Increased Utilization of Ambulatory Robot Assisted Laparoscopic Prostatectomy during COVID-19 Pandemic: Results from a State Administrative Database
Zhiyu (Jason) Qian, MD1, Jamie Ye, MPH1, David Friedlander, MD2, Mara Koelker, MD1, Muhieddine Labban, MD1, Quoc-Dien Trinh, MD1, Alexander Putnam Cole, MD1.
1Brigham and Women's Hospital, Boston, MA, USA, 2University of North Carolina School of Medicine, Chapel Hill, NC, USA.
Background: Robot-Assisted Laparoscopic Prostatectomy (RALP) is a gold standard procedure for localized prostate cancer. There have been increased reports of RALP being performed in ambulatory setting with same day discharge—which has been shown to provide similar efficacy compared to a traditional overnight hospitalization. With the outbreak of COVID-19 leading to high hospital bed demand, there has been increased interest in ambulatory prostatectomy. We therefore sought to analyze the utilization of ambulatory RALP before and during COVID pandemic using a large state administrative database.
Methods: We identified men who underwent RALP within the State Inpatient Database and the State Ambulatory Surgery Database in California between 2018 and 2020, which provided a representative sample of surgeries performed in a state in various care settings. California was chosen as a highly populous state with a combination of urban, rural patients in a number of different health systems. Relative patient demographic and clinical parameters were recorded. Univariate and Multivariate analyses were performed to investigate the clinical and demographic metrics that associates with ambulatory RALP utilization prior to and during the first waves of COVID-19 pandemic.
Results: During study period, 10612 men underwent RALP in inpatient setting, while 6774 underwent RALP at ambulatory surgical centers. Univariate analysis showed patients who received RALP in ambulatory surgical centers are more likely to be older (66 vs 64, p<0.0001), Non-Hispanic white (61.7% vs. 57.9%, p<0.0001), residing outside of metropolitan area (28.2% vs. 30.8%, p<0.0001). Patients who received RALP after the first wave of COVID in March 2020 were more likely to receive the procedure in ambulatory setting (53.8% vs. 33.5%, p <0.0001). No difference was found in Charlson Comorbidity Index between groups (63.3% vs. 62.9%, p = 0.634). Multivariate analysis showed that patients who received RALP after the first wave of COVID were 2.31 times more likely to receive the procedure at an ambulatory center instead of inpatient setting (p<0.0001). Patients covered by Medicare insurance is 1.54 times more likely to receive an ambulatory RALP compared to those with private insurance (p=0.010)
Conclusions: While the factors underlying the shift towards outpatient robotic prostatectomy are likely complex, our comparison of a study period immediately prior to and during the first waves of the COVID-19 revealed that outpatient prostatectomies increased by 20.3% pre and post-pandemic with a more than two-fold increase in adjusted odds of outpatient RALP following the initial wave of the COVID-19 pandemic. Such association could be potentially explained by the limited hospital beds from the pandemic, encouraging more efficient use of space and resources. While further studies are warranted to investigate its long-term outcomes, the observed increasing uptake of RALP in ambulatory setting could potentially improve the accessibility and cost efficacy in COVID era.
Table 1. Multivariable Logistic Regression for men undergoing RALP at Ambulatory Settings in Reference to Inpatient Settings.
|Odds Ratio||95% CI||p-value|
|Non-Hispanic Black||1.1816||0.8970, 1.5564||0.2352|
|Median Houshold Income|
|Quartile 1 (wealthiest)||ref|
|Quartile 2||1.0842||0.8678, 1.3545||0.4765|
|Quartile 3||0.959||0.7189, 1.2793||0.776|
|Quartile 4 (poorest)||0.7479||0.5185, 1.0789||0.1202|
|Large metro area, >=1,000,000||ref|
|Small metro area, >=1,000,000||1.4647||0.8897, 2.4113||0.1335|
|Before first wave (3/2020)||ref|
|After first wave||2.3162||1.7632, 3.0427||<0.0001|
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