Predictors of Index Surgical Care Setting during Penile Prosthesis Surgery: Impact on Perioperative Outcomes and Cost
Alexandra Berger, MD, David Friedlander, MD, Martin Kathrins, MD, Quoc-Dien Trinh, MD
Brigham and Women's Hospital/Harvard University, Boston, MA
BACKGROUND: Penile prostheses (PP) are indicated in patients with refractory erectile dysfunction. PP insertion is traditionally performed as an inpatient procedure, but is now felt to be safe in the outpatient setting, which is more cost-effective. However, few studies have determined which patients undergo PP procedures in the outpatient setting. Thus, we sought to identify predictors of index PP care setting and perioperative outcomes and cost associated with inpatient versus outpatient procedures. METHODS: All-payer data from the 2014 Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL) and New York (NY) were used to identify all patients undergoing index inflatable PP (IPP) or malleable PP (MPP) insertion. Patient demographics, regional data, total charges (converted to costs), and 30-day revisit rates were measured. Multivariable logistic regression adjusted for facility-level clustering was utilized. RESULTS: Of the 1,894 patients undergoing index PP, 387 (20.4%) received care in the inpatient setting compared to 1,507 (79.6%) in the ambulatory setting. The median cost associated with inpatient PP was $11,224.74, compared to $9,480.01 for outpatient PP (p<0.001). Predictors of receiving care in the ambulatory setting included fewer comorbidities (CCI ≥2 vs. 0: OR 0.43, 95% CI 0.28-0.64; p<0.001), payer status (Medicaid vs. Medicare: OR 0.28, 95% CI 0.11-0.71; p=0.008), race (black vs. white: OR 0.57, 95% CI 0.33-0.99; p=0.05), small metro area (small metro vs. large metro: OR 3.15, 95% CI 1.29-7.70; p=0.01), and state of index procedure (FL vs. NY: OR 34.16, 95% CI 9.54-122.3; p<0.001). There was no difference in 30-day revisit rates between inpatient or outpatient PP (8.0% vs 6.23%, p=0.21). CONCLUSIONS: Both clinical and non-clinical factors predict the care setting of index PP procedure and inpatient PP is associated with higher procedural costs. Our findings may help providers better identify patients who should be considered for outpatient PP procedures. 
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