The Cost Debate in Robotic Surgery and the Impact of Skills
Robotic-assisted surgery has grown over the past few years with over 600,000 procedures carried out in 2015. Increasingly, the debate over the clinical value of robotic-assisted surgery is being replaced by a focus on the cost of robotic surgery over other types of intervention. In an infographic published in 2015, the ECRI institute estimated that the average robotic-assisted case incurred an additional $3,000 to $6,000 per procedure.
This article is not meant to debate cost accounting and whether or not this number is correct, but rather to look at what some of the factors are that could be driving these costs and what can be done about it.
CAVA robotics is an organization that a focuses on delivering proprietary, unprecedented, diagnostic and prescriptive robotic change management programs for hospital administration, their surgeons and OR crew. CAVA’s approach is data-driven and allows hospitals to analyze what is truly driving their costs.
“Generally speaking there are two primary factors that drive costs” says Dr. Rick Low, CAVA Medical Director. “On the one hand, you have costs that are driven by the operational inefficiencies of bringing a large system into the OR. These are driven by consumables, OR times, setup times, and the lack of standardization of procedures around the implementation of the system. This accounts for 50% of the cost driver to the hospital. The other 50% of cost is tied to the technical skills of the surgeons, the first assistants and the OR teams, in general,” concludes Dr. Low. “This excludes variables like complications, readmissions, and medical malpractice which most hospitals do not factor into the bottom line analysis of the surgical options and may actually be in some cases much more costly.”
Recent data analysis has shown that there is a relationship between surgical skills and patient outcomes. In a study published by NJM in 2013, Dr. Birkmayer asked 20 surgeons from the state of Michigan to provide a video of their bariatric surgical cases. These cases were then evaluated by a group of independent surgeons and grouped by skill level into quartiles. This stratification was then used to study approximately 10,300 cases that the group had carried out over a 7 year period. Those in the bottom quartile had 2.5 times more readmissions (6.7% vs 2.7%), 3 times more complications (14.5% vs 5.2%) and 5 times more mortalities (0.26% vs 0.05%). Interestingly there was also a significant difference in case volumes between the two groups.
CAVA Robotics has been able to do a similar analysis on robotic surgery thanks to its database gathered from 36 institutions, with 205 surgeons, and over 200,000 cases. They found a similar pattern, using case volume as a delimiter, and found differences in operating times, complications rates, length of stay, and re-admissions.
The tables below illustrate the data for two procedures, Cholecystectomies and Benign Hysterectomies.
An interesting similarity is the same approximate 3-fold difference in complications that was found in both the CAVA group and the Berkmayer paper.
One can also estimate the cost impact of the skills variation by taking average costs for OR time, complications, LOS and re-admissions, on a very conservative estimate the difference between the top and the bottom performers could be between $7,000 and $10,000 per case when these factors are taken into account. With the average US hospital doing 250 robotic cases a year and 62 of these cases being carried out by the bottom quartile, this could cost the institution $500,000 more than those cases being carried out by the top 25%.
Faced with this scenario what are hospitals to do? One option, which is being actively implemented by some institutions, is to severely limit access to the new technology only to surgeons who have demonstrated a high level of skill and who have completed a high volume of cases. Another option is put in proficiency thresholds (using simulation) that surgeons must meet before they are allowed to continue operating.
In a paper on the predictive validity of simulation training by Dr. Patrick Culligan, it was demonstrated that a properly developed curriculum with expert level benchmarks would allow new surgeons to achieve expert level clinical performance starting with their first case. However, the study showed that an average of 20 hours of simulation was required and in some cases nearly 40 hours to achieve these results. In another study done by Dr. Andrea Moglia, the fact that surgeons might have different innate abilities was confirmed and the study was able to identify that only 6% of a student population had native expert level skills, while for the majority it was more about how much training time they would need to reach the same level of skills.
In short, any new technology as it is introduced to into an organization will have a cost impact, be it through the disruption it has to that organization or whether it is caused by the skill variation of its users. Making sure that all team members are properly trained to validated proficiency levels, with the support of simulation systems, will help reduce unfavorable outcomes for the patient and reduce the costs for the institutions.