Currently Viewing:
The American Journal of Managed Care June 2017
Comparative Effectiveness and Costs of Insulin Pump Therapy for Diabetes
Ronald T. Ackermann, MD, MPH; Amisha Wallia, MD, MS; Raymond Kang, MA; Andrew Cooper, MPH; Theodore A. Prospect, FSA, MAAA; Lewis G. Sandy, MD, MBA; and Deneen Vojta, MD
Currently Reading
Radical Prostatectomy Innovation and Outcomes at Military and Civilian Institutions
Jeffrey J. Leow, MBBS, MPH; Joel S. Weissman, PhD; Linda Kimsey, PhD; Andrew Hoburg, PhD; Lorens A. Helmchen, PhD; Wei Jiang, MS; Nathanael Hevelone, MPH; Stuart R. Lipsitz, ScD; Louis L. Nguyen, MD, MPH, MBA; and Steven L. Chang, MD, MS
How Do Medicare Advantage Beneficiary Payments Vary With Tenure?
Paul D. Jacobs, PhD, and Eamon Molloy, PhD
Patient Ratings of Veterans Affairs and Affiliated Hospitals
Paul A. Heidenreich, MD, MS; Aimee Zapata, MS; Lisa Shieh, MD, PhD; Nancy Oliva, PhD, RN; and Anju Sahay, PhD
Using "Roll-up" Measures in Healthcare Quality Reports: Perspectives of Report Sponsors and National Alliances
Jennifer L. Cerully, PhD; Steven C. Martino, PhD; Lise Rybowski, MBA; Melissa L. Finucane, PhD; Rachel Grob, PhD; Andrew M. Parker, PhD; Mark Schlesinger, PhD; Dale Shaller, MPA; and Grant Martsolf, PhD, MPH, RN
Does the Offer of Free Prescriptions Increase Generic Prescribing?
Bruce Stuart, PhD; Franklin Hendrick, PhD; J. Samantha Dougherty, PhD; and Jing Xu, PhD
Patients' Views on Price Shopping and Price Transparency
Hannah L. Semigran, BA; Rebecca Gourevitch, MS; Anna D. Sinaiko, PhD; David Cowling, PhD; and Ateev Mehrotra, MD, MPH
Heterogeneity of Nonadherent Buprenorphine Patients: Subgroup Characteristics and Outcomes
Charles Ruetsch, PhD; Joseph Tkacz, MS; Vijay R. Nadipelli, MS, BPharm; Brenna L. Brady, PhD; Naoko Ronquest, PhD; Hyong Un, MD; and Joseph Volpicelli, MD, PhD
A Comparison of Retrospective Attribution Rules
Lucas Higuera, MA, and Caroline Carlin, PhD

Radical Prostatectomy Innovation and Outcomes at Military and Civilian Institutions

Jeffrey J. Leow, MBBS, MPH; Joel S. Weissman, PhD; Linda Kimsey, PhD; Andrew Hoburg, PhD; Lorens A. Helmchen, PhD; Wei Jiang, MS; Nathanael Hevelone, MPH; Stuart R. Lipsitz, ScD; Louis L. Nguyen, MD, MPH, MBA; and Steven L. Chang, MD, MS
Minimally invasive radical prostatectomy was more commonly performed in civilian hospitals compared with military hospitals among TRICARE beneficiaries, with comparable postoperative outcomes.
In this study of TRICARE beneficiaries with prostate cancer, we found a substantially greater diffusion of MIRP among civilian institutions compared with MHS institutions between FY 2005 and FY 2010, and this difference was most pronounced after 2008, coinciding with the widespread adoption of robotic MIRP in the United States.13 Despite the increasing disparity in MIRP diffusion, we observed similarity in surgical morbidity for these 2 healthcare environments based on postoperative complications and functional outcomes (ie, incontinence and erectile dysfunction). Our findings support the hypothesis that market forces may accelerate the adoption of clinical innovation, such as MIRP, among civilian hospitals, which rely heavily on generating revenue to deliver healthcare; however, the increased tendency to adopt MIRP was not associated with a meaningful improvement in surgical morbidity.

The strength of the current study is that we assessed men from a common insured population that were managed in 2 different healthcare environments distinguished, in large part, by the role of hospital revenue source in healthcare delivery. Because the delivery of health services at civilian institutions is reliant on generating sufficient revenue, it is feasible that the motivation for technology adoption stems from an aim to maximize revenue by attracting new patients or avoiding a loss of patients.19,20 In contrast to civilian hospitals, the MHS is supported by appropriations from the DoD. These budgetary decisions have an unusually broad scope of maintaining the health of all military personnel, their dependents, and retirees, as well as supporting military readiness, providing medical education, and improving public health. These competing priorities, coupled with the idiosyncrasies of federal appropriations laws and budgeting, may slow the adoption of technology within the MHS.

