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Invited Commentary
April 4, 2022

Cost-effectiveness of Robotic-Assisted Prostatectomy in the UK—Are We Doing Enough?

Author Affiliations
  • 1National Clinician Scholars Program, Durham Veterans Affairs Medical Center, Durham, North Carolina
  • 2Division of Urology, Department of Surgery, Duke University, Durham, North Carolina
  • 3Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston
JAMA Netw Open. 2022;5(4):e225747. doi:10.1001/jamanetworkopen.2022.5747

The global economic burden of cancer care continues to rise, with countries such as the US projecting costs up to $246 billion by 2030.1 Breakthroughs in advanced imaging techniques, novel treatments (ie, antiandrogen therapies), and the adoption of robotic surgery have contributed to these increasing costs, making high-quality health care increasingly unaffordable and threatening to crowd out other essential social services. Cost-effectiveness analyses (CEA) that identify high-value care components are potentially one tool that can help drive down these health care costs.

In JAMA Network Open, Labban et al2 developed a Markov model to compare the cost-effectiveness of a robotic-assisted laparoscopic prostatectomy, open radical prostatectomy, and laparoscopic-assisted radical prostatectomy from the UK National Health Service’s perspective. Although several international and US-based studies have performed CEAs comparing robotic prostatectomy with other modalities, the results have been mixed. In this study, the authors focused on a base case of a 65-year-old man who underwent a radical prostatectomy and found an incremental cost-effectiveness ratio of £4293 per quality-adjusted life-year, which was cost-effective because it was below the £30 000 willingness-to-pay threshold. Importantly, this was modeled for a 10-year follow-up to realize the benefits of robotics because the primary driver of cost-effectiveness was the lower risk of biochemical recurrence.

These results are timely because nearly 85% of prostatectomies are performed robotically.3 Detractors of the robotic approach might argue that performing CEA when the proverbial horse is out of the barn lacks utility. To their point, it is unlikely that we will ever see robotic prostate surgeons return to open surgery despite the conclusions of future studies. The reduced length of stay for patients, decreased blood loss, surgeon ergonomics, flatter learning curve, and ability to teach trainees more effectively has likely cemented robotic-assisted prostatectomy’s place in our care pathway. However, there remains an important role for CEAs to help guide implementation and serve as a benchmark when comparing other robotic or technological advances.

Several important points are worth considering. Cost-effectiveness analyses as currently designed can identify smaller components of high-value care to allay undue financial burden on our patients (ie, financial toxicity) as well as the strain on health systems and payors supporting them. Other studies that have reinforced the cost-effectiveness of robotic prostatectomy have demonstrated similar results only after analyzing costs over a longer time horizon.4 Cost-effectiveness analyses performed too early in the life cycle of a technological adoption may run the risk of inaccurately denoting a technology as cost-ineffective. By performing longitudinal CEAs and maintaining flexibility and an eye toward the future, we can prevent stifling innovations inappropriately.

The question remains, are CEAs enough? If the goal of such studies is to reduce costs and improve outcomes for our patients, the answer is no. Most specialty health care worldwide remains entrenched in a fee-for-service model that hinders our ability to operationalize the data derived from CEAs to drive value.5,6 In the US, the Centers for Medicare & Medicaid Services under the current administration have renewed their strategy for value-based care models to address the shortcomings of our volume-based system by 2030.7 Such value-based models will incentivize high-quality low-cost care.

To drive value, the question we should be asking is not robotic vs open. It is time to accept robotic prostatectomy as a fixture in a urologist’s armamentarium. Instead, we should ask ourselves how we can continue to innovate and transform health care delivery. We can start by pushing the envelope with perioperative approaches such as same-day discharge, nonnarcotic protocols, early catheter removal, and refinement of surgical technique. However, prostate cancer treatment is still a small piece of a much larger pie. To achieve real success, we must take on leadership roles in cultivating a health care infrastructure that incentivizes surgeons to innovate, develop CEAs at scale across the continuum of disease (ie, localized and advanced prostate cancer), and share responsibility for patient-centered care. Only then will we able to achieve our goal of driving down costs and improving value for our patients.

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Article Information

Published: April 4, 2022. doi:10.1001/jamanetworkopen.2022.5747

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Golla V et al. JAMA Network Open.

Corresponding Author: Stephen B. Williams, MD, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555 (stbwilli@utmb.edu).

Conflict of Interest Disclosures: None reported.

Mariotto  AB, Enewold  L, Zhao  J, Zeruto  CA, Yabroff  KR.  Medical care costs associated with cancer survivorship in the United States.   Cancer Epidemiol Biomarkers Prev. 2020;29(7):1304-1312. doi:10.1158/1055-9965.EPI-19-1534 PubMedGoogle Scholar
Labban  M, Dasgupta  P, Song  C,  et al.  Cost-effectiveness of robotic-assisted radical prostatectomy for localized prostate cancer in the UK.   JAMA Netw Open. 2022;5(4):e225740. doi:10.1001/jamanetworkopen.2022.5740Google Scholar
Crew  B.  Worth the cost? a closer look at the da Vinci robot’s impact on prostate cancer surgery.   Nature. 2020;580(7804):S5-S7. doi:10.1038/d41586-020-01037-w Google Scholar
Okhawere  KE, Shih  IF, Lee  SH, Li  Y, Wong  JA, Badani  KK.  Comparison of 1-year health care costs and use associated with open vs robotic-assisted radical prostatectomy.   JAMA Netw Open. 2021;4(3):e212265. doi:10.1001/jamanetworkopen.2021.2265 PubMedGoogle Scholar
Reid  RO, Tom  AK, Ross  RM, Duffy  EL, Damberg  CL.  Physician compensation arrangements and financial performance incentives in US health systems.   JAMA Health Forum. 2022;3(1):e214634. doi:10.1001/jamahealthforum.2021.4634 Google Scholar
Gusmano  MK, Laugesen  M, Rodwin  VG, Brown  LD.  Getting the price right: how some countries control spending in a fee-for-service system.   Health Aff (Millwood). 2020;39(11):1867-1874. doi:10.1377/hlthaff.2019.01804 PubMedGoogle Scholar
Brooks-LaSure  C, Fowler  E, Seshamani  M, Tsai  D. Innovation at the Centers for Medicare and Medicaid Services: a vision for the next 10 years. Health Affairs Blog. August 12, 2021. Accessed November 2, 2021. https://www.healthaffairs.org/do/10.1377/forefront.20210812.211558/full/
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    1 Comment for this article
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    Gerald Silverberg, BA | UNU-MERIT & IIASA
    “To drive value, the question we should be asking is not robotic vs open.”

    Indeed. The question should at the very least be robotic vs open vs laparoscopic vs primary radiotherapy. Since the latter  reduces the QoL patient risks (incontinence, impotence, surgical complications) while realizing comparable BCR and OS at comparable or lower costs, this sort of CEA might identify it as a dominant alternative.