialisée en économie de la santé), Hôtel-Dieu, AP-HP, 1, place du Parvis-Notre-Dame, 75004 Paris, France
| | - H Rabetrano
- URC-Eco (unité de recherche clinique spécialisée en économie de la santé), Hôtel-Dieu, AP-HP, 1, place du Parvis-Notre-Dame, 75004 Paris, France
| | - M Soulié
- Département d'urologie-andrologie-transplantation rénale, CHU Rangueil, 1, avenue Jean-Poulhès, 31059 Toulouse cedex 9, France
| | - L Salomon
- Service d'urologie et de transplantation rénale et pancréatique, CHU Mondor, 51, avenue Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France.
| | - I Durand-Zaleski
- URC-Eco (unité de recherche clinique spécialisée en économie de la santé), Hôtel-Dieu, AP-HP, 1, place du Parvis-Notre-Dame, 75004 Paris, France
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16
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Tandogdu Z, Vale L, Fraser C, Ramsay C. A Systematic Review of Economic Evaluations of the Use of Robotic Assisted Laparoscopy in Surgery Compared with Open or Laparoscopic Surgery. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:457-67. [PMID: 26239361 DOI: 10.1007/s40258-015-0185-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Robot assisted laparoscopic (RAL) surgery developed to overcome the limitations of laparoscopy to assist in surgical procedures, has high capital and operating costs. Systematically assembled evidence demonstrating its clinical and cost effectiveness would be helpful for its adoption by decision makers. OBJECTIVE To summarise the evidence on the cost-effectiveness of robot-assisted laparoscopic (RAL) surgery compared with relevant alternatives. Methods and results of identified studies were assessed to identify the deficiencies in evidence and areas for further research. METHODS Studies reporting both costs and outcomes for comparisons of RAL with laparoscopy and/or open surgery were systematically identified. Searches were conducted in February 2015 on MEDLINE, EMBASE and NHS EED. Quality of the included studies was assessed against a standard checklist for economic analyses. Length of hospital stay and operating time (determinants of cost), cost of intervention, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) were extracted. To aid comparison, costs were converted into a common currency and price year (2014 US dollars). RESULTS Forty-seven eligible studies were identified (full economic evaluation n = 6 and cost analysis n = 41). Economic models were used in 11 (23%) studies. Only three studies used a model considered representative of the disease and clinical pathway with a time-horizon allowing capture of relevant differences in outcomes across strategies. The cost of RAL varied substantially between uses, ranging from US$7011 for hysterectomy to over US$30,000 for radical cystectomy. The majority of estimates were between US$15,000 and US$25,000 per person. In part this difference is explained by the difference between studies in which costs were included. It was also identified to have higher costs than the alternatives it was compared against. Incremental cost per QALY for RAL radical prostatectomy was US$28,801-$31,763 over a 10-year period assuming 200 cases per annum. CONCLUSION The clinical evidence available for RAL overall and used within included studies is limited. RAL surgery costs were consistently higher than open and laparoscopic surgery. Therefore, in adopting the robotic technology decision makers need to take into account the cost effectiveness within their own systems. Economic models generated and published for radical prostatectomy and hysterectomy may be adapted to other health systems if the care pathway is similar to provide locally relevant data.
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Affiliation(s)
- Zafer Tandogdu
- Northern Institute for Cancer Research, Newcastle University, Newcastle Upon Tyne, UK
- Health Economics Group, Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Luke Vale
- Health Economics Group, Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
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17
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Sotelo RJ, Haese A, Machuca V, Medina L, Nuñez L, Santinelli F, Hernandez A, Kural AR, Mottrie A, Giedelman C, Mirandolino M, Palmer K, Abaza R, Ghavamian R, Shalhav A, Moinzadeh A, Patel V, Stifelman M, Tuerk I, Canes D. Safer Surgery by Learning from Complications: A Focus on Robotic Prostate Surgery. Eur Urol 2015; 69:334-44. [PMID: 26385157 DOI: 10.1016/j.eururo.2015.08.060] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 08/31/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND The uptake of robotic surgery has led to changes in potential operative complications, as many surgeons learn minimally invasive surgery, and has allowed the documentation of such complications through the routine collection of intraoperative video. OBJECTIVE We documented intraoperative complications from robot-assisted radical prostatectomy (RARP) with the aim of reporting the mechanisms, etiology, and necessary steps to avoid them. Our goal was to facilitate learning from these complications to improve patient care. DESIGN, SETTING, AND PARTICIPANTS Contributors delivered videos of complications that occurred during laparoscopic and robotic prostatectomy between 2010 and 2015. SURGICAL PROCEDURE Surgical footage was available for a variety of complications during RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Based on these videos, a literature search was performed using relevant terms (prostatectomy, robotic, complications), and the intraoperative steps of the procedures and methods of preventing complications were outlined. RESULTS AND LIMITATIONS As a major surgical procedure, RARP has much potential for intra- and postoperative complications related to patient positioning, access, and the procedure itself. However, with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, we suggest that the majority of such complications are preventable. CONCLUSIONS Considering the complexity of the procedure, RARP is safe and reproducible for the surgical management of prostate cancer. Insight from experienced surgeons may allow surgeons to avoid complications during the learning curve. PATIENT SUMMARY Robot-assisted radical prostatectomy has potential for intra- and postoperative complications, but with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, most complications are preventable.
