• David-Dan Nguyen, Maya Marchese, Manuel Ozambela, Naeem Bhojani, Gezzer Ortega, Quoc-Dien Trinh, and David F Friedlander.
• Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
• J. Endourol. 2020 Dec 1; 34 (12): 1248-1254.

Abstract Introduction and Objectives: Budgetary constraints and novel minimally invasive surgical approaches have resulted in surgical care being increasingly provided at ambulatory centers rather than traditional inpatient settings. Despite increasing use of ambulatory-based procedure for bladder outlet obstruction (BOO) procedures, little is known about the effect of care setting on perioperative outcomes and costs. We sought to compare 30-day readmissions rates and costs of BOO procedure performed in the ambulatory vs inpatient setting. Methods: Using Florida and New York all-payer data from the 2014 Healthcare Cost and Utilization Project State Databases, we identified patients who underwent transurethral resection, thermotherapy, or laser/photovaporization for BOO. Patient demographics, regional data, 30-day readmissions rates, and costs (from converted charges) associated with the index procedure and revisits were analyzed. Predictors of 30-day revisits were also identified by fitting a multivariate logistic regression model with facility-level clustering. Results: Of the 15,094 patients identified, 1444 (9.6%) had a 30-day revisit at a median cost of $4263.43. The 30-day readmission rate for inpatient cases was significantly higher than that of surgeries performed in the ambulatory setting (12.0% vs 8.1%, p < 0.001). Payer status (private vs Medicare: odds ratio [OR] = 0.77, 95% confidence interval [CI] = 0.62-0.95; p = 0.02) and index care setting (ambulatory vs inpatient: OR = 0.48, 95% CI = 0.40-0.57; p < 0.001) predicted 30-day revisits. Conclusions: We identified that index care setting and payer status are independent predictors of 30-day revisit after BOO procedure, with the inpatient setting and Medicare insurance associated with higher odds of revisit. Ambulatory procedures are significantly less costly than procedures performed in the inpatient setting, even after accounting for ambulatory procedures leading to an admission. There is an obvious cost benefit of offering BOO procedure in the ambulatory setting to the appropriate patient. In the context of value-based health care initiatives, our findings have important implications for policymakers seeking to reduce variation in nonclinical sources of perioperative costs and outcomes.

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