Abstract
IMPORTANCE: Given the widespread adoption and clinical benefits of minimally invasive surgery approaches (MIS) in partial nephrectomy (PN) and radical nephrectomy (RN), assessment of long-term cost implications is relevant. OBJECTIVE: To compare health care utilization and expenditures within 1 year after MIS and open surgery (OS). DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted using a US commercial claims database between 2013 and 2018. A total of 5104 patients aged 18 to 64 years who underwent PN or RN for kidney cancer and were continuously insured for 180 days before and 365 days after surgery were identified. An inverse probability of treatment weighting analysis was performed to examine differences in costs and use of health care services. EXPOSURES: Surgical approach (MIS or OS). MAIN OUTCOMES AND MEASURES: Outcomes assessed included 1-year total health care expenditure, health care utilizations, and estimated days missed from work. RESULTS: Of the 5104 patients, 2639 had PN (2008 MIS vs 631 OS) and 2465 had RN (1816 MIS vs 649 OS) and most were male (PN: 1657 [62.8%]; RN: 399 [63.1%]) and between 55 and 64 years of age (PN: 1034 [51.3%]; RN: 320 [55.7%]). Patients who underwent MIS had lower index hospital length of stay compared with OS (mean [95% CI] for PN: 2.45 [2.37-2.53] vs 3.78 [3.60-3.97] days; P < .001; for RN: 2.82 [2.73-2.91] vs 4.62 [4.41-4.83] days; P < .001), and lower index expenditure for RN ($28 999 [$28 243-$29 796] vs $31 977 [$30 729-$33 329]; P < .001). For PN, index expenditure was lower for OS than MIS (mean [95% CI], $27 480 [$26 263-$28 753] vs $30 380 [$29614-$31 167]; P < .001). Patients with MIS had lower 1-year postdischarge readmission rate (PN: 15.1% vs 21.5%; odds ratio [OR], 0.65; 95% CI, 0.52-0.82; P < .001; RN: 15.6% vs 18.9%; OR, 0.79; 95% CI, 0.63-1.00; P = .05), and fewer hospital outpatient visits (mean [95% CI] for PN: 4.69 [4.48-4.90] vs 5.25 [4.84-5.66]; P = .01; RN: 5.50 [5.21-5.80] vs 6.71 [6.12-7.30]; P < .001) than those with OS. For RN, MIS was associated with 1.47 fewer missed workdays (95% CI, 0.57-2.38 days; P = .001). The reduction in health care use in MIS was associated with lower or similar total cumulative expenditures compared with OS (mean difference [95% CI] for PN: $331 [-$3250 to $3912]; P = .85; for RN: -$11 265 [-$17 065 to -$5465]; P < .001). CONCLUSIONS AND RELEVANCE: In this cohort study, MIS was associated with lower or similar total cumulative expenditure than OS in the period 1 year after discharge from the index surgery. These findings suggest that downstream expenditures and resource utilization should be considered when evaluating surgical approach for nephrectomy.