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Affiliation(s)
- René J Sotelo
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela; University of Southern California, Los Angeles, CA, USA.
| | - Alexander Haese
- Martini Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany
| | - Victor Machuca
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela
| | - Luis Medina
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela
| | - Luciano Nuñez
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela
| | | | | | | | | | | | | | | | - Ronney Abaza
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Arieh Shalhav
- Duchossois Center for Advanced Medicine, Chicago, IL, USA
| | - Alireza Moinzadeh
- Lahey Hospital and Medical Center Institute of Urology, Burlington, MA, USA
| | - Vipul Patel
- Global Robotics Institute, Celebration, FL, USA
| | | | - Ingolf Tuerk
- St. Elizabeth's Medical Center, Brighton, MA, USA
| | - David Canes
- Lahey Hospital and Medical Center Institute of Urology, Burlington, MA, USA
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18
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Leyvi G, Schechter CB, Sehgal S, Greenberg MA, Snyder M, Forest S, Mais A, Wang N, DeLeo P, DeRose JJ. Comparison of Index Hospitalization Costs Between Robotic CABG and Conventional CABG: Implications for Hybrid Coronary Revascularization. J Cardiothorac Vasc Anesth 2015; 30:12-8. [PMID: 26597467 DOI: 10.1053/j.jvca.2015.07.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the direct costs of the index hospitalization and 30-day morbidity and mortality incurred during robotic and conventional coronary artery bypass grafting at a single institution based on hospital clinical and financial records. DESIGN Retrospective study, propensity-matched groups with one-to-one nearest neighbor matching. SETTING University hospital, a tertiary care center. PARTICIPANTS Two thousand eighty-eight consecutive patients who underwent primary coronary artery bypass grafting (CABG) from January 2007 to March 2012. INTERVENTIONS One hundred forty-one matched pairs were created and analyzed. MEASUREMENTS AND MAIN RESULTS Robotic CABG was associated with a decrease in operative time (5.61±1.1 v 6.6±1.15 hours, p<0.001), a lower need for blood transfusion (12.8% v 22.6%, p = 0.04), a shorter length of stay (6 [4-9]) v 7 [5-11] days, p = 0.001), a shorter ICU stay (31 [24-49] hours v 52 [32-96.5] hours, p<0.001) and lower NY state complications composite rate (4.26% v 13.48%, p = 0.01). In spite of that, the cost of robotic procedures was not significantly different from matched conventional cases ($18,717.35 [11,316.1-34,550.6] versus $18,601 [13,137-50,194.75], p = 0.13), except 26 hybrid coronary revascularizations in which angioplasty was performed on the same admission (hybrid 25,311.1 [18,537.1-41,167.85] versus conventional 18,966.13 [13,337.75-56,021.75], p = 0.02). CONCLUSION Robotically assisted CABG does not increase the cost of the index hospitalization when compared to conventional CABG unless hybrid revascularization is performed on the same admission.
