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The cost of robotic surgery
Author's Accepted Manuscript
The Cost of Robotic Surgery Vikram Attaluri MD, FACS, Elisabeth C. McLemore MD, FACS, FASCRS
www.elsevier.com/locate/yscrs
PII: DOI: Reference:
S1043-1489(16)30011-2 http://dx.doi.org/10.1053/j.scrs.2016.04.004 YSCRS556
To appear in:
Seminars in Colon and Rectal Surgery
Cite this article as: Vikram Attaluri MD, FACS, Elisabeth C. McLemore MD, FACS, FASCRS, The Cost of Robotic Surgery, Seminars in Colon and Rectal Surgery, http://dx.doi.org/10.1053/j.scrs.2016.04.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Seminars in Colon and Rectal Surgery: Issue on Robotics
The Cost of Robotic Surgery
Vikram Attaluri, MD, FACS; Elisabeth C. McLemore, MD, FACS, FASCRS Colon and Rectal Surgery Kaiser Permanente Los Angeles Medical Center
Kaiser Permanente, Department of Surgery 4760 Sunset Blvd, 3rd Floor Los Angeles, CA 90027 [email protected]
Abstract
The introduction of robotic surgery has the potential to change colorectal surgery. Though the benefits of this instrument are still being evaluated, many hospitals have already started using it so as not be left behind in the competition for patients. While there are benefits in decreased conversion rates and possibly better longterm functional outcomes, there has yet to be published evidence that the use of a robot is cost effective in colorectal surgery. Given the high cost of investment, further work needs to be done in high volume centers to identify a cost-effective strategy to implement this technology.
INTRODUCTION
Robotic surgery has significantly changed the practice of rectal surgery and to a lesser extent colon surgery. Similar to the introduction of laparoscopic surgery, questions and criticisms have been raised regarding the overall benefit to the patient and the health care system as the medical community at large has moved rather swiftly towards widespread purchase of robotic surgical platforms and equipment.
When evaluating the cost effectiveness of robotic surgery, many factors need to be taken into account. These include both direct and indirect costs. Indirect costs would be related to non-patient factors. Direct costs can be broken down into fixed direct costs such as the clinical managers, and variable direct costs such as nursing care and medication.1 On the other side, one must take into account the potential benefits of superior outcomes such as any reduction in the length of stay and any beneficial impact on long-term function2.
COLON
While much of the focus with robot assisted surgery is on rectal cancer, some groups have explored its use for colon resection as well. deSouza et al published a comparison of robotic and laparoscopic right colectomy in 2010. This retrospective analysis compared 40 robot assisted right colectomies to 135 laparoscopic right
colectomies from 2005 to 2009. They identified no significant difference in postoperative outcomes or pathologic outcomes. They did note a significantly higher operative time, 159 min for robotic and 118 min for laparoscopic surgery. Cost increased significantly with robotic surgery, $15,192 vs $12,362. The authors stated this was due to both increased direct and indirect cost but did not provide further detail.1
Park et. al published their experience with a randomized controlled trial looking at laparoscopic vs robot assisted right hemicolectomy. 35 patients were in each group at this single institution study in Korea. The robotic approach was associated with a significantly longer operative time at 195 min vs 130 min for the laparoscopic group. Of note, 30 of 35 patients in the robotic group underwent an intracorpeal anastomosis, as opposed to only 7 out of 35 in the laparoscopic group. This did not result in any significant difference in post-operative outcomes or oncologic outcomes such as margin distance or lymph node harvest. The final cost to the hospital was $12,235 for the robotic approach and $10,320 for the laparoscopic approach on a case by case basis. This additional cost was almost entirely due to intra-operative surgical cost ($9,061 for robotic vs $6098 laparoscopic.) In addition, the authors note that the Korean health system does not cover the added expense of robotic surgery, and the patients are charged directly for the additional costs associated with robotic surgery.3. These costs do not take into account the initial capital purchase of the robotic system nor the annual robotic equipment maintenance and service fees.
