Minimally invasive radical prostatectomy vs. retropubic radical prostatectomy

Jim C. Hu, MD, MPH; Xiangmei Gu, MS; Stuart R. Lipsitz, ScD; Michael J. Barry, MD; Anthony V. D’Amico, MD, PhD; Aaron C. Weinberg, MD; Nancy L. Keating, MD, MPH

JAMA. 2009;302(14):1557-1564. 
Full Text 
Context Minimally invasive radical prostatectomy (MIRP) has diffused rapidly despite limited data on outcomes and greater costs compared with open retropubic radical prostatectomy (RRP).
Objective To determine the comparative effectiveness of MIRP vs RRP.
Design, Setting, and Patients Population-based observational cohort study using US Surveillance, Epidemiology, and End Results Medicare linked data from 2003 through 2007. We identified men with prostate cancer who underwent MIRP (n = 1938) vs RRP (n = 6899).
Main Outcome Measures We compared postoperative 30-day complications, anastomotic stricture 31 to 365 days postoperatively, long-term incontinence and erectile dysfunction more than 18 months postoperatively, and postoperative use of additional cancer therapies, a surrogate for cancer control.
Results Among men undergoing prostatectomy, use of MIRP increased from 9.2% (95% confidence interval [CI], 8.1%-10.5%) in 2003 to 43.2% (95% CI, 39.6%-46.9%) in 2006-2007. Men undergoing MIRP vs RRP were more likely to be recorded as Asian (6.1% vs 3.2%), less likely to be recorded as black (6.2% vs 7.8%) or Hispanic (5.6% vs 7.9%), and more likely to live in areas with at least 90% high school graduation rates (50.2% vs 41.0%) and with median incomes of at least $60 000 (35.8% vs 21.5%) (all P < .001). In propensity score–adjusted analyses, MIRP vs RRP was associated with shorter length of stay (median, 2.0 vs 3.0 days; P<.001) and lower rates of blood transfusions (2.7% vs 20.8%; P < .001), postoperative respiratory complications (4.3% vs 6.6%; P = .004), miscellaneous surgical complications (4.3% vs 5.6%; P = .03), and anastomotic stricture (5.8% vs 14.0%; P < .001). However, MIRP vs RRP was associated with an increased risk of genitourinary complications (4.7% vs 2.1%; P = .001) and diagnoses of incontinence (15.9 vs 12.2 per 100 person-years; P = .02) and erectile dysfunction (26.8 vs 19.2 per 100 person-years; P = .009). Rates of use of additional cancer therapies did not differ by surgical procedure (8.2 vs 6.9 per 100 person-years; P = .35).
Conclusion Men undergoing MIRP vs RRP experienced shorter length of stay, fewer respiratory and miscellaneous surgical complications and strictures, and similar postoperative use of additional cancer therapies but experienced more genitourinary complications, incontinence, and erectile dysfunction.

Author Affiliations: Division of Urologic Surgery (Drs Hu and Weinberg), Center for Surgery and Public Health (Drs Hu, Lipsitz, and Weinberg and Ms Gu), Department of Radiation Oncology (Dr D’Amico), and Division of General Internal Medicine (Dr Keating), Brigham and Women's Hospital, Lank Center for Genitourinary Oncology, Dana Farber Cancer Institute (Dr Hu), The Medical Practices Evaluation Center, Massachusetts General Hospital (Dr Barry), and Department of Health Care Policy, Harvard Medical School (Dr Keating), Boston. 

Comment in

• Minimally invasive vs open radical prostatectomy. [JAMA. 2010]
• Words of wisdom. Re: Comparative effectiveness of minimally invasive vs open radical prostatectomy. [Eur Urol. 2010]
• Words of wisdom. Re: Comparative effectiveness of minimally invasive vs open radical prostatectomy. [Eur Urol. 2010]
• Words of wisdom. Re: comparative effectiveness of minimally invasive versus open radical prostatectomy. [Eur Urol. 2010]

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JAMA. 2013 Apr 17;309(15):1599-606. doi: 10.1001/jama.2013.2773.

Relationship between occurrence of surgical complications and hospital finances.

Eappen S, Lane BH, Rosenberg B, Lipsitz SA, Sadoff D, Matheson D, Berry WR, Lester M, Gawande AA.

Source

Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

Abstract

IMPORTANCE:

The effect of surgical complications on hospital finances is unclear.

OBJECTIVE:

To determine the relationship between major surgical complications and per-encounter hospital costs and revenues by payer type.

