Referring Radical Prostatectomies to High-Volume Providers Could Save Millions

A new study of the geographic distribution of cancer surgeries in the Medicare population has shown that performing radical prostatectomies in high-volume centers leads to improved outcomes and reduced costs of care. Referring patients to a high-volume provider within 100 miles could save >$20 million annually, according to data presented at the 2016 American Society of Clinical Oncology annual meeting and published just before the meeting.1

“Redirecting radical prostatectomy patients to high-volume providers is associated with better medical and oncologic outcomes, shorter length of stay, and fewer complications. Referrals within 100 miles are not only feasible but could save significant societal costs,” said Sarmad Sadeghi, MD, PhD, of the USC Norris Comprehensive Cancer Center, Los Angeles, CA, who presented the study results.

Previous studies by Vickers and colleagues have shown that surgical experience correlates with better oncologic outcomes from radical prostatectomy in early-stage prostate cancer. Whether the savings associated with prostatectomies referred to high-volume centers can offset referral cost, however, largely depends on patients’ distance from these centers.

“With fewer biochemical failures and cancer recurrences, patients that get their surgery with high-volume surgeons clearly do better, but it’s hard to estimate referral costs, which may include the cost of travel, lodging, missed earnings, and lost income,” said Dr Sadeghi.

Dr Sadeghi and colleagues analyzed the Medicare Provider Utilization and Payment Data from 2012 and 2013 to estimate the differences between high- and low-volume providers in terms of effectiveness outcomes (oncologic and nononcologic) and cost outcomes (oncologic failure only). They grouped Medicare providers according to the number of radical prostatectomies performed, and calculated the travel distance between providers based on the surgical volume. Opportunity costs were calculated for radical prostatectomies within 100 miles of the highest-volume providers.

Improved Clinical and Financial Outcomes

The database included 241,740 prostate cancer cases in 2012 and 238,590 cases in 2013, and 32% of these cases had a radical prostatectomy. Overall, 15% of providers performed >30% of the radical prostatectomies (≥30 cases annually).

Each referred prostatectomy is associated with a savings of $1800 in the next 20 years, and each year, surgeons with below-median volume who are within driving distance of a top 10% surgeon perform approximately 13,800 prostatectomies. There­fore, the savings can be >$20 million annually, Dr Sadeghi said.

“These results indicate that a lot of patients could be easily redirected to a high-volume provider. In centers of population, it’s not difficult to find an experienced surgeon within driving distance,” said Dr Sadeghi.

Dr Sadeghi called redirecting radical prostatectomies to high-volume surgeons a “win–win scenario.” Even for low-volume providers, because prostatectomies are not a major part of their practice, redirecting patients should not influence their bottom line, he said.

Although advancing technology may eventually help to balance outcomes, experience will always be a key part of clinical practice, according to Dr Sadeghi.

“Nobody is arguing that they can train a physician to emerge from residency and have the best outcomes in cancer surgery,” he said.

“After we put these numbers together, we’ll see how much interest we get from hospital organizations and commercial groups like insurance companies,” Dr Sadeghi concluded.


  1. Barzi A, Klein EA, Dorff TB, et al. Prostatectomy at high-volume centers improves outcomes and lowers the costs of care for prostate cancer. Prostate Cancer Prostatic Dis. 2016;19:84-91.

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