RECTAL
Many authors have looked at robotic colon surgery as a training pathway to robotic rectal cancer surgery. While many surgeons more routinely manage colon cancer with laparoscopic segmental colectomy, significantly fewer surgeons have adopted laparoscopic surgery for rectal cancer as laparoscopic pelvic surgery is more technically challenging and may be associated with inferior oncologic outcomes4. Certainly, low rectal tumors within the confines of a narrow pelvis pose a challenge for any surgical approach. In addition the close proximity of pelvic nerves present a challenge for long-term functional outcomes. For these reasons, robotic surgery was seen as a particularly hopeful tool for rectal cancer surgery.
Baek et al were among the first to publish cost analysis of robotic rectal surgery. They retrospectively evaluated 154 robotic and 150 laparoscopic rectal cancer cases from 2007-2010 in a single institution. Similar to the work in colon cases, they identified a longer operative time 285 min vs 219 min and higher total hospital cost ($14,647 vs $9,978) for robot assisted surgery. This was largely due to the difference in operating room cost, $8,849 vs $2,289. There was no significant difference in post-operative outcomes. Because total operating room costs were higher for robotic surgery, hospital profit was also lower, $689 vs $1,671. One possible confounding factor is that the tumor location was significantly lower for the
robotic group. They were able to provide a breakdown of the costs; one significant factor was the initial investment for the robot, which they factored as a depreciation cost of $2,246 per case in their analysis. 5 Again, these costs do not take into account the initial capital purchase of the robotic system nor the annual robotic equipment maintenance and service fees.
As health care systems began to purchase the robotic equipment with great interest and enthusiasm, robotic colorectal surgery gained wider adoption, and an analysis of various administrative databases have been performed to further evaluate the cost of robotic surgery. Pigazzi et al utilized the National Inpatient Sample from 2009-2010 to compare cost of laparoscopic vs robotic colorectal surgery. The authors identified that conversion to open procedures were significantly lower for both colon (OR 0.41) and rectal (OR 0.10) robotic cases. However, they still noted significantly higher charges for both colon ($62,761 vs $45,557) and for rectal ($74,327 vs $45,557) robotic cases. There was no other difference noted for morbidity, or length of stay except for increased bleeding risk in robotic colon procedures.6
The published literature thus far consistently reveals higher operative costs associated with robotic surgery. However, for true comparative studies one would need to look more closely at other factors such as lower conversion rates, long term functional outcome, effects on surgeons, etc. Robotic rectal surgery has been
associated with better functional outcomes early in the post-operative period7. While the difference in functional outcome progressively lessened by 6 to 12 months, these results are interesting as they reveal a possible significant advantage that is not currently taken into account in short-term cost comparisons.
In an ideal evaluation of the impact of robotic surgery on patients and the health care system, the capital-intensive investment would be confined to a small number of high volume centers. However, the rapid worldwide purchase and adoption of the da Vinci robotic system suggests that factors other than published outcome data are driving the capital investment in the robotic systems. This more closely resembles an arms race in medical technology acquisition amongst health care systems and the associated marketing and advertisement of the acquisition rather than an improved patient outcome driven acquisition of medical equipment. As Keller et al stated, the cost of the robotic platform at $2.5 million and an annual charge of $200,000 remains a heavy burden for many hospitals8. Keller et al estimated that the acquisition and maintenance cost of a system for hospital performing 100 robotic cases would be an additional $5,500 per robotic case. For 250 cases, the cost would drop to $2,000 per case. They go on to state that only 20% of hospitals in California have at least 100 cases per year and only 3% have 250 or more per year. As few if any colorectal programs achieve this volume, this
emphasizes the need to work with other disciplines such as urology and gynecology to minimize cost. In addition, the healthcare industry would benefit from a rigorous study of the cost effectiveness of this technology. Left alone to market forces, there appears to be a significant increase in spending with questionable benefit shown to date.
1.
deSouza AL, Prasad LM, Park JJ, Marecik SJ, Blumetti J, Abcarian H. Robotic Assistance in Right Hemicolectomy: Is There a Role? Dis Colon Rectum. 2010;53(7):1000–1006. doi:10.1007/DCR.0b013e3181d32096.
