The diffusion of minimally invasive radical prostatectomy in the United States: a case study of the introduction of new surgical devices.

BACKGROUND: The diffusion of minimally invasive radical prostatectomy (MIRP) in the United States may have led to adverse patient outcomes due to rapid surgeon adoption and collective inexperience. We hypothesized that throughout the early period of minimally invasive surgery, MIRP patients had inferior outcomes as compared with those who had open radical prostatectomy (ORP). METHODS: We used the Surveillance, Epidemiology and End RESULTS-Medicare dataset and identified men who had ORP and MIRP for prostate cancer from 2003-2009. Study endpoints were receipt of subsequent cancer treatment, and evidence of postoperative voiding dysfunction, erectile dysfunction (ED) and bladder outlet obstruction. We used proportional hazards regression to estimate the impact of surgical approach on each endpoint, and included an interaction term to test for modification of the effect of surgical approach by year of surgery. RESULTS: ORP (n=5362) and MIRP (n=1852) patients differed in their clinical and demographic characteristics. Controlling for patient characteristics and surgeon volume, there was no difference in subsequent cancer treatments (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.76-1.05), although MIRP was associated with a higher risk of voiding dysfunction (HR 1.31, 95% CI 1.20-1.43) and ED (HR 1.43, 95% CI 1.31-1.56), but a lower risk of bladder outlet obstruction (HR 0.86, 95% CI 0.75-0.97). There was no interaction between approach and year for any outcome. When stratifying the analysis by year, MIRP consistently had higher rates of ED and voiding dysfunction with no substantial improvement over time. CONCLUSIONS: MIRP patients had adverse urinary and sexual outcomes throughout the diffusion of minimally invasive surgery. This may have been a result of the rapid adoption of robotic surgery with inadequate surgeon preparedness.

The economic impact of a multifactorial intervention to improve postoperative rehabilitation of hip fracture patients.

OBJECTIVE: To assess the cost savings associated with a patient education and high-intensity strength intervention to improve rehabilitation after hip fracture. METHODS: Economic analysis conducted alongside a randomized controlled trial, using cost-benefit ratios and net present value statistics. Study subjects were aged over 64 years and were followed for 18 months postsurgery. Resource utilization data were gathered by telephone questionnaire. Medicare reimbursement rates and prevailing costs for services not covered by Medicare were used to convert utilization patterns into costs. Intervention costs were obtained from program records. RESULTS: The cost of the intervention was $722 per patient. Over the followup period, median costs were $11,941 and $21,577 for the intervention and control groups, respectively, yielding an average program benefit of $9,636. Cost-benefit ratios exceeded 4.5, and net present value exceeded $150,974. CONCLUSION: The results indicate that the benefits of the intervention exceeded its costs.

Economic considerations in the care of patients with head and neck malignancies.

In an era of cost-consciousness and managed care, quality concerns practice variability attributed to nonmedical factors, and growing attention to outcomes research, there is increasing interest in the economics of malignant disease. This review explores economic issues pertinent to the management of patients with head and neck malignancies. Using economic principles to evaluate medical practice does not uniformly mean that less money should be spent; rather, the intention is to optimize efficiency in the use of limited resources. Accordingly costs are best evaluated in the context of other outcomes of interest. The available economic literature for head and neck tumors is limited; it is often compromised by the use of facility charges as a proxy for true costs and the adoption of a truncated economic perspective. Given the potential health policy implications of such studies, their methodologies and results warrant careful scrutiny. Many opportunities exist for further research.

Assessing cost-effectiveness analyses in rheumatoid arthritis and osteoarthritis.

Economic considerations are now a source of great concern to clinicians and policy analysts. Many cost-effectiveness analyses have been published in the area of arthritis, most with substantial methodologic deficiencies. The goal of this article is to outline a method for evaluating cost-effectiveness assessment within the field of rheumatology. We do so by critically evaluating 6 cost-effectiveness analyses--2 in rheumatoid arthritis and 4 in osteoarthritis--as a basis for appraising the literature and developing future studies.