Prior population-based studies of nonfederal hospitals report that MIRP is associated with increased surgical volume. Chang et al demonstrated that surgeons, particularly high-volume surgeons, who adopted robotic MIRP experienced an increase in overall annual volume of RP.13 Similarly, Makarov et al reported that hospitals that acquired the robotic platform were associated with a significant increase in annual RP volume, while hospitals without the robotic platform experienced a loss in volume.21 Complementing the prior investigations, this study provides data that support the hypothesis that maximizing hospital revenue may have influenced the likelihood of adopting technology such as MIRP (Figure).

Despite the argument that hospital revenue drives technology dissemination, we also observed a substantial increase in the proportion of patients undergoing MIRP in the MHS during the final 2 years of the study. We speculated that this upward trend may be associated with a motivation to maintain parity with civilian hospitals22 and to keep TRICARE enrollees from seeking care at civilian hospitals to undergo MIRP. Surgeons at civilian hospitals may feel more of a need to learn new techniques to remain competitive for patient referrals in a “private” environment. In terms of reimbursement incentives at the physician level, a common misconception among nonurologists is that perhaps MIRP offers better reimbursement for the physician than ORP. However, this has not been found to be true; reimbursement to physicians for both ORP and MIRP has been found to be similar on a per-case basis.23

Regardless of the true motivation for this increased utilization by military hospitals of MIRP in the latter years of our study, we concluded that the adoption of technology is influenced by a multitude of factors, among which generating revenue is likely to represent one of the most important issues for civilian hospitals. Although both civilian and military hospitals were observed to have an increasing trend in utilization of MIRP, the proportion in military hospitals was lower (Figure) compared with civilian hospitals across all years. We hypothesized that this could be due to certain military facilities having an overall lower caseload of RP, which does not justify the establishment of an MIS program, and which has substantial upfront investment and ongoing maintenance costs. Although this may appear to be a lack of technological diffusion in the military system, it might actually point to prudent adoption of technology in select facilities that have the necessary surgical volume to allow for cost-conscious and safe dissemination.

Our study design permitted an evaluation of the possible impact of MIRP adoption on patient outcomes. We found that civilian hospital procedures were associated with a decrease in blood transfusions and a slightly shorter LOS, which are commonly noted among patients undergoing MIS procedures.9,24 There was, however, no difference between procedures performed in civilian and military hospitals in the 30-day major complication rate (ie, Clavien grades 3-5) or in the long-term functional outcomes of postoperative incontinence and erectile function. The incidence of anastomotic strictures was also lower in civilian hospitals, but this did not achieve statistical significance in the adjusted analysis. Even with subgroup analysis focusing only on institutions offering MIRP, we did not detect any differences in outcomes between civilian and military hospitals, suggesting that our findings are not influenced by unmeasured factors associated with the availability of MIRP (eg, the availability of the robotic platform).

Our finding of relative equivalence in morbidity between healthcare systems, despite differences in the adoption of MIRP, is consistent with contemporary population-based studies that report mixed results regarding the perioperative outcomes of ORP and MIRP.8,9,11,25 There are, however, unmeasured factors, such as differences in the time for convalescence, total pain medication use, and patient satisfaction, which may preferentially favor MIRP given the decrease in surgical trauma associated with MIS.26 In our adjusted model, LOS and blood transfusion were slightly reduced for civilian hospitals even after adjusting for surgical approach (Table 2), possibly reflecting advantages at the civilian hospitals that are not quantified by the Clavien classification system for surgical complications or captured by assessment of functional outcomes.

Given the absence of a morbidity improvement for MIRP, we concluded that its rapid adoption among civilian hospitals was not based on data in the medical literature. In fact, well-executed studies regarding MIRP are only recently available.8,9,11,25 There are challenging obstacles for critical evaluation through a randomized controlled trial, most notably: 1) the difficulty in accruing patients willing to defer their choice for management to randomization, 2) the impracticality in blinding patients and surgeons, and 3) the challenges in controlling for surgeon learning curve and variations in technique.27 We surmised that the promise of new surgical innovation to improve outcomes is intensely attractive, particularly for a procedure like RP, which is associated with detrimental functional issues, such as urinary incontinence and erectile dysfunction, thereby creating pressure for surgeons and hospitals to explore new technologies. Consequently, despite the absence of Level I evidence demonstrating superiority or equivalence of MIRP over ORP, a large percentage of surgeons in the United States has now adopted robotic MIRP,13 and the majority of RP surgeries are now performed with the robotic platform.8-10


