Comparison of Trends and Safety of Same-Day Discharge for Robot-Assisted Laparoscopic Prostatectomy During the Pre-pandemic and Pandemic Periods: Findings from the National Cancer Database
Muhieddine Labban, MD1, Samuel Lyon, MD2, Jane R. Kielhofner, BS1, Benjamin V. Stone, MD1, Dejan Filipas, MD1, Edoardo Beatrici, MD1, Sandeep Voleti, BS1, Alexander P. Cole, MD1, Quoc-Dien Trinh, MD, MBA1, Kathy G. Niknejad, MD1.
1Brigham and Women's Hospital, BOSTON, MA, USA, 2Medical College of Georgia at Augusta University, Augusta, GA, USA.
BACKGROUND: The COVID-19 pandemic has placed significant stress on the already strained United States healthcare system. In particular, there was a lack of available hospital beds. While hospital systems prioritized those admissions to cancer patients needing urgent surgical procedures, they also encouraged early discharge to optimize resources and bed availability. Therefore, we sought to (1) evaluate the trends of same-day discharge for robot-assisted laparoscopic prostatectomy (RALP) in the "Pre-pandemic" and "Pandemic" periods and (2) examine the independent effect of same-day discharge on readmissions and mortality. METHODS: We queried the National Cancer Database to select men who underwent RALP with or without pelvic lymph node dissection for prostate cancer in the "Pre-pandemic" (2018-2019) and "Pandemic" (2020) periods. We compared patient sociodemographic and clinical data, facility type, and facility RALP volume quartiles for those who had same-day discharge versus non-same-day discharge. We used a multivariable logistic regression to report the odds of same-day discharge during the "Pandemic" compared to the "Pre-pandemic" period adjusting for covariates. Then, we used an inverse probability treatment weighting (IPTW) model adjusting for covariates to evaluate the independent effect of same-day discharge on 30-day readmissions, 30-day mortality, and 90-day mortality. RESULTS: Among the 111,117 men in the cohort, 8,997 (8.1%) had a same-day discharge (Table 1). The 2018-2020 trends in same-day discharge are depicted in Figure 1. Men with more comorbidities, non-private insurance, and high-risk prostate cancer were less likely to be discharged on the same day (p<0.001). Academic facilities and facilities in the top RALP volume quartile had a higher proportion of same-day discharge (p<0.001). Compared to the "Pre-pandemic" period, there was an increase in the odds of same-day discharge during the "Pandemic" period (aOR 1.38; 95%CI 1.31-1.45; p<0.001). After IPTW adjustment, we found no difference in the odds of 30-day readmissions (aOR 0.90; 95%CI 0.77-1.06; p=0.21), 30-day mortality (aOR 0.98; 95%CI 0.48-2.01; p=0.95), or 90-day mortality (aOR 1.09; 95%CI 0.61-1.98; p=0.77) between same-day and non-same-day discharges. CONCLUSIONS: Same-day discharge for RALP has been safely and commonly used during the COVID-19 pandemic. Further institutional studies are warranted to (1) evaluate 30-day complications and (2) evaluate the role of enhanced recovery after surgery protocols that could facilitate same-day discharge after RALP. Table 1: Comparison of baseline patient- and hospital-level characteristics for same-day discharge and non-same-day discharge for RALP.
| Non-Same Day discharge | Same day discharge | Total | p-value | Raw Standardized Differences | Weighted Standardized Differences | |
| N=102,120 | N=8,997 | N=111,117 | (%) | (%) | ||
| Age | ||||||
| <60 | 30,583 (29.9%) | 2,827 (31.4%) | 33,410 (30.1%) | |||
