Abstract and Introduction
Abstract
Objective To determine casemix adjusted hospital level utilization of minimally invasive surgery for four common surgical procedures (appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy) in the United States.
Design Retrospective review.
Setting United States.
Participants Nationwide inpatient sample database, United States 2010.
Methods For each procedure, a propensity score model was used to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, hospitals were categorized into thirds (low, medium, and high) based on their actual to predicted proportion of utilization of minimally invasive surgery.
Main outcome measures The primary outcome measures were the actual and predicted proportion of procedures performed with minimally invasive surgery. Secondary outcome measures included surgical complications and hospital characteristics.
Results Mean hospital utilization of minimally invasive surgery was 71.0% (423/596) for appendectomy (range 40.9-93.1% (244-555)), 28.4% (154/541) for colectomy (6.7-49.8% (36/541-269/541)), 13.0% (65/499) for hysterectomy (0.0-33.6% (0/499-168/499)), and 32.0% (67/208) for lung lobectomy (3.6-65.7% (7.5/208-137/208)). Utilization of minimally invasive surgery was highly variable for each procedure type. There was noticeable discordance between actual and predicted utilization of the surgery (range of actual to predicted ratio for appendectomy 0-1.49; colectomy 0-3.88; hysterectomy 0-6.68; lung lobectomy 0-2.51). Surgical complications were less common with minimally invasive surgery compared with open surgery, respectively: overall rate for appendectomy 3.94% (1439/36 513) v 7.90% (958/12 123), P<0.001; for colectomy: 13.8% (1689/12 242) v 35.8% (8837/24 687), P<0.001; for hysterectomy: 4.69% (270/5757) v 6.64% (1988/29 940), P<0.001; and for lung lobectomy: 17.1% (367/2145) v 25.4% (971/3824), P<0.05. High utilization of minimally invasive surgery was associated with urban location (appendectomy: odds ratio 4.66, 95% confidence interval 1.17 to 18.5; colectomy: 4.59, 1.04 to 20.3; hysterectomy: 15.0, 2.98 to 75.0), large hospital size (hysterectomy: 8.70, 1.62 to 46.8), teaching hospital (hysterectomy: 5.41, 1.27 to 23.1), Midwest region (appendectomy: 7.85, 1.26 to 49.1), south region (appendectomy: 21.0, 3.79 to 117; colectomy: 10.0, 1.83 to 54.7), and west region (appendectomy: 9.33, 1.48 to 58.8).
Conclusion Hospital utilization of minimally invasive surgery for appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy varies widely in the United States, representing a disparity in the surgical care delivered nationwide
Introduction
Surgical complications represent a substantial burden of harm to patients and in the United States alone are estimated to cost $25b annually. For select procedures, however, complications can be reduced by using minimally invasive surgery. Strong evidence has shown superior patient outcomes for this type of surgery over traditional open surgery for many common procedures.
A Cochrane review of 67 randomized control trials concluded that laparoscopic appendectomy was associated with a reduction in surgical site infections, postoperative pain, and time to return to normal activity compared with open surgery. A 2004 randomized controlled trial of 863 colorectal resections established that laparoscopy was associated with superior patient outcomes (reduction in postoperative pain, postoperative analgesic requirements, and hospital length of stay) compared with open surgery, a finding later affirmed by a Cochrane review of 25 randomized controlled trials. For hysterectomy for benign disease, a Cochrane review of 34 randomized controlled trials found that laparoscopy was associated with a reduction in surgical site infections, hospital length of stay, time to return to normal activities, and blood loss compared with open surgery. Similarly, a 2007 meta-analysis comparing video assisted thoracic surgery with open thoracotomy for lung lobectomy for cancer concluded that the minimally invasive operation was associated with a reduction in postoperative pain, analgesia requirement, and time to return to normal activity and with improved adherence to chemotherapy and postoperative vital lung capacity. Furthermore, in the setting of cancer, minimally invasive colectomy, hysterectomy, and lung lobectomy have been associated with the same stage specific survival as the open approach.
Despite the extensive body of evidence to support the use of minimally invasive surgery, choice of surgery is often a matter of surgeon preference. Little is known about the current adoption of laparoscopy in US hospitals. We hypothesized that there is wide variation in the utilization of minimally invasive surgery and designed a study to measure this potential disparity in surgical care.