Introduction:

For patients with kidney cancer, contemporary radical nephrectomy (RN) pathways have moved towards optimized workflows, refined care team structures, and utilization of minimally invasive techniques. In addition, the pressure to avoid inpatient stays during the COVID-19 pandemic has also accelerated care pathways for earlier discharge. Meanwhile, the Centers for Medicare and Medicaid Services has maintained RN on the inpatient only procedure list preventing its widespread adoption in ambulatory surgical centers. In this context, little is known regarding the evolution of discharge patterns of RN. Herein, we aimed to characterize national trends in next day discharge (NDD) after RN, identify its patient and hospital predictors, and its implications for total hospital charges. 

Methods:

Years 2016-2020 of the National Inpatient Survey (NIS) were queried to identify RN for kidney cancer.  The primary outcome was NDD, defined as a length of stay (LOS) of 1 day or less. Survey weighted univariable and multivariable logistic regressions were performed to identify patient and hospital level factors associated with NDD. The association of NDD with total hospital charges was tested using univariable and multivariable generalized linear models using a gamma distribution. STATA and R Studio were used for data abstraction and analysis, respectively. 

Results:

Of 224,750 RNs, 34,640 (15.4%) of patients had NDD. The proportion of NDD significantly increased from 2016 to 2020 (overall 10.2% vs 24.3%, p<0.0001), though this remained significant only for MIS, not open, RN (Figure 1). Several variables were associated with NDD (Table 1). Hospital factors associated with NDD include a smaller number of beds (OR 1.54, p<0.001) and highest RN volume quartile (OR 1.78 for highest vs lowest quartile, p<0.001). In addition, a minimally invasive approach (OR 3.58, p<0.001) was associated with NDD. NDD was associated with lower total hospital charges compared to non-NDD: $50,798 vs $68,058, p<0.0001. On multivariable generalized linear models, NDD remained associated with lower total hospital charges (OR 0.64, p<0.001).  

Conclusion:

The incidence of NDD after RN has considerably more than doubled from 2016 to 2020, and NDD was associated with lower total hospital charges. NDD was more common after minimally invasive RN in high volume centers with a smaller number of total hospital beds, indicating that both minimally invasive care pathways and hospital bed turnover pressure may be driving the trend of increased NDD. Further study is warranted to ensure that patient satisfaction and readmission rates are not compromised by NDD. We also anticipate increased numbers of minimally invasive RNs will be performed with same day discharge in the future, opening the door for RN removal from the inpatient only list. 

Funding: AUA Urology Care Foundation Research Scholar Award