Our findings must be interpreted within the context of several important limitations to our study design. First, we used administrative data from TRICARE (claims for reimbursement for civilian hospitals and utilization records for military hospitals), which is not designed for documenting a patient’s clinical course and outcome. It is possible that more granular clinical information might have altered the associations we report or revealed new relationships not identified in the current study. However, the TRICARE claims data share many similarities with Medicare claims data, which have been used extensively to evaluate surgical outcomes.28

Second, we could not adjust for tumor stage and grade because these characteristics are not reliably captured with claims data; however, in men with prostate cancer, tumor characteristics are unlikely to influence the postoperative complications, LOS, and long-term functional outcomes. Third, to assess for postoperative urinary incontinence and erectile dysfunction, we considered surgical intervention as a proxy for functional status. Admittedly, we cannot exclude the possibility that there may be a disparity in the threshold to undergo those surgical interventions between civilian and military institutions.

Fourth, although we had hospital volume data for military hospitals, we did not have that same reliable data for civilian hospitals, precluding us from adjusting for surgical volume as a possible confounder, especially when this has been previously shown to affect postoperative outcomes.29,30 Lastly, we did not have reliable estimates for costs and revenues to comprehensively assess the differential amount of revenue generated by adoption of MIRP over ORP; this may have garnered additional insights regarding the potential financial incentives of adopting MIRP.


To our knowledge, this is the first study assessing the potential impact of the type of healthcare delivery system on the adoption of MIRP in the United States. Based on TRICARE enrollee data, we observed that adoption was more rapid among civilian hospitals, which are comprised of institutions heavily reliant on generating hospital revenue to deliver health services. Further analysis, however, showed that the increased use of MIRP did not translate into a marked improvement in outcomes, thus highlighting the potential dangers of embracing new clinical innovations prior to the availability of evidence showing benefit. Our findings are particularly relevant as the delivery of healthcare in the United States is undergoing dramatic change. Future work should focus on determining if the goals of cost containment and of revenue based on quality, the principles underlying accountable care organizations, promote or repress clinical innovation in the United States.

Author Affiliations: Center for Surgery and Public Health (JJL, JSW, WJ, NH, SRL, LLN, SLC), and Division of Urology (JJL, SLC), and Division of Vascular Surgery (LLN), Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Services (LK, AH), Bethesda, MD; Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University (LHH), Washington, DC.

Source of Funding: Henry M. Jackson Foundation HU0001-11-1-0023 The Comparative Effectiveness and Provider Induced Demand Collaboration (EPIC): A Clinical and Economic Analysis of Variation in Healthcare.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JJL, JSW, LK, LHH, WJ, NH, SRL, LLN, SLC); acquisition of data (LK, AH, LLN, SLC); analysis and interpretation of data (JJL, LK, AH, LHH, WJ, NH, SRL, LLN, SLC); drafting of the manuscript (JJL, JSW, AH); critical revision of the manuscript for important intellectual content (JJL, LK, LHH, WJ, NH, SRL, LLN, SLC); statistical analysis (JJL, WJ, NH, SRL, LLN, SLC); provision of patients or study materials (LK); obtaining funding (LLN, SLC); administrative, technical, or logistic support (AH, LLN, SLC); and supervision (JSW, LK, LHH, WJ, NH, SRL, LLN, SLC).

Address Correspondence to: Steven L. Chang, MD, MS, Brigham and Women’s Hospital, Division of Urology, 45 Francis St, Boston, MA 02115. E-mail: 

1. Xu T, Hutfless SM, Cooper MA, Zhou M, Massie AB, Makary MA. Hospital cost implications of increased use of minimally invasive surgery. JAMA Surg. 2015;150(5):489-490. doi: 10.1001/jamasurg.2014.4052.

2. Klemm J, Mehr SR. Prostate cancer. Am J Manag Care. 2012;18(spec 3):SP119-SP121.

3. Sanda MG, Dunn RL, Michalski J, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med. 2008;358(12):1250-1261. doi: 10.1056/NEJMoa074311.

4. Shore N. Management of early-stage prostate cancer. Am J Manag Care. 2014;20(suppl 12): S260-S272.

5. Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR. Laparoscopic radical prostatectomy: initial short-term experience. Urology. 1997;50(6):854-857.

6. Abbou CC, Hoznek A, Salomon L, et al. Laparoscopic radical prostatectomy with a remote controlled robot. J Urol. 2001;165(6, pt 1):1964-1966.

7. Binder J, Kramer W. Robotically-assisted laparoscopic radical prostatectomy. BJU Int. 2001;87(4):408-410.

8. Trinh QD, Sammon J, Sun M, et al. Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample. Eur Urol. 2012;61(4):679-685. doi: 10.1016/j.eururo.2011.12.027.

