Has laparoscopic colorectal surgery become more cost-effective over time?

Regional variations and deprivation are linked to poorer access to laparoscopic and robotic colorectal surgery: a national study in England

BACKGROUND

Laparoscopic and now robotic colorectal surgery has rapidly increased in prevalence; however, little is known about how uptake varies by region and sociodemographics. The aim of this study was to quantify the uptake of minimally invasive colorectal surgery (MIS) over time and variations by region, sociodemographics and ethnicity.

METHODS

Retrospective analysis of routinely collected healthcare data (Clinical Practice Research Datalink linked to Hospital Episode Statistics) for all adults having elective colorectal resectional surgery in England from 1 January 2006 to 31 March 2020. Sociodemographics between modalities were compared and the association between sociodemographic factors, region and year on MIS was compared in multivariate logistic regression analysis.

RESULTS

A total of 93,735 patients were included: 52,098 open, 40,622 laparoscopic and 1015 robotic cases. Laparoscopic surgery surpassed open in 2015 but has plateaued; robotic surgery has rapidly increased since 2017, representing 3.2% of cases in 2019. Absolute differences up to 20% in MIS exist between regions, OR 1.77 (95% CI 1.68-1.86) in South Central and OR 0.75 (95% CI 0.72-0.79) in the North West compared to the largest region (West Midlands). MIS was less common in the most compared to least deprived (14.6% of MIS in the most deprived, 24.8% in the least, OR 0.85 95% CI 0.81-0.89), with a greater difference in robotic surgery (13.4% vs 30.5% respectively). Female gender, younger age, less comorbidity, Asian or 'Other/Mixed' ethnicity and cancer indication were all associated with increased MIS.

CONCLUSIONS

MIS has increased over time, with significant regional and socioeconomic variations. With rapid increases in robotic surgery, national strategies for procurement, implementation, equitable distribution and training must be created to avoid worsening health inequalities.

Robotic versus laparoscopic proctectomy: a comparative study of short-term economic and clinical outcomes

BACKGROUND

Although several studies compare the clinical outcomes and costs of laparoscopic and robotic proctectomy, most of them reflect the outcomes of the utilisation of older generation robotic platforms. The aim of this study is to compare the financial and clinical outcomes of robotic and laparoscopic proctectomy within a public healthcare system, utilising a multi-quadrant platform.

METHODS

Consecutive patients undergoing laparoscopic and robotic proctectomy between January 2017 and June 2020 in a public quaternary centre were included. Demographic characteristics, baseline clinical, tumour and operative variables, perioperative, histopathological outcomes and costs were compared between the laparoscopic and robotic groups. Simple linear regression and generalised linear model analyses with gamma distribution and log-link function were used to determine the impact of the surgical approach on overall costs.

RESULTS

During the study period, 113 patients underwent minimally invasive proctectomy. Of these, 81 (71.7%) underwent a robotic proctectomy. A robotic approach was associated with a lower conversion rate (2.5% versus 21.8%;P = 0.002) at the expense of longer operating times (284 ± 83.4 versus 243 ± 89.8 min;P = 0.025). Regarding financial outcomes, robotic surgery was associated with increased theatre costs (A$23,019 ± 8235 versus A$15,525 ± 6382; P < 0.001) and overall costs (A$34,350 ± 14,770 versus A$26,083 ± 12,647; P = 0.003). Hospitalisation costs were similar between both approaches. An ASA ≥ 3, non-metastatic disease, low rectal cancer, neoadjuvant therapy, non-restorative resection, extended resection, and a robotic approach were identified as drivers of overall costs in the univariate analysis. However, after performing a multivariate analysis, a robotic approach was not identified as an independent driver of overall costs during the inpatient episode (P = 0.1).

CONCLUSION

Robotic proctectomy was associated with increased theatre costs but not with increased overall inpatient costs within a public healthcare setting. Conversion was less common for robotic proctectomy at the expense of increased operating time. Larger studies will be needed to confirm these findings and examine the cost-effectiveness of robotic proctectomy to further justify its penetration in the public healthcare system.

[Impact of the Nursing Personnel Strengthening Act on minimally invasive surgery exemplified by right-sided hemicolectomy from an economic perspective]

BACKGROUND

In the past, a reduced length of postoperative hospital stay was considered a sufficient trade-off to refinance the additional costs associated with minimally invasive surgery; however, with the implementation of the Nursing Personnel Strengthening Act and disincorporation of nursing costs, this argumentation needs to be fundamentally reevaluated.