2.
Baek SK, Carmichael JC, Pigazzi A. Robotic surgery: colon and rectum. Cancer J. 2013;19(2):140–146. doi:10.1097/PPO.0b013e31828ba0fd.
3.
Park JS, Choi GS, Park SY, Kim HJ, Ryuk JP. Randomized clinical trial of robotassisted versus standard laparoscopic right colectomy. Br J Surg. 2012;99(9):1219–1226. doi:10.1002/bjs.8841.
4.
Fleshman J, Branda M, Sargent DJ, et al. Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes. JAMA. 2015;314(13):1346. doi:10.1001/jama.2015.10529.
5.
Baek S-J, Kim S-H, Cho J-S, Shin J-W, Kim J. Robotic versus Conventional Laparoscopic Surgery for Rectal Cancer: A Cost Analysis from A Single Institute in Korea. World J Surg. 2012;36(11):2722–2729. doi:10.1007/s00268-012-
1728-4. 6.
Halabi WJ, Kang CY, Jafari MD, et al. Robotic-assisted Colorectal Surgery in the United States: A Nationwide Analysis of Trends and Outcomes. World J Surg. 2013;37(12):2782–2790. doi:10.1007/s00268-013-2024-7.
7.
Kim JY, Kim N-K, Lee KY, Hur H, Min BS, Kim JH. A Comparative Study of Voiding and Sexual Function after Total Mesorectal Excision with Autonomic Nerve Preservation for Rectal Cancer: Laparoscopic Versus Robotic Surgery. Ann Surg Oncol. 2012;19(8):2485–2493. doi:10.1245/s10434-012-2262-1.
8.
Keller DS, Senagore AJ, Lawrence JK, Champagne BJ, Delaney CP. Comparative effectiveness of laparoscopic versus robot-assisted colorectal resection. Surg Endosc. 2013;28(1):212–221. doi:10.1007/s00464-013-3163-5.
The Cost of Robotic Surgery Vikram Attaluri MD, FACS, Elisabeth C. McLemore MD, FACS, FASCRS
www.elsevier.com/locate/yscrs
PII: DOI: Reference:
S1043-1489(16)30011-2 http://dx.doi.org/10.1053/j.scrs.2016.04.004 YSCRS556
To appear in:
Seminars in Colon and Rectal Surgery
Cite this article as: Vikram Attaluri MD, FACS, Elisabeth C. McLemore MD, FACS, FASCRS, The Cost of Robotic Surgery, Seminars in Colon and Rectal Surgery, http://dx.doi.org/10.1053/j.scrs.2016.04.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Seminars in Colon and Rectal Surgery: Issue on Robotics
The Cost of Robotic Surgery
Vikram Attaluri, MD, FACS; Elisabeth C. McLemore, MD, FACS, FASCRS Colon and Rectal Surgery Kaiser Permanente Los Angeles Medical Center
Kaiser Permanente, Department of Surgery 4760 Sunset Blvd, 3rd Floor Los Angeles, CA 90027 [email protected]
Abstract
The introduction of robotic surgery has the potential to change colorectal surgery. Though the benefits of this instrument are still being evaluated, many hospitals have already started using it so as not be left behind in the competition for patients. While there are benefits in decreased conversion rates and possibly better longterm functional outcomes, there has yet to be published evidence that the use of a robot is cost effective in colorectal surgery. Given the high cost of investment, further work needs to be done in high volume centers to identify a cost-effective strategy to implement this technology.
INTRODUCTION
Robotic surgery has significantly changed the practice of rectal surgery and to a lesser extent colon surgery. Similar to the introduction of laparoscopic surgery, questions and criticisms have been raised regarding the overall benefit to the patient and the health care system as the medical community at large has moved rather swiftly towards widespread purchase of robotic surgical platforms and equipment.