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Affiliation(s)
- Galina Leyvi
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Bronx, NY.
| | | | - Sankalp Sehgal
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Bronx, NY
| | | | - Max Snyder
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Bronx, NY
| | - Stephen Forest
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, NY
| | - Alec Mais
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Bronx, NY
| | | | - Patrice DeLeo
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, NY
| | - Joseph J DeRose
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, NY
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19
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Imkamp F, Herrmann TR, Tolkach Y, Dziuba S, Stolzenburg JU, Rassweiler J, Sulser T, Zimmermann U, Merseburger AS, Kuczyk MA, Burchardt M. Acceptance, Prevalence and Indications for Robot-Assisted Laparoscopy - Results of a Survey Among Urologists in Germany, Austria and Switzerland. Urol Int 2015; 95:336-45. [DOI: 10.1159/000430502] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 04/13/2015] [Indexed: 11/19/2022]
Abstract
Background: Robotic-assisted laparoscopy (RAL) is being widely accepted in the field of urology as a replacement for conventional laparoscopy (CL). Nevertheless, the process of its integration in clinical routines has been rather spontaneous. Objective: To determine the prevalence of robotic systems (RS) in urological clinics in Germany, Austria and Switzerland, the acceptance of RAL among urologists as a replacement for CL and its current use for 25 different urological indications. Materials and Methods: To elucidate the practice patterns of RAL, a survey at hospitals in Germany, Austria and Switzerland was conducted. All surgically active urology departments in Germany (303), Austria (37) and Switzerland (84) received a questionnaire with questions related to the one-year period prior to the survey. Results: The response rate was 63%. Among the participants, 43% were universities, 45% were tertiary care centres, and 8% were secondary care hospitals. A total of 60 RS (Germany 35, Austria 8, Switzerland 17) were available, and the majority (68%) were operated under public ownership. The perception of RAL and the anticipated superiority of RAL significantly differed between robotic and non-robotic surgeons. For only two urologic indications were more than 50% of the procedures performed using RAL: pyeloplasty (58%) and transperitoneal radical prostatectomy (75%). On average, 35% of robotic surgeons and only 14% of non-robotic surgeons anticipated RAL superiority in some of the 25 indications. Conclusions: This survey provides a detailed insight into RAL implementation in Germany, Austria and Switzerland. RAL is currently limited to a few urological indications with a small number of high-volume robotic centres. These results might suggest that a saturation of clinics using RS has been achieved but that the existing robotic capacities are being utilized ineffectively. The possible reasons for this finding are discussed, and certain strategies to solve these problems are offered.
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The role of open and laparoscopic stone surgery in the modern era of endourology. Nat Rev Urol 2015; 12:392-400. [DOI: 10.1038/nrurol.2015.141] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Kim CW, Baik SH, Roh YH, Kang J, Hur H, Min BS, Lee KY, Kim NK. Cost-effectiveness of robotic surgery for rectal cancer focusing on short-term outcomes: a propensity score-matching analysis. Medicine (Baltimore) 2015; 94:e823. [PMID: 26039115 PMCID: PMC4616367 DOI: 10.1097/md.0000000000000823] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Although the total cost of robotic surgery (RS) is known to be higher than that of laparoscopic surgery (LS), the cost-effectiveness of RS has not yet been verified. The aim of the study is to clarify the cost-effectiveness of RS compared with LS for rectal cancer.From January 2007 through December 2011, 311 and 560 patients underwent totally RS and conventional LS for rectal cancer, respectively. A propensity score-matching analysis was performed with a ratio of 1:1 to reduce the possibility of selection bias. Costs and perioperative short-term outcomes in both the groups were compared. Additional costs due to readmission were also analyzed.The characteristics of the patients were not different between the 2 groups. Most perioperative outcomes were not different between the groups except for the operation time. Complications within 30 days of surgery were not significantly different. Total hospital charges and patients' bill were higher in RS than in LS. The total hospital charges for patients who recovered with or without complications were higher in RS than in LS, although their short-term outcomes were similar. In patients with complications, the postoperative course after RS appeared to be milder than that of LS. Total hospital charges for patients who were readmitted due to complications were similar between the groups.RS showed similar short-term outcomes with higher costs than LS. Therefore, cost-effectiveness focusing on short-term perioperative outcomes of RS was not demonstrated.
