Trends in the Setting and Cost of Ambulatory Urological Surgery: An Analysis of 5 States in the Healthcare Cost and Utilization Project

Introduction: With the rising costs of health care, surgical procedures have migrated from the inpatient to outpatient setting with more than 60% of urological procedures performed in the ambulatory setting. Ambulatory surgical centers have the potential to reduce costs but may also lead to overutilization. We assessed utilization of ambulatory surgical centers for urological procedures, case mix distribution compared to hospital based outpatient surgery departments and cost implications. Methods: All outpatient urological procedures were identified from 5 states in the United States (2010 to 2014) using all payer data. Patient demographics, regional data, facility type (ambulatory surgical center vs hospital based outpatient surgery department) and total charges (converted to costs and inflation adjusted to 2014 USD) were determined. Analyses of overall number of procedures, population adjusted rates, annual percent change and adjusted linear regression models were performed. Results: Of more than 37 million surgical procedures 1,842,630 (4.9%) were urological with overall annual percent change +0.97% (+1.09% hospital based outpatient surgery departments vs +0.41% ambulatory surgical centers) and 20.0% performed in ambulatory surgical centers. The proportion performed in ambulatory surgical centers decreased slightly with time (-0.48% per year, p <0.001). Overall costs totaled $4.78 billion, representing 7.6% of all ambulatory surgery (average cost per procedure $2,603.76). All procedures demonstrated reduced costs per case when performed in ambulatory surgical centers (range -$800 to -$1,800). Unadjusted net cost increase per procedure per year was +$147.79 (+$113.98 adjusted). Providers performing the top quartile (Q1) of procedures demonstrated reduced costs. Conclusions: Ambulatory urological surgery represents 5% of all surgical cases but 7.6% of costs. The rate of procedures is increasing steadily with performance in ambulatory surgical centers outpaced by those in hospital based outpatient surgery departments. The cost of ambulatory urological surgery is rising out of proportion to explanation by inflation, patient factors or case mix.