When evaluating the cost effectiveness of robotic surgery, many factors need to be taken into account. These include both direct and indirect costs. Indirect costs would be related to non-patient factors. Direct costs can be broken down into fixed direct costs such as the clinical managers, and variable direct costs such as nursing care and medication.1 On the other side, one must take into account the potential benefits of superior outcomes such as any reduction in the length of stay and any beneficial impact on long-term function2.
COLON
While much of the focus with robot assisted surgery is on rectal cancer, some groups have explored its use for colon resection as well. deSouza et al published a comparison of robotic and laparoscopic right colectomy in 2010. This retrospective analysis compared 40 robot assisted right colectomies to 135 laparoscopic right
colectomies from 2005 to 2009. They identified no significant difference in postoperative outcomes or pathologic outcomes. They did note a significantly higher operative time, 159 min for robotic and 118 min for laparoscopic surgery. Cost increased significantly with robotic surgery, $15,192 vs $12,362. The authors stated this was due to both increased direct and indirect cost but did not provide further detail.1
Park et. al published their experience with a randomized controlled trial looking at laparoscopic vs robot assisted right hemicolectomy. 35 patients were in each group at this single institution study in Korea. The robotic approach was associated with a significantly longer operative time at 195 min vs 130 min for the laparoscopic group. Of note, 30 of 35 patients in the robotic group underwent an intracorpeal anastomosis, as opposed to only 7 out of 35 in the laparoscopic group. This did not result in any significant difference in post-operative outcomes or oncologic outcomes such as margin distance or lymph node harvest. The final cost to the hospital was $12,235 for the robotic approach and $10,320 for the laparoscopic approach on a case by case basis. This additional cost was almost entirely due to intra-operative surgical cost ($9,061 for robotic vs $6098 laparoscopic.) In addition, the authors note that the Korean health system does not cover the added expense of robotic surgery, and the patients are charged directly for the additional costs associated with robotic surgery.3. These costs do not take into account the initial capital purchase of the robotic system nor the annual robotic equipment maintenance and service fees.
RECTAL
Many authors have looked at robotic colon surgery as a training pathway to robotic rectal cancer surgery. While many surgeons more routinely manage colon cancer with laparoscopic segmental colectomy, significantly fewer surgeons have adopted laparoscopic surgery for rectal cancer as laparoscopic pelvic surgery is more technically challenging and may be associated with inferior oncologic outcomes4. Certainly, low rectal tumors within the confines of a narrow pelvis pose a challenge for any surgical approach. In addition the close proximity of pelvic nerves present a challenge for long-term functional outcomes. For these reasons, robotic surgery was seen as a particularly hopeful tool for rectal cancer surgery.
Baek et al were among the first to publish cost analysis of robotic rectal surgery. They retrospectively evaluated 154 robotic and 150 laparoscopic rectal cancer cases from 2007-2010 in a single institution. Similar to the work in colon cases, they identified a longer operative time 285 min vs 219 min and higher total hospital cost ($14,647 vs $9,978) for robot assisted surgery. This was largely due to the difference in operating room cost, $8,849 vs $2,289. There was no significant difference in post-operative outcomes. Because total operating room costs were higher for robotic surgery, hospital profit was also lower, $689 vs $1,671. One possible confounding factor is that the tumor location was significantly lower for the
robotic group. They were able to provide a breakdown of the costs; one significant factor was the initial investment for the robot, which they factored as a depreciation cost of $2,246 per case in their analysis. 5 Again, these costs do not take into account the initial capital purchase of the robotic system nor the annual robotic equipment maintenance and service fees.