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Affiliation(s)
- Chang Woo Kim
- Division of Colon and Rectal Surgery (CWK, SHB, JK, HH, BSM, KYL, NKK), Department of Surgery, Severance Hospital; and Biostatistics Collaboration Unit (YHR), Yonsei University College of Medicine, Seoul, South Korea
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Kim J, ElRayes W, Wilson F, Su D, Oleynikov D, Morien M, Chen LW. Disparities in the receipt of robot-assisted radical prostatectomy: between-hospital and within-hospital analysis using 2009-2011 California inpatient data. BMJ Open 2015; 5:e007409. [PMID: 25941184 PMCID: PMC4420943 DOI: 10.1136/bmjopen-2014-007409] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Despite the rapid proliferation of robot-assisted radical prostatectomy (RARP), little attention has been paid to patient utilisation of this newest surgical innovation and barriers that may result in disparities in access to RARP. The goal of this study is to identify demographic and economic factors that decrease the likelihood of patients with prostate cancer (PC) receiving RARP. DESIGN, SETTING AND PARTICIPANTS A retrospective, pooled, cross-sectional study was conducted using 2009-2011 California State Inpatient Data and American Hospital Association data. Patients who were diagnosed with PC and underwent radical prostatectomy (RP) from 225 hospitals in California were identified, using ICD-9-CM diagnosis and procedure codes. PRIMARY OUTCOME MEASURES Patients' likelihood of receiving RARP was associated with patient and hospital characteristics using the two models: (1) between-hospital and (2) within-hospital models. Multivariate binomial logistic regression was used for both models. The first model predicted patient access to RARP-performing hospitals versus non-RARP-performing hospitals, after adjusting for patient and hospital-level covariates (between-hospital variation). The second model examined the likelihood of patients receiving RARP within RARP-performing hospitals (within-hospital variation). RESULTS Among 20,411 patients who received RP, 13,750 (67.4%) received RARP, while 6661 (32.6%) received non-RARP. This study found significant differences in access to RARP-performing hospitals when race/ethnicity, income and insurance status were compared, after controlling for selected confounding factors (all p<0.001). For example, Hispanic, Medicare and Medicaid patients were more likely to be treated at non-RARP-performing hospitals versus RARP-performing hospitals. Within RARP-performing hospitals, Medicaid patients had 58% lower odds of receiving RARP versus non-RARP (adjusted OR 0.42, p<0.001). However, there were no significant differences by race/ethnicity or income within RARP-performing hospitals. CONCLUSIONS Significant differences exist by race/ethnicity and payer status in accessing RARP-performing hospitals. Furthermore, payer status continues to be an important predictor of receiving RARP within RARP-performing hospitals.
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Affiliation(s)
- Jungyoon Kim
- Department of Health Services Research & Administration, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Wael ElRayes
- Department of Health Services Research & Administration, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Fernando Wilson
- Department of Health Services Research & Administration, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Dejun Su
- Department of Health Promotion, Social and Behavioral Health, Center for Reducing Health Disparities, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Dmitry Oleynikov
- Center for Advanced Surgical Technology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Marsha Morien
- Department of Health Services Research & Administration, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Li-Wu Chen
- Department of Health Services Research & Administration, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Independent predictors of prolonged operative time during robotic-assisted radical prostatectomy. J Robot Surg 2015; 9:117-23. [DOI: 10.1007/s11701-015-0497-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/16/2015] [Indexed: 12/20/2022]
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ARE POLICY DECISIONS ON SURGICAL PROCEDURES INFORMED BY ROBUST ECONOMIC EVIDENCE? A SYSTEMATIC REVIEW. Int J Technol Assess Health Care 2014; 30:381-93. [DOI: 10.1017/s0266462314000531] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives: The aim of this study was to examine the empirical and methodological cost-effectiveness evidence of surgical interventions for breast, colorectal, or prostate cancer.Methods: A systematic search of seven databases including MEDLINE, EMBASE, and NHSEED, research registers, the NICE Web site and conference proceedings was conducted in April 2012. Study quality was assessed in terms of meeting essential, preferred and UK NICE specific requirements for economic evaluations.Results: The seventeen (breast = 3, colorectal = 7, prostate = 7) included studies covered a broad range of settings (nine European; eight non-European) and six were published over 10 years ago. The populations, interventions and comparators were generally well defined. Very few studies were informed by literature reviews and few used synthesized clinical evidence. Although the interventions had potential differential effects on recurrence and mortality rates, some studies used relatively short time horizons. Univariate sensitivity analyses were reported in all studies but less than a third characterized all uncertainty with a probabilistic sensitivity analysis. Although a third of studies incorporated patients’ health-related quality of life data, only four studies used social tariff values.Conclusions: There is a dearth of recent robust evidence describing the cost-effectiveness of surgical interventions in the management of breast, colorectal and prostate cancers. Many of the recent publications did not satisfy essential methodological requirements such as using clinical evidence informed by a systematic review and synthesis. Given the ratio of potential benefit and harms associated with cancer surgery and the volume of resources consumed by these, there is an urgent need to increase economic evaluations of these technologies.
