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Introduction- Private civilian institutions exist in a financial environment that engenders competition for patients to increase profits, and, in theory, competition can promote clinical innovations. We sought to determine whether reimbursement structure altered the adoption of minimally invasive radical prostatectomy (RP), and if differential adoption was associated with a difference in clinical outcomes.
Methods- A retrospective cohort review from the Tricare administrative data looked at men with prostate cancer (ICD-9: 185) who received a RP (ICD-9: 60.5) between 2005 and 2010, excluding men who underwent salvage RP, for a final cohort of 5,082 men. Surgery occurred at civilian hospitals, where revenue is a fee-for-service reimbursement system, or military hospitals, which are supported through federal government appropriations. With description statistics and regression analysis, we assessed yearly utilization of minimally invasive RP, 30-day postoperative complications, preoperative and long-term outcomes.
Results- A total of 3,366 men underwent RP in military hospitals compared to 1,716 in civilian hospitals, with minimal clinicodemographic differences between the groups. Overall, adoption of minimally invasive RP in civilian hospitals was 30% greater. There were fewer blood transfusions (OR 0.44) and shorter length of stay (IRR 0.85) among civilian hospitals, while postoperative complications, urinary incontinence and erectile dysfunction were comparable.
Conclusions- A fee-for-service reimbursement structure of civilian hospitals was associated with a more rapid adoption of minimally invasive radical prostatectomy but no clinically significant improvement in outcomes. Further studies are needed to determine if changes in the United States healthcare system will impact future development and dissemination of clinical innovation.