October 8, 2014

Study: Robotic surgery means higher costs, more complications

Daily Briefing

Robotic surgery—often touted as a less invasive surgery option with shorter recovery times than laparoscopy—might actually have a higher rate of complications and be more costly to patients, according to a new study by researchers from Columbia University.

Background on robotic technology

Robotic surgical systems, such as the da Vinci robot, make small incisions to conduct various surgical procedures, including removing ovaries and ovarian cysts. Supporters claim the robotic surgeries involve less blood loss than traditional minimally invasive surgery and have shorter recovery times and hospital stays.

However, others argue that regular laparoscopic surgery has the same benefits, without the high purchasing cost of robotic technology.

In 2013, Columbia researchers—the same ones who authored the new study—found that robotic surgery for hysterectomies was more expensive and did not achieve better outcomes than laparoscopic surgery. Similarly, another study this year found that using robotic surgery tools to treat bladder cancer did not provide better outcomes or reduce complications.

This year, the American College of Obstetricians and Gynecologists (ACOG) issued a statement arguing that robotic surgery was not the most effective or cost-efficient hysterectomy strategy.

Details of Columbia study

For the most recent study, which was published in the journal Obstetrics & Gynecology, researchers examined the records of more than 87,000 women who had ovaries or ovarian cysts removed at 502 hospitals from 2009 to 2012. During that time, the use of surgical robots increased significantly, from 3.5% to 15% of ovarian surgeries and from 2.4% to 12.9% of cyst removals.

The researchers found that 7.1% of patients who underwent a robotic surgical procedure to have their ovaries removed had complications—including injuries to their bladders, ureters, and kidneys during surgery—compared with just 6% of those who underwent traditional laparoscopy. Similarly, 3.7% of patients who had robotic surgery to remove cysts experienced complications, compared with 2.7% of laparoscopy patients.

Researchers attribute the increase in complications in part to "surgeons gaining experience on a new technology."

Researchers also found the difference in cost to be significant. Compared to regular laparoscopy, robotic surgery costs an average of $2,504 more for removing ovaries and $3,311 more for removing cysts.

What the experts are saying

Jason Wright, chief of gynecologic oncology at Columbia and the study's lead author, says "There's a widespread belief that newer is better but our findings question that," adding, "People need to stop and critically analyze whether using this expensive technology will really add any benefit for patients."

Robert Edwards, UPMC's vice chair of gynecologic services, argues that robotic surgery could be important in very complex cases that require increased mobility. But he acknowledges that the "pendulum has swung a little too far" and hospitals should "take a hard look at why and how it is being used."

Vik Srinivasan, a senior analyst at The Advisory Board Company, says many hospitals have been willing to absorb the extra cost of robotic surgeries in an effort to gain market share. However, this has become more difficult as more hospitals adopt the technology. "Now, hospitals are wondering, do we risk losing patients and surgeons if we don't have this key technology?" he says, adding, "Those are the tough questions that have to think through" (Beck, Wall Street Journal, 10/7).

The Advisory Board's take

Vik Srinivasan, Senior Analyst

This study is further proof that hospitals need to think carefully about both their initial investment in the da Vinci robot and their protocols for monitoring its ongoing use.

Though many hospitals question the ROI of this multi-million dollar investment before making it, few scrutinize the robot’s use as rigorously as they should once the investment has been made. Without this oversight, programs may see financial losses continue years after investing in a robot without any improvement in clinical outcomes for patients.

Establishing a governance body composed of surgeons and administrators helps promote cost-effective and clinically appropriate use of the robot. Complication rates rise when there is limited oversight of what procedures are converted to the robot, and how new robot users are credentialed. The process of creating this oversight need not be adversarial—high-volume surgeons with superior outcomes are often the hospital’s closest allies in monitoring effective use.

At the end of the day, the robot is a surgical instrument like any other. For key surgeries, it can be a valuable tool in the hands of an experienced surgeon. The challenge of making the robot cost effective is most acute when a hospital provides inadequate guidance on how, where, and by whom it is used. 

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