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Teljeur C, O'Neill M, Moran PS, Harrington P, Flattery M, Murphy L, Ryan M. Economic evaluation of robot-assisted hysterectomy: a cost-minimisation analysis. BJOG 2014; 121:1546-53. [DOI: 10.1111/1471-0528.12836] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2014] [Indexed: 11/28/2022]
Affiliation(s)
- C Teljeur
- Health Information and Quality Authority; Dublin Ireland
| | - M O'Neill
- Health Information and Quality Authority; Dublin Ireland
| | - PS Moran
- Health Information and Quality Authority; Dublin Ireland
| | - P Harrington
- Health Information and Quality Authority; Dublin Ireland
| | - M Flattery
- Health Information and Quality Authority; Dublin Ireland
| | - L Murphy
- Health Information and Quality Authority; Dublin Ireland
| | - M Ryan
- Health Information and Quality Authority; Dublin Ireland
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Using prediction intervals from random-effects meta-analyses in an economic model. Int J Technol Assess Health Care 2014; 30:44-9. [PMID: 24472222 DOI: 10.1017/s0266462313000676] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES When incorporating treatment effect estimates derived from a random-effect meta-analysis it is tempting to use the confidence bounds to determine the potential range of treatment effect. However, prediction intervals reflect the potential effect of a technology rather than the more narrowly defined average treatment effect. Using a case study of robot-assisted radical prostatectomy, this study investigates the impact on a cost-utility analysis of using clinical effectiveness derived from random-effects meta-analyses presented as confidence bounds and prediction intervals, respectively. METHODS To determine the cost-utility of robot-assisted prostatectomy, an economic model was developed. The clinical effectiveness of robot-assisted surgery compared with open and conventional laparoscopic surgery was estimated using meta-analysis of peer-reviewed publications. Assuming treatment effect would vary across studies due to both sampling variability and differences between surgical teams, random-effects meta-analysis was used to pool effect estimates. RESULTS Using the confidence bounds approach the mean and median ICER was €24,193 and €26,731/QALY (95%CI: €13,752 to €68,861/QALY), respectively. The prediction interval approach produced an equivalent mean and median ICER of €26,920 and €26,643/QALY (95%CI: -€135,244 to €239,166/QALY), respectively. Using prediction intervals, there is a probability of 0.042 that robot-assisted surgery will result in a net reduction in QALYs. CONCLUSIONS Using prediction intervals rather than confidence bounds does not affect the point estimate of the treatment effect. In meta-analyses with significant heterogeneity, the use of prediction intervals will produce wider ranges of treatment effect, and hence result in greater uncertainty, but a better reflection of the effect of the technology.
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Close A, Robertson C, Rushton S, Shirley M, Vale L, Ramsay C, Pickard R. Comparative cost-effectiveness of robot-assisted and standard laparoscopic prostatectomy as alternatives to open radical prostatectomy for treatment of men with localised prostate cancer: a health technology assessment from the perspective of the UK National Health Service. Eur Urol 2013; 64:361-9. [PMID: 23498062 DOI: 10.1016/j.eururo.2013.02.040] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 02/25/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Robot-assisted laparoscopic prostatectomy is increasingly used compared with a standard laparoscopic technique, but it remains uncertain whether potential benefits offset higher costs. OBJECTIVE To determine the cost-effectiveness of robotic prostatectomy. DESIGN, SETTING, AND PARTICIPANTS We conducted a care pathway description and model-based cost-utility analysis. We studied men with localised prostate cancer able to undergo either robotic or laparoscopic prostatectomy for cure. We used data from a meta-analysis, other published literature, and costs from the UK National Health Service and commercial sources. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Care received by men for 10 yr following radical prostatectomy was modelled. Clinical events, their effect on quality of life, and associated costs were synthesised assuming 200 procedures were performed annually. RESULTS AND LIMITATIONS Over 10 yr, robotic prostatectomy was on average (95% confidence interval [CI]) £1412 (€1595) (£1304 [€1473] to £1516 [€1713]) more costly than laparoscopic prostatectomy but more effective with mean (95% CI) gain in quality-adjusted life-years (QALYs) of 0.08 (0.01-0.15). The incremental cost-effectiveness ratio (ICER) was £18 329 (€20 708) with an 80% probability that robotic prostatectomy was cost effective at a threshold of £30 000 (€33 894)/QALY. The ICER was sensitive to the throughput of cases and the relative positive margin rate favouring robotic prostatectomy. CONCLUSIONS Higher costs of robotic prostatectomy may be offset by modest health gain resulting from lower risk of early harms and positive margin, provided >150 cases are performed each year. Considerable uncertainty persists in the absence of directly comparative randomised data.
