Cost-utility analysis on robot-assisted and laparoscopic prostatectomy based on long-term functional outcomes

Abstract

Robot-Assisted Radical Prostatectomy (RARP) is one of the standard treatment options for prostate cancer. However, controversy still exists on its added value. Based on a recent large-sample retrospective cluster study from the Netherlands showing significantly improved long-term urinary functioning after RARP compared to Laparoscopic RP (LRP), we evaluated the cost-effectiveness of RARP compared to LRP. A decision tree was constructed to measure the costs and effects from a Dutch societal perspective over a ~ 7 year time-horizon. The input was based on the aforementioned study, including patient-reported consumption of addition care and consumed care for ergonomic issues reported by surgeons. Intervention costs were calculated using a bottom-up costing analysis in 5 hospitals. Finally, a probabilistic-, one-way sensitivity- and scenario analyses were performed to show possible decision uncertainty. The intervention costs were €9964 for RARP and €7253 for LRP. Total trajectory costs were €12,078 for RARP and €10,049 for LRP. RARP showed higher QALYs compared to LRP (6.17 vs 6.11). The incremental cost-utility ratio (ICUR) was €34,206 per QALY gained, in favour of RARP. As a best-case scenario, when RARP is being centralized (> 150 cases/year), total trajectory costs decreased to €10,377 having a higher utilization, and a shorter procedure time and length of stay resulting in an ICUR of €3495 per QALY gained. RARP showed to be cost-effective compared to LRP based on data from a population-based, large scale study with 7 years of follow-up. This is a clear incentive to fully reimburse RARP, especially when hospitals provide RARP centralized.

Figure 1

Results from the one-way sensitivity analysis. This figure presents the results of the deterministic one-way sensitivity analysis. This figure shows the influence of the observed uncertainty (lower and upper value) surrounding a specific parameter on the main outcome measure. All parameters starting with a “p” indicate a probability. From this figure we learn that the uncertainty surrounding the intervention costs, definitions and utility value showed the largest deviation from the base case ICUR. However this uncertainty does not affect our conclusion. ICUR = incremental cost-utility ratio. * the uncertainty from this parameter was a combined value, the uncertainty surrounding the chance of using 1, 2 and 3 or more pads were changed at the same time. The SE surrounding these parameters can be found in Table 1.

Figure 2

Results from the probabilistic sensitivity analysis. (a) presents all potential outcomes given the distribution surrounding the parameter. The trend lines show the WTP thresholds. All potential outcomes are below the WTP threshold of €80,000. The majority of outcomes also fall below the WTP threshold of €50,000. (b) shows the probability of RARP being cost-effective, given a certain WTP threshold. The probability of RARP being cost-effective at a WTP threshold of €80,000 is 99.8%.

Figure 3

Results from scenario 3. This figure presents the incremental cost-utility ratio (ICUR) when the Da Vinci is used more often. For example when also used for other indications. Showing an ICUR below €20,000 when ≥ 250 procedures are performed per year with the Da Vinci robot. When the robot is fully used, RARP even shows the potential to be cost-saving compared to LRP.