The Northeastern Society of Plastic Surgeons

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Has the robot caught up? National trends in utilization and cost for robotic pyeloplasty in the United States from 2003-2015
Briony K. Varda, MD, Wendy Y. Wang, PhD, Michael Kurtz, MD MPH, Richard S. Lee, MD, Caleb P. Nelson, MD MPH, Steven L. Chang, MD MS.
Boston Children's Hospital, Boston, MA, USA.

Introduction
Laparoscopic pyeloplasty (LP) and robotic-assisted laparoscopic pyeloplasty (RP) were introduced over 15 years ago as alternatives to open pyeloplasty (OP). Since then, the literature has suggested increasing robotic utilization and a trend towards cost parity with the open procedure. However, there are few contemporary, multi-institutional data describing these trends. We aimed to characterize the utilization and cost trends for pediatric pyeloplasty in the United States from 2003 to 2015.
Methods
Using the Perspective database (Premier, Inc., Charlotte, North Carolina), we identified pediatric patients (<18 years old) who underwent OP, LP and RP (ICD-9 55.87) in the U.S. from 2003 to 2015. Inpatient projection weights and adjustments for provider clustering were used to create a nationally representative sample. Baseline patient and procedure variables were compared across procedure types using the Rao-Scott Chi-Square test. The annual proportion of each technique and the associated median 90-day costs were calculated, as well as the average annual growth rates (AAGR). We then stratified utilization trends by infants (<1 year old), children (1-12 years old) and adolescents (13-18 years old).
Results
During the study period 11,899 pyeloplasties were performed, including 8,909 OP (75%), 1,173 LP (10%), and 1,818 RP (15%). Baseline patient and procedure characteristics were similar across the cohorts except for age: OP was rarely performed in adolescents (11%) and RP was rarely performed in infants (10%; p<0.0001). The total number of pyeloplasty cases decreased from 1,277 cases in 2003 to 562 cases in 2015 (-7% AAGR). While OP and LP decreased annually by a rate of 10% and 12% respectively, RP grew annually by 29% (figure 1a). By 2015, RP accounted for 40% of cases. Among the RP patients, the largest growth was among children (+45% AAGR) and adolescents (+20% AAGR) with RP comprising 84% of cases among adolescents in 2015 (figure 1c, d). Although the annual growth rate for RP was 19% among infants, the majority of cases in 2015 were still performed using an open approach (85%; figure 1b). The average annual median cost was $9,508 (IQR $5,769) for OP, $9,642 for LP (IQR $6,713), and $12,508 (IQR $8,340) for RP. The average annual rate of change in cost for each procedure was -0.52% (OP), -2.6% (LP) and -0.18% (RP; figure 2).
Conclusions
Between 2003 and 2015 the overall number of pyeloplasties performed in the U.S. declined substantially. Despite this, the robotic approach has experienced rapid growth with the largest proportion of procedures being performed in adolescent patients. Cost has been relatively stagnant over time for all procedures, resulting in a persistent cost difference between the robotic and open approach.


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