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Affiliation(s)
- Andrew Close
- School of Biology, Newcastle University, Newcastle upon Tyne, UK
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O'Neill M, Moran PS, Teljeur C, O'Sullivan OE, O'Reilly BA, Hewitt M, Flattery M, Ryan M. Robot-assisted hysterectomy compared to open and laparoscopic approaches: systematic review and meta-analysis. Arch Gynecol Obstet 2013; 287:907-18. [PMID: 23291924 DOI: 10.1007/s00404-012-2681-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 12/06/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE To review the safety and effectiveness of robot-assisted hysterectomy compared to traditional open and conventional laparoscopic surgery, differentiating radical, simple total with node staging, and simple total hysterectomy. METHODS Medline, Embase, the Cochrane library, and the Journal of Robotic Surgery were searched for controlled trials and observational studies with historic or concurrent controls. Data were pooled using random effects meta-analysis. RESULTS Compared to open surgery, robot-assisted radical hysterectomy is associated with reduced hospital stay and blood transfusions. For simple total hysterectomy with node staging, robot-assisted surgery is associated with reduced hospital stay, complications, and blood transfusions compared to open surgery. Compared to conventional laparoscopic surgery, robot-assisted simple total hysterectomy with node staging is associated with complications and conversions. CONCLUSIONS Compared to open surgery, robot-assisted hysterectomy offers benefits for reduced length of hospital stay and blood transfusions. The best evidence of improved outcomes is for simple total hysterectomy with node staging. Study quality was poor.
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Affiliation(s)
- Michelle O'Neill
- Health Technology Assessment, Health Information and Quality Authority, George's Court, George's Lane, Dublin 7, Ireland.
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Hyams ES, Mullins JK, Pierorazio PM, Partin AW, Allaf ME, Matlaga BR. Impact of robotic technique and surgical volume on the cost of radical prostatectomy. J Endourol 2012; 27:298-303. [PMID: 22967039 DOI: 10.1089/end.2012.0147] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Our present understanding of the effect of robotic surgery and surgical volume on the cost of radical prostatectomy (RP) is limited. Given the increasing pressures placed on healthcare resource utilization, such determinations of healthcare value are becoming increasingly important. Therefore, we performed a study to define the effect of robotic technology and surgical volume on the cost of RP. METHODS The state of Maryland mandates that all acute-care hospitals report encounter-level and hospital discharge data to the Health Service Cost Review Commission (HSCRC). The HSCRC was queried for men undergoing RP between 2008 and 2011 (the period during which robot-assisted laparoscopic radical prostatectomy [RALRP] was coded separately). High-volume hospitals were defined as >60 cases per year, and high-volume surgeons were defined as >40 cases per year. Multivariate regression analysis was performed to evaluate whether robotic technique and high surgical volume impacted the cost of RP. RESULTS There were 1499 patients who underwent RALRP and 2565 who underwent radical retropubic prostatectomy (RRP) during the study period. The total cost for RALRP was higher than for RRP ($14,000 vs 10,100; P<0.001) based primarily on operating room charges and supply charges. Multivariate regression demonstrated that RALRP was associated with a significantly higher cost (β coeff 4.1; P<0.001), even within high-volume hospitals (β coeff 3.3; P<0.001). High-volume surgeons and high-volume hospitals, however, were associated with a significantly lower cost for RP overall. High surgeon volume was associated with lower cost for RALRP and RRP, while high institutional volume was associated with lower cost for RALRP only. CONCLUSIONS High surgical volume was associated with lower cost of RP. Even at high surgical volume, however, the cost of RALRP still exceeded that of RRP. As robotic surgery has come to dominate the healthcare marketplace, strategies to increase the role of high-volume providers may be needed to improve the cost-effectiveness of prostate cancer surgical therapy.