As health care systems began to purchase the robotic equipment with great interest and enthusiasm, robotic colorectal surgery gained wider adoption, and an analysis of various administrative databases have been performed to further evaluate the cost of robotic surgery. Pigazzi et al utilized the National Inpatient Sample from 2009-2010 to compare cost of laparoscopic vs robotic colorectal surgery. The authors identified that conversion to open procedures were significantly lower for both colon (OR 0.41) and rectal (OR 0.10) robotic cases. However, they still noted significantly higher charges for both colon ($62,761 vs $45,557) and for rectal ($74,327 vs $45,557) robotic cases. There was no other difference noted for morbidity, or length of stay except for increased bleeding risk in robotic colon procedures.6
The published literature thus far consistently reveals higher operative costs associated with robotic surgery. However, for true comparative studies one would need to look more closely at other factors such as lower conversion rates, long term functional outcome, effects on surgeons, etc. Robotic rectal surgery has been
associated with better functional outcomes early in the post-operative period7. While the difference in functional outcome progressively lessened by 6 to 12 months, these results are interesting as they reveal a possible significant advantage that is not currently taken into account in short-term cost comparisons.
In an ideal evaluation of the impact of robotic surgery on patients and the health care system, the capital-intensive investment would be confined to a small number of high volume centers. However, the rapid worldwide purchase and adoption of the da Vinci robotic system suggests that factors other than published outcome data are driving the capital investment in the robotic systems. This more closely resembles an arms race in medical technology acquisition amongst health care systems and the associated marketing and advertisement of the acquisition rather than an improved patient outcome driven acquisition of medical equipment. As Keller et al stated, the cost of the robotic platform at $2.5 million and an annual charge of $200,000 remains a heavy burden for many hospitals8. Keller et al estimated that the acquisition and maintenance cost of a system for hospital performing 100 robotic cases would be an additional $5,500 per robotic case. For 250 cases, the cost would drop to $2,000 per case. They go on to state that only 20% of hospitals in California have at least 100 cases per year and only 3% have 250 or more per year. As few if any colorectal programs achieve this volume, this
emphasizes the need to work with other disciplines such as urology and gynecology to minimize cost. In addition, the healthcare industry would benefit from a rigorous study of the cost effectiveness of this technology. Left alone to market forces, there appears to be a significant increase in spending with questionable benefit shown to date.
1.
deSouza AL, Prasad LM, Park JJ, Marecik SJ, Blumetti J, Abcarian H. Robotic Assistance in Right Hemicolectomy: Is There a Role? Dis Colon Rectum. 2010;53(7):1000–1006. doi:10.1007/DCR.0b013e3181d32096.
2.
Baek SK, Carmichael JC, Pigazzi A. Robotic surgery: colon and rectum. Cancer J. 2013;19(2):140–146. doi:10.1097/PPO.0b013e31828ba0fd.
3.
Park JS, Choi GS, Park SY, Kim HJ, Ryuk JP. Randomized clinical trial of robotassisted versus standard laparoscopic right colectomy. Br J Surg. 2012;99(9):1219–1226. doi:10.1002/bjs.8841.
4.
Fleshman J, Branda M, Sargent DJ, et al. Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes. JAMA. 2015;314(13):1346. doi:10.1001/jama.2015.10529.
5.
Baek S-J, Kim S-H, Cho J-S, Shin J-W, Kim J. Robotic versus Conventional Laparoscopic Surgery for Rectal Cancer: A Cost Analysis from A Single Institute in Korea. World J Surg. 2012;36(11):2722–2729. doi:10.1007/s00268-012-
1728-4. 6.
Halabi WJ, Kang CY, Jafari MD, et al. Robotic-assisted Colorectal Surgery in the United States: A Nationwide Analysis of Trends and Outcomes. World J Surg. 2013;37(12):2782–2790. doi:10.1007/s00268-013-2024-7.
7.
Kim JY, Kim N-K, Lee KY, Hur H, Min BS, Kim JH. A Comparative Study of Voiding and Sexual Function after Total Mesorectal Excision with Autonomic Nerve Preservation for Rectal Cancer: Laparoscopic Versus Robotic Surgery. Ann Surg Oncol. 2012;19(8):2485–2493. doi:10.1245/s10434-012-2262-1.
8.
Keller DS, Senagore AJ, Lawrence JK, Champagne BJ, Delaney CP. Comparative effectiveness of laparoscopic versus robot-assisted colorectal resection. Surg Endosc. 2013;28(1):212–221. doi:10.1007/s00464-013-3163-5.