9. Gandaglia G, Sammon JD, Chang SL, et al. Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era. J Clin Oncol. 2014;32(14):1419-1426. doi: 10.1200/JCO.2013.53.5096.

10. Leow JJ, Chang SL, Meyer CP, et al. Robot-assisted versus open radical prostatectomy: a contemporary analysis of an all-payer discharge database. Eur Urol. 2016;70(5):837-845. doi: 10.1016/j.eururo.2016.01.044.

11. Hu JC, Gu X, Lipsitz SR, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009;302(14):1557-1564. doi: 10.1001/jama.2009.1451.

12. Ulmer WD, Prasad SM, Kowalczyk KJ, et al. Factors associated with the adoption of minimally invasive radical prostatectomy in the United States. J Urol. 2012;188(3):775-780. doi: 10.1016/j.juro.2012.05.014.

13. Chang SL, Kibel AS, Brooks JD, Chung BI. The impact of robotic surgery on the surgical management of prostate cancer in the USA. BJU Int. 2014;115(6):929-936. doi: 10.1111/bju.12850.

14. Escarce JJ. Externalities in hospitals and physician adoption of a new surgical technology: an exploratory analysis. J Health Econ. 1996;15(6):715-734.

15. Horwitz JR, Nichols A. Hospital ownership and medical services: market mix, spillover effects, and nonprofit objectives. J Health Econ. 2009;28(5):924-937. doi: 10.1016/j.jhealeco.2009.06.008.

16. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-213.

17. Leow JJ, Reese SW, Jiang W, et al. Propensity-matched comparison of morbidity and costs of open and robot-assisted radical cystectomies: a contemporary population-based analysis in the United States. Eur Urol. 2014;66(3):569-576. doi: 10.1016/j.eururo.2014.01.029.

18. Pope GC, Kautter J, Ellis RP, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financ Rev. 2004;25(4):119-141.

19. Horwitz JR. Making profits and providing care: comparing nonprofit, for-profit, and government hospitals. Health Aff (Millwood). 2005;24(3):790-801.

20. Teplensky JD, Pauly MV, Kimberly JR, Hillman AL, Schwartz JS. Hospital adoption of medical technology: an empirical test of alternative models. Health Serv Res. 1995;30(3):437-465.

21. Makarov DV, Yu JB, Desai RA, Penson DF, Gross CP. The association between diffusion of the surgical robot and radical prostatectomy rates. Med Care. 2011;49(4):333-339. doi: 10.1097/MLR.0b013e318202adb9.

22. Barbash GI, Friedman B, Glied SA, Steiner CA. Factors associated with adoption of robotic surgical technology in US hospitals and relationship to radical prostatectomy procedure volume. Ann Surg. 2014;259(1):1-6. doi: 10.1097/SLA.0b013e3182a5c8b8.

23. Tomaszewski JJ, Matchett JC, Davies BJ, Jackman SV, Hrebinko RL, Nelson JB. Comparative hospital cost-analysis of open and robotic-assisted radical prostatectomy. Urology. 2012;80(1):126-129. doi: 10.1016/j.urology.2012.03.020.

24. Jaschinski T, Mosch C, Eikermann M, Neugebauer EA. Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials. BMC Gastroenterol. 2015;15:48. doi: 10.1186/s12876-015-0277-3.

25. Liu JJ, Maxwell BG, Panousis P, Chung BI. Perioperative outcomes for laparoscopic and robotic compared with open prostatectomy using the National Surgical Quality Improvement Program (NSQIP) database. Urology. 2013;82(3):579-583. doi: 10.1016/j.urology.2013.03.080.

26. Zeliadt SB, Moinpour CM, Blough DK, et al. Preliminary treatment considerations among men with newly diagnosed prostate cancer. Am J Manag Care. 2010;16(5):e121-e130.

27. McCulloch P, Taylor I, Sasako M, Lovett B, Griffin D. Randomised trials in surgery: problems and possible solutions. BMJ. 2002;324(7351):1448-1451.

28. Lawthers AG, McCarthy EP, Davis RB, Peterson LE, Palmer RH, Iezzoni LI. Identification of in-hospital complications from claims data. is it valid? Med Care. 2000;38(8):785-795.

29. Alibhai SM, Leach M, Tomlinson G. Impact of hospital and surgeon volume on mortality and complications after prostatectomy. J Urol. 2008;180(1):155-162. doi: 10.1016/j.juro.2008.03.040.

30. Hu JC, Gold KF, Pashos CL, Mehta SS, Litwin MS. Role of surgeon volume in radical prostatectomy outcomes. J Clin Oncol. 2003;21(3):401-405. 
Copyright AJMC 2006-2019 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up