Northampton General Day Case BPH service evaluation – adoption of Urolift

Aims:

• To determine whether offering Urolift to patients as alternative to TURP for troublesome symptoms of Benign Prostate Hyperplasia (BPH) would result in cost and efficiency savings for the trust
• If beneficial secure agreement for adoption of Urolift for suitable patients

Objectives:

• Collect data (clinical and financial) on the impact of adoption
• Adopt Urolift as a day case procedure to be done in operating theatres
• Utilise the already established surgical day case unit for patient recovery
• Utilise the Urology centre outpatient to prepare patients for the procedure and to offer the post discharge follow up

The Urology department at NGH has 6 Urological surgeons. Prior to adoption of Urolift in 2017, the main surgical intervention to alleviate troublesome symptoms of BPH was bipolar transurethral resection of the prostate (TURP). In 2016/2017 around 200 Bipolar TURP procedures were done. The average length of stay was 2.3 days

The clinician who champion adoption of Urolift had recently started working at NGH, and prior to this appointment he had been offering Urolift at another trust. He was therefore skilled at the procedure and familiar with the service requirements.

The team were aware of the potential cost savings, reduced incidence of cancellations and patient benefits to Urolift and wanted to adopt it locally for suitable men.

The cost of Urolift is covered under national Tariff which meant that negotiations with local commissioners would not be required to secure financial support for adoption. On the national tariff, reimbursement for a Urolift procedure is on average £145 higher than for TURP (see attachment). Providers should use the OPCS procedure code M68.3 for Urolift (prostatic urethral lift) under the National Tariff Payment System. This generates a code for the service (HRG:LB70) which generates a claim for payment via SUS (Secondary Users Services). This ready-created commissioning model reduced the cost barriers to adoption and therefore supported the case for adoption.

Instead of developing a business case and requesting ongoing funding for Urolift it was agreed that the team would run a pilot to look at the impact and learning. As part of the pilot they set clinical key priority indicators (KPI) which included collecting information in prostate sizes, number of implants used, time in theatre, complications and impact and financial KPI’s which allowed extrapolation to bed days saved.

A Urolift day case pilot proposal was developed and submitted to the divisional management for approval. A submission to the governance committee was also required because it was a new intervention.

Urolift was adopted with only 1 urological surgeon doing the procedure (the Urolift lead clinician who had been doing the procedure at another trust). The team decided on this approach to use his experiences to establish the service.

The team compared the impact of 20 Urolift cases to 20 bi-polar TURP cases. The data (see key findings) was presented to the divisional management team and finance team alongside patient satisfaction findings and final approval was given for ongoing use of Urolift at the trust.

Urolift is undertaken in the operating theatres. Patients either receive a general anaesthetic or local anaesthetic with sedation. Which anaesthetic method is chosen is based upon a mixture of clinician, anaesthetist and patient discussion and consideration of factors. Some patients cannot tolerate the procedure without a general anaesthetic. Getting comfortable on the table can be difficult. The type of anaesthetic method used does not affect the patient’s length of stay.

Patients are assessed individually at the trust but in general Urolift is offered to men with moderate to severe lower urinary tract symptoms who do not want medications or where they have failed and where they want to keep their sexual function. They would not offer it for prostates more than 80-100g

To establish the service the team developed a new day case pathway which required approval by the governance team. The team were able to utilise the day case surgery department and so patients recovered in the hospital’s day case unit. This cares for people who have had a variety of day case procedures. The nurse staff therefore required training on the post-operative care for these patients.

The urology service at Northampton General has a dedicated ‘urology centre’ which is an outpatients service led by band 6 and 7 nurses. This department is responsible for the pre-operative checks patients would have prior to a BPH intervention and so these nurses required training in the pre-op process for patients undergoing Urolift. This centre was also responsible for being a point of contact for patients following discharge after a BPH procedure and so they required training in the Urolift post-operative recovery to be able to deal with the queries.

As part of the adoption process the team undertook external communications work raising awareness among the CCG, GP leads. They also raised awareness among the general public via the local BBC radio.

There is an increase in the number of referrals from outside of the trust’s catchment area requesting Urolift. There is a plan to train another urological surgeon in the Urolift procedure.

Since adoption of Urolift, HoLEP is now also offered at the trust for prostate sizes over 100g. Each of the interventions on offer at the trust complement each other.

A six-month retrospective study was undertaken at NGH of forty patients with BPH who had undergone either a TURP procedure (n=20) or a Urolift procedure (n=20). The costs associated with each procedure was derived from tracing resources used by the individual patients and calculating the cost of those resources using actual expenditure by the trust. We also collected data on theatre time and length of stay.

Over a period of six months, forty patients at NGH received a surgical treatment for their lower urinary tract symptoms (Urolift N=20, TURP N=20). The costs were divided into Direct costs, Indirect costs and Overheads associated with each procedure. The average operating time for TURP was 45.3 minutes compare to 20.11 minutes for Urolift. Equally the average length of inpatient stay after TURP was 2.1 days while all UroLift procedures were performed as a day case procedure (average length of stay of 0.27 days). We calculated the total cost to the trust per patient of TURP at £3,131 and £2,260 for Urolift, a difference in cost of £871 (Table 1).

During the 6-month period during which UroLift was offered to patients there was a reduction in bed days by 36.7, giving rise to a net saving of £11,529 (£270/bed/day). During the same period, there was a reduction in theatre running time of 8.4 hours, giving rise to a cost saving of £6,242 (£743/hour theatre time) (Table 2).

The average tariff income for TURP was £2,093 and Urolift was £2,297, based on the tariff prices (2018/19) HRG LB25F, LB25E (TURP) and LB70D, LB70C (UroLift). Overall, there was a net cost saving of £21,495 when comparing UroLift with TURP (Figure 4)

Table 1: Cost per patient

Table 2. Net impact of UroLift (n=20) vsTURP (n=20)

Table 3 Cost impact summary

The study has demonstrated that the minimally invasive procedure prostatic urethral lift (UroLift) has proven to be more cost effective than TURP with a reduced cost to the trust and a lesser impact on hospital resources.

Whilst UroLift is not appropriate for all patients with BPH, it remains a cost effective and preferred option in many patients. In the future, early recognition and selection of patients who are good candidates for UroLift could reduce the financial and resource burden of BPH surgery.

It is important to show the benefits to the trust’s finance team who may see a barrier in the initial upfront costs of Urolift compared with TURP.