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Affiliation(s)
- Elias S Hyams
- Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
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Biehn Stewart S, Reed SD, Moul JW. Will the future of health care lead to the end of the robotic golden years? Eur Urol 2012; 65:325-7; discussion 327-8. [PMID: 23116656 DOI: 10.1016/j.eururo.2012.10.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 10/12/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Suzanne Biehn Stewart
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Shelby D Reed
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Judd W Moul
- Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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Bolenz C, Freedland SJ, Hollenbeck BK, Lotan Y, Lowrance WT, Nelson JB, Hu JC. Costs of radical prostatectomy for prostate cancer: a systematic review. Eur Urol 2012; 65:316-24. [PMID: 22981673 DOI: 10.1016/j.eururo.2012.08.059] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 08/28/2012] [Indexed: 12/29/2022]
Abstract
CONTEXT Robot-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted as a new approach for radical prostatectomy (RP) in patients with prostate cancer (PCa). The use of new technology may increase costs for RP. OBJECTIVE To summarize data on direct costs of various approaches to RP and to discuss the consequences of cost differences. EVIDENCE ACQUISITION A systematic literature search was performed in March 2012 using the PubMed, Web of Science, and Cochrane Library databases. A complex search strategy was applied. Articles were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Articles reporting on direct costs of RP (open retropubic [RRP], radical perineal [RPP], laparoscopic [LRP], RALP) in men with clinically localized PCa were eligible for study inclusion. EVIDENCE SYNTHESIS Of 1218 articles initially screened by title, the multistep, systematic search identified 11 studies presenting direct costs of different approaches to RP. Of the 11 studies, 7 compared the costs of different RP approaches. Minimally invasive RP (MIRP) (ie, LRP or RALP) was more expensive than RRP in most studies, mainly due to increased surgical instrumentation costs. In the comparative studies, costs ranged from (in US dollars) $5058 to $11,806 for MIRP and from $4075 to $6296 for RRP, with RALP having the highest direct costs. In one study applying standardized, health economic-evaluation criteria, RALP was not found to be cost effective. Limitations of this review include significant differences in observational study designs and an absence of prospective comparative studies. Moreover, there are limited post-RP data on the costs of adjuvant treatments and other health care-related expenses after PCa surgery. CONCLUSIONS Few studies compared direct costs of different approaches to RP. The use of new technology, particularly RALP, results in added costs for the procedure. Cost effectiveness of new technologies should be assessed before widespread adoption. To date, in the lone study to evaluate this, RALP was not found to be cost effective from a health care, economic standpoint. However, longer follow-up of patients is required to better evaluate its impact on overall costs and quality of PCa care.
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Affiliation(s)
- Christian Bolenz
- Department of Urology, Mannheim Medical Center, University of Heidelberg, Mannheim, Germany.
| | - Stephen J Freedland
- Department of Surgery - Durham VA Medical Center, and Departments of Surgery (Urology) and Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Yair Lotan
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William T Lowrance
- Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Joel B Nelson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jim C Hu
- David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
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Bismarck E, Schmitz-Dräger B, Schöffski O. Was erwartet die Medizin von der Gesundheitsökonomie? Urologe A 2012; 51:533-8. [DOI: 10.1007/s00120-011-2778-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rosenberg J, Fischer A, Haglind E. Current controversies in colorectal surgery: the way to resolve uncertainty and move forward. Colorectal Dis 2012; 14:266-9. [PMID: 22122825 DOI: 10.1111/j.1463-1318.2011.02896.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The are currently a number of unsolved clinical questions in colorectal surgery with new surgical principles being introduced without proper scientific high-level evidence. These include complete mesocolic excision with central ligation for colonic cancer, extralevator abdominoperineal excision for low rectal cancer, robotic surgery for various colorectal procedures, laparoscopic lavage without resection for Hinchey Stage III perforated sigmoid diverticulitis, and the use of the single port technique for laparoscopic surgery. Before general implementation the new modalities should ideally be evalueted in randomized studies and meta-analyses. Many randomized studies, however, cannot give the final answer to the research question because they are underpowered and it is therefore important to perform well-designed studies that are large enough to provide the final answer. A way forward could therefore be to form multicenter and even multinational research groups in order to ensure accrual of sufficient sample sizes.
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Affiliation(s)
- J Rosenberg
- Department of Surgery, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
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Moore CM, Emberton M, Bown SG. Photodynamic therapy for prostate cancer-an emerging approach for organ-confined disease. Lasers Surg Med 2011; 43:768-75. [DOI: 10.1002/lsm.21104] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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