METHOD

Using right-sided hemicolectomy as an example, a retrospective case analysis was conducted. Cost reductions associated with the length of hospital stay were compared before and after the introduction of the revised German diagnosis-related groups (aG-DRG) and offset against the increased material and personnel costs.

RESULTS

Among the analyzed cases, the utilization of minimally invasive surgical techniques led to a substantial cost reduction per case compared to conventional surgical treatment. After the introduction of the aG-DRGs the financial benefits of a shortened hospital stay are greatly diminished and cannot be used to refinance the expenses necessary to perform minimally invasive surgery. From a strictly economical perspective, there is a strong incentive to only perform open surgical procedures.

CONCLUSION

Disincorporation of nursing costs has destabilized the fragile concept of indirect refinancing of advanced operative techniques by the financial incentives associated with a shorter hospital stay. In order to comply with statutory regulations to implicate a performance-based funding, there is an urgent necessity to adjust the grouping algorithms for minimally invasive surgical procedures to the corresponding flat rates.

Education and Training in Transanal Endoscopic Surgery and Transanal Total Mesorectal Excision

There is a paradigm shift in surgical training, and new tool and technology are being used to facilitate mastery of the content and technical skills. The transanal procedures for rectal cancer-transanal endoscopic surgery (TES) and transanal total mesorectal excision (TaTME)-have a distinct learning curve for competence in the procedures, and require special training for familiarity with the "bottom-up" anatomy, procedural risks, and managing complex cases. These procedures have been models for structured education and training, using multimodal tools, to ensure safe implementation of TES and TaTME into clinical practice. The goal of this work was to review the current state of surgical education, the introduction and learning curve of the TES and TaTME procedures, and the established and future models for education of the transanal procedures for rectal cancer.

The Introduction of Laparoscopic Colorectal Surgery: Can It Improve Hospital Economics?

INTRODUCTION

Clinical benefits of laparoscopic surgery are well established, but evidence for financial benefits is limited. This study aimed to compare the financial impact of the introduction of laparoscopic colorectal surgery.

METHODS

This study included patients who underwent colorectal surgery between January 2010 and 2015. We collected a range of financial data and divided the patients into 2 groups. Primary outcome was total cost defined by surgical-related costs.

RESULTS

A total of 1,246 patients were included, of which 440 surgeries were performed laparoscopically. The total median cost of laparoscopy was higher compared to open surgery (EUR 4,665 vs. EUR 4,268, p = 0.001). Laparoscopy was associated with higher equipment costs (EUR 857 vs. EUR 232, p < 0.001), longer operating time (3.2 vs. 2.5 hours, p < 0.001), and more readmissions (10.9 vs. 8.5%, p < 0.001). However, after adjusting for heterogeneity, no difference was found in total cost. Surgical-related costs were counterbalanced by lower costs associated with shorter median hospital stay (6 vs. 9 days, p < 0.001), less morbidity (37.3 vs. 55.1%, p < 0.001), and less mortality (1.8 vs. 5.6%, p = 0.013) for laparoscopy.

CONCLUSION

During the introduction of laparoscopy for colorectal surgery, no significant differences were found in total cost between laparoscopic and open colorectal surgery. However, favorable postoperative outcomes were achieved with laparoscopic surgery.

A National study on the adoption of laparoscopic colorectal surgery in the elderly population: current state and value proposition

BACKGROUND

The economic and clinical benefits of laparoscopic colorectal surgery are proven, yet may be underutilized in appropriate cases, especially in the elderly. Since the elderly constitute the greatest colorectal surgical volume, our goal was to identify trends in utilization and impact of laparoscopy in this cohort.

METHODS

A national review of elective inpatient colorectal resections from the Premier Inpatient Database between 2010 and 2015 was performed. Patients were included if elderly (≥ 65 years), then grouped into open or laparoscopic procedures. The main outcome measures were trends in utilization by approach and total costs for the episode of care, length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models controlled for differences across platforms, adjusting for patient demographic, comorbidities and hospital characteristics.

RESULTS

In 70,655 elderly patients evaluated, laparoscopic adoption remained lower than open throughout the study period. Rates increased until 2013, then declined, with increasing rates of open surgery. Laparoscopy was associated with significantly lower mean total costs ($4012 less/case), complications and readmissions (36% and 33% less, respectively), and shorter LOS (2.6 less days) than open cases (all p < 0.0001). When complications occurred, they were less severe and the readmission episodes were less costly with laparoscopy than open colorectal surgery.