DESIGN, SETTING, AND PARTICIPANTS:

Retrospective analysis of administrative data for all inpatient surgical discharges during 2010 from a nonprofit 12-hospital system in the southern United States. Discharges were categorized by principal procedure and occurrence of 1 or more postsurgical complications, using International Classification of Diseases, Ninth Revision, diagnosis and procedure codes. Nine common surgical procedures and 10 major complications across 4 payer types were analyzed. Hospital costs and revenue at discharge were obtained from hospital accounting systems and classified by payer type. MAIN OUTCOMES AND MEASURES: Hospital costs, revenues, and contribution margin (defined as revenue minus variable expenses) were compared for patients with and without surgical complications according to payer type.

RESULTS:

Of 34,256 surgical discharges, 1820 patients (5.3%; 95% CI, 4.4%-6.4%) experienced 1 or more postsurgical complications. Compared with absence of complications, complications were associated with a $39,017 (95% CI, $20,069-$50,394; P < .001) higher contribution margin per patient with private insurance ($55,953 vs $16,936) and a $1749 (95% CI, $976-$3287; P < .001) higher contribution margin per patient with Medicare ($3629 vs $1880). For this hospital system in which private insurers covered 40% of patients (13,544), Medicare covered 45% (15,406), Medicaid covered 4% (1336), and self-payment covered 6% (2202), occurrence of complications was associated with an $8084 (95% CI, $4903-$9740; P < .001) higher contribution margin per patient ($15,726 vs $7642) and with a $7435 lower per-patient total margin (95% CI, $5103-$10,507; P < .001) ($1013 vs -$6422).

CONCLUSIONS AND RELEVANCE:

In this hospital system, the occurrence of postsurgical complications was associated with a higher per-encounter hospital contribution margin for patients covered by Medicare and private insurance but a lower one for patients covered by Medicaid and who self-paid. Depending on payer mix, many hospitals have the potential for adverse near-term financial consequences for decreasing postsurgical complications.

Comment in

The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.

Destroy user interface controlMaking surgical complications pay. [JAMA. 2013]

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Public release date: 9-Jan-2012

Contact: Marge Dwyer
mhdwyer@hsph.harvard.edu
617-432-8416
Harvard School of Public Health 

Nicotine replacement therapies may not be effective in helping people quit smoking

Boston, MA – Nicotine replacement therapies (NRTs) designed to help people stop smoking, specifically nicotine patches and nicotine gum, do not appear to be effective in helping smokers quit long-term, even when combined with smoking cessation counseling, according to a new study by researchers at Harvard School of Public Health (HSPH) and the University of Massachusetts Boston.

The study appears January 9, 2012 in an advance online edition of Tobacco Control and will appear in a later print issue.

"What this study shows is the need for the Food and Drug Administration, which oversees regulation of both medications to help smokers quit and tobacco products, to approve only medications that have been proven to be effective in helping smokers quit in the long-term and to lower nicotine in order to reduce the addictiveness of cigarettes," said co-author Gregory Connolly, director of the Center for Global Tobacco Control at HSPH.

In the prospective cohort study the researchers, including lead author Hillel Alpert, research scientist at HSPH, and co-author Lois Biener of the University of Massachusetts Boston's Center for Survey Research, followed 787 adult smokers in Massachusetts who had recently quit smoking. The participants were surveyed over three time periods: 2001-2002, 2003-2004, and 2005-2006. Participants were asked whether they had used a nicotine replacement therapy in the form of the nicotine patch (placed on the skin), nicotine gum, nicotine inhaler, or nasal spray to help them quit, and if so, what was the longest period of time they had used the product continuously. They also were asked if they had joined a quit-smoking program or received help from a doctor, counselor, or other professional.

The results showed that, for each time period, almost one-third of recent quitters reported to have relapsed. The researchers found no difference in relapse rate among those who used NRT for more than six weeks, with or without professional counseling. No difference in quitting success with use of NRT was found for either heavy or light smokers.

"This study shows that using NRT is no more effective in helping people stop smoking cigarettes in the long-term than trying to quit on one's own," Alpert said. He added that even though clinical trials (studies) have found NRT to be effective, the new findings demonstrate the importance of empirical studies regarding effectiveness when used in the general population.

Biener said that using public funds to provide NRT to the population at large is of questionable value, particularly when it reduces the amount of money available for smoking interventions shown in previous studies to be effective, such as media campaigns, promotion of no smoking policies, and tobacco price increases.

Smoking cessation medications have been available over the counter since 1996, yet U.S. Centers for Disease Control and Prevention statistics show that the previous adult smoking rate decline and quitting rates have stalled in the past five years.

###

Funding for the study was provided by the National Cancer Institute, State and Community Tobacco Control Interventions Research Grant Program.

"A Prospective Cohort Study Challenging the Effectiveness of Population-based Medical Intervention for Smoking Cessation," Hillel R. Alpert, Gregory N. Connolly, Lois Biener. Tobacco Control, doi:10.1136/tobaccocontrol-2011-050129, online January 9, 2012.

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