| 60-69 | 53,205 (52.1%) | 4,648 (51.7%) | 57,853 (52.1%) | 0.004 | -4.1% | 0.8% |
| 70-79 | 17,977 (17.6%) | 1,501 (16.7%) | 19,478 (17.5%) | |||
| >80 | 355 (0.3%) | 21 (0.2%) | 376 (0.3%) | |||
| Race/Ethnicity | ||||||
| White non-Hispanic | 78,218 (76.6%) | 6,973 (77.5%) | 85,191 (76.7%) | |||
| Black non-Hispanic | 14,002 (13.7%) | 1,076 (12.0%) | 15,078 (13.6%) | |||
| Hispanic | 5,528 (5.4%) | 514 (5.7%) | 6,042 (5.4%) | <0.001 | -1.6% | 1.1% |
| AANHPI | 2,763 (2.7%) | 262 (2.9%) | 3,025 (2.7%) | |||
| Other | 686 (0.7%) | 75 (0.8%) | 761 (0.7%) | |||
| Unknown | 923 (0.9%) | 97 (1.1%) | 1,020 (0.9%) | |||
| Charlson Comorbidity Index | ||||||
| CCI = 0 | 82,083 (80.4%) | 7,635 (84.9%) | 89,718 (80.7%) | <0.001 | -12.4% | 1.0% |
| CCI ≥ 1 | 20,037 (19.6%) | 1,362 (15.1%) | 21,399 (19.3%) | |||
| Insurance Coverage | ||||||
| Private | 53,679 (53.0%) | 5,060 (56.9%) | 58,739 (53.3%) | |||
| Medicare | 40,699 (40.2%) | 3,339 (37.6%) | 44,038 (40.0%) | |||
| Medicaid | 3,434 (3.4%) | 244 (2.7%) | 3,678 (3.3%) | <0.001 | -9.3% | 1.3% |
| Other Government | 2,528 (2.5%) | 166 (1.9%) | 2,694 (2.4%) | |||
| not insured | 993 (1.0%) | 82 (0.9%) | 1,075 (1.0%) | |||
| Educational Attainment | ||||||
| High | 56,604 (65.4%) | 5,188 (65.7%) | 61,792 (65.4%) | 0.50 | -0.6% | 2.1% |
| Low | 30,007 (34.6%) | 2,705 (34.3%) | 32,712 (34.6%) | |||
| Census Median Income | ||||||
| <$38,000 | 11,344 (13.1%) | 942 (11.9%) | 12,286 (13.0%) | |||
| $38,000-$47,999 | 17,355 (20.0%) | 1,458 (18.5%) | 18,813 (19.9%) | <0.001 | 9.1% | -1.8% |
| $48,000-$62,999 | 23,814 (27.5%) | 1,946 (24.7%) | 25,760 (27.3%) | |||
| $63,000+ | 34,063 (39.3%) | 3,544 (44.9%) | 37,607 (39.8%) | |||
| D'Amico Risk Classification | ||||||
| Low-risk | 10,419 (10.6%) | 972 (11.2%) | 11,391 (10.6%) | |||
| Intermediate-risk | 59,893 (60.7%) | 5,395 (62.0%) | 65,288 (60.8%) | <0.001 | 4.7% | -1.8% |
| High-risk | 28,428 (28.8%) | 2,339 (26.9%) | 30,767 (28.6%) | |||
| Pelvic lymph node dissection | ||||||
| No | 20,333 (19.9%) | 1,703 (18.9%) | 22,036 (19.8%) | 0.026 | 4.3% | -0.8% |
| Yes | 81,732 (80.1%) | 7,285 (81.1%) | 89,017 (80.2%) | |||
| Facility Type | ||||||
| Academic | 43,401 (42.5%) | 4,468 (49.7%) | 47,869 (43.1%) | <0.001 | -17.7% | 1.2% |
| Non-Academic | 58,672 (57.5%) | 4,526 (50.3%) | 63,198 (56.9%) | |||
| Facility RALP caseload | ||||||
| Very-low volume | 9,006 (8.8%) | 829 (9.2%) | 9,835 (8.9%) | |||
| Low volume | 28,533 (27.9%) | 2,360 (26.2%) | 30,893 (27.8%) | <0.001 | 14.4% | -2.0% |
| Moderate volume | 28,983 (28.4%) | 1,864 (20.7%) | 30,847 (27.8%) | |||
| High volume | 35,598 (34.9%) | 3,944 (43.8%) | 39,542 (35.6%) | |||
| Period | <0.001 | 13.3% | 1.3% | |||
| Pre-pandemic | 74,812 (73.3%) | 5,985 (66.5%) | 80,797 (72.7%) | |||
| Pandemic | 27,308 (26.7%) | 3,012 (33.5%) | 30,320 (27.3%) | |||
| Outcomes | ||||||
| 30-Day Readmissions | ||||||
| No | 99,358 (97.6%) | 8,757 (97.9%) | 108,115 (97.6%) | 0.067 | - | - |
| Yes | 2,429 (2.4%) | 186 (2.1%) | 2,615 (2.4%) | |||
| 30-Day Mortality | ||||||
| No | 71,659 (99.8%) | 5,795 (99.8%) | 77,454 (99.8%) | 0.97 | - | - |
| Yes | 125 (0.2%) | 10 (0.2%) | 135 (0.2%) | |||
| 90-Day Mortality | ||||||
| No | 70,555 (99.8%) | 5,596 (99.8%) | 76,151 (99.8%) | 0.99 | - | - |
| Yes | 176 (0.2%) | 14 (0.2%) | 190 (0.2%) | |||
| † Standardized difference = difference in means or proportions divided by standard error. Imbalance is defined as an absolute value > 10% (small effect size). |
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