CONCLUSION

The adoption of laparoscopy in the elderly has lagged behind open surgery and even declined in recent years despite being associated with improved clinical outcomes and reduced cost. With this tremendous value proposition to increase use of laparoscopic surgery in the elderly, further work needs to evaluate root causes of the disparity.

Cost comparison of laparoscopic colectomy versus open colectomy in colon cancer

BACKGROUND

Laparoscopic colectomy has been shown to be safe, oncologically comparable, and clinically beneficial over open colectomy for colon cancer, but utilization remains low. Objectives To evaluate the cost of laparoscopic colectomy vs open colectomy for colon cancer.

METHODS

The authors conducted a retrospective claims data analysis using the 2012 and 2013 Truven Health Analytics MarketScan Commercial Claims and Encounter Database. The denominator population consisted of individuals who had commercial insurance coverage in all months of 2012 and >1 month in 2013 and pharmacy coverage throughout eligibility. The study population included individuals aged 18-64 years who were identified with colon cancer in 2013 and underwent an elective inpatient open colectomy or laparoscopic colectomy between January and November 2013. The cost and re-admission rate of open vs laparoscopic colectomy were compared after risk, adjusting for comorbidities, demographics, and geographic region.

RESULTS

During the study period, 1299 elective inpatient colon cancer colectomies were performed (open, n = 558; laparoscopic, n = 741). After risk adjustment, the laparoscopic vs open group was shown to have lower re-admission rates (6.61 and 10.93 per 100 cases, respectively, p = .0165), lower average re-admission costs ($1676 and $3151, respectively, p = .0309), and lower 30-day post-discharge healthcare utilization costs ($4842 and $7121, respectively, p = .0047). Average allowed cost for the combined inpatient and 30-day post-discharge period was lower for laparoscopic vs open colectomy cases ($36,395 and $44,226, respectively, p < .001).

CONCLUSIONS

The cost of laparoscopic colectomy was found to be statistically significantly less than that of open colectomy in patients undergoing elective surgery for colon cancer.

A new perspective on the value of minimally invasive colorectal surgery-payer, provider, and patient benefits

BACKGROUND

The clinical benefits of minimally invasive surgery (MIS) are proven, but overall financial benefits are not fully explored. Our goal was to evaluate the financial benefits of MIS from the payer's perspective to demonstrate the value of minimally invasive colorectal surgery.

METHODS

A Truven MarketScan^® claim-based analysis identified all 2013 elective, inpatient colectomies. Cases were stratified into open or MIS approaches based on ICD-9 procedure codes; then costs were assessed using a similar distribution across diagnosis related groups (DRGs). Care episodes were compared for average allowed costs, complication, and readmission rates after adjusting costs for demographics, comorbidities, and geographic region.

RESULTS

A total of 4615 colectomies were included-2054 (44.5 %) open and 2561 (55.5 %) MIS. Total allowed episode costs were significantly lower MIS than open ($37,540 vs. $45,284, p < 0.001). During the inpatient stay, open cases had significantly greater ICU utilization (3.9 % open vs. 2.0 % MIS, p < 0.001), higher overall complications (52.8 % open vs. 32.3 % MIS, p < 0.001), higher colorectal-specific complications (32.5 % open vs. 17.9 % MIS, p < 0.001), longer LOS (6.39 open vs. 4.44 days MIS, p < 0.001), and higher index admission costs ($39,585 open vs. $33,183 MIS, p < 0.001). Post-discharge, open cases had significantly higher readmission rates/100 cases (11.54 vs. 8.28; p = 0.0013), higher average readmission costs ($3055 vs. $2,514; p = 0.1858), and greater 30-day healthcare costs than MIS ($5699 vs. $4357; p = 0.0033). The net episode cost of care was $7744/patient greater for an open colectomy, even with similar DRG distribution.

CONCLUSIONS

In a commercially insured population, the risk-adjusted allowed costs for MIS colectomy episodes were significantly lower than open. The overall cost difference between MIS and open was almost $8000 per patient. This highlights an opportunity for health plans and employers to realize financial benefits by shifting from open to MIS for colectomy. With increasing bundled payment arrangements and accountable care sharing programs, the cost impact of shifting from open to MIS introduces an opportunity for cost savings.

Real-world cost-effectiveness of laparoscopy versus open colectomy for colon cancer: a nationwide population-based study

BACKGROUND

Laparoscopic colectomy is increasingly being adopted for the treatment of colon cancer; however, the long-term effectiveness of this approach in a real-world clinical setting has yet to be verified. This study aims to compare the effectiveness and costs associated with laparoscopic and open colectomy from the perspective of the National Health Insurance (NHI) system in Taiwan.

METHODS

A nationwide population-based colon cancer cohort was observed by linking the Taiwan Cancer Registry, claims data from NHI system, and the National Death Registry. Adult patients with Stage I to Stage III colon cancer who underwent primary cancer resection using either laparoscopy or open colectomy between 2009 and 2011 were included. A propensity score-matched cohort (1745 pairs) was applied to examine three clinical endpoints: overall survival, recurrence-free survival, and disease-free survival within 2 years after the operation. To comply with the perspective as well as the analytic horizon of the study, we limited the research to NHI claims from the study population for the corresponding time period. The health outcomes and net monetary benefits were verified by multivariate mixed-effect models.

RESULTS

This analysis revealed that laparoscopy resulted in longer overall survival (adjusted difference 16.8 days, 95 % CI 7.3-26.2), recurrence-free survival (16.8 days, 5.0-28.6) and disease-free survival (26.4 days, 7.4-45.4), compared to open colectomy at 2 years post-op. Laparoscopy also led to a significantly shorter length of stay (3.2 days, 2.4-3.9) and lower index hospitalization costs (US$ 455, 181-729) than open colectomy; however, no differences in costs were observed over the long term. Overall, laparoscopy was more cost-effective than open colectomy under various willingness-to-pay thresholds in the setting of the Taiwan NHI.

CONCLUSIONS

The continued adoption of laparoscopy in primary curable colon cancer resection is expected to reduce health care costs over the short term while providing considerable health benefits over the long term.

A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery

BACKGROUND

Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery.

METHODS

The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach.

RESULTS

A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group.

CONCLUSIONS

Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.

The current status of emergent laparoscopic colectomy: a population-based study of clinical and financial outcomes

BACKGROUND

Population-based studies evaluating laparoscopic colectomy and outcomes compared with open surgery have concentrated on elective resections. As such, data assessing non-elective laparoscopic colectomies are limited. Our goal was to evaluate the current usage and outcomes of laparoscopic in the urgent and emergent setting in the USA.

METHODS

A national inpatient database was reviewed from 2008 to 2011 for right, left, and sigmoid colectomies in the non-elective setting. Cases were stratified by approach into open or laparoscopic groups. Demographics, perioperative clinical variables, and financial outcomes were compared across each group.

RESULTS

A total of 22,719 non-elective colectomies were analyzed. The vast majority (95.8 %) was open. Most cases were performed in an urban setting at non-teaching hospitals by general surgeons. Colorectal surgeons were significantly more likely to perform a case laparoscopic than general surgeons (p < 0.001). Demographics were similar between open and laparoscopic groups; however, the disease distribution by approach varied, with significantly more severe cases in the open colectomy arm (p < 0.001). Cases performed laparoscopically had significantly better mortality and complication rates. Laparoscopic cases also had significantly improved outcomes, including shorter length of stay and hospital costs (all p < 0.001).

CONCLUSIONS

Our analysis revealed less than 5 % of urgent and emergent colectomies in the USA are performed laparoscopically. Colorectal surgeons were more likely to approach a case laparoscopically than general surgeons. Outcomes following laparoscopic colectomy in this setting resulted in reduced length of stay, lower complication rates, and lower costs. Increased adoption of laparoscopy in the non-elective setting should be considered.

Robotic colorectal surgery: summary of the current evidence

BACKGROUND

Several studies have confirmed that laparoscopic colorectal surgery results in improved early post-operative outcomes. Nevertheless, conventional laparoscopic approach and instruments have several limitations. Robotic approach could potentially address of many of these limitations.

OBJECTIVES

This review aims to present a summary of the current evidence on the role of robotic colorectal surgery.

METHODS

A comprehensive search of electronic databases (Pubmed, Science Direct and Google scholar) using the key words "rectal surgery", "laparoscopic", "colonic" and "robotic." Evidence from these data was critically analysed and summarised to produce this article.

RESULTS

Robotic colorectal surgery is both safe and feasible. However, it has no clear advantages over standard laparoscopic colorectal surgery in terms of early postoperative outcomes or complications profile. It has shorter learning curve but increased operative time and cost. It could offer potential advantage in resection of rectal cancer as it has a lower conversion rates even in obese individuals, distal rectal tumours and patