Surgeon behavior and surgical modality drive variation in the cost of the surgical management of BPH

Introduction and ObjectiveIdentifying actionable variability in care is critical to standardizing treatment and controlling cost. As our institution moves toward bundled payment for benign prostatic hyperplasia (BPH) surgery,... [ view full abstract ]

Introduction and Objective

Identifying actionable variability in care is critical to standardizing treatment and controlling cost. As our institution moves toward bundled payment for benign prostatic hyperplasia (BPH) surgery, it is important to assess the relationship between clinical factors, physician preference, and cost of care.

Methods

Using time-driven activity-based costing of 358 complete episodes of surgical care for BPH, a variation metric of episodic cost standard deviation divided by mean cost was calculated by surgeon, surgical technique, and prostate size.

Results

Mean episodic cost and standard deviation were $3,529 +/- $570, yielding an overall variation metric of 0.16. Variation metrics ranged from 0.03—0.34 among 18 surgeons. The variation metric for 288 bipolar transurethral resections of prostate (TURPs) was 0.16, 0.10 for 41 laser vaporization, 0.09 for 20 monopolar TURPs, and 0.08 for 9 open prostatectomies.  Based on prostate size, the variation metric ranged from 0.17 in prostates < 40 grams, 0.16 for glands between 40—80 grams, and 0.09 for glands > 80 grams.  ANOVA with Tukey pairwise comparison revealed a significantly higher (p<0.05) average episodic cost between open prostatectomy and the 3 other surgical techniques. There was no significant difference in episode cost based on prostate size among endoscopic approaches.

Conclusion

Variation in the surgical management of BPH appears to be predominantly driven by surgeon behavior and, to a lesser degree, surgical approach, at our institution.  Prostate size does not appear to influence variation in the surgical management of BPH.  Efforts focused on clarifying the cause of variation at the surgeon-level and based on surgical technique are most likely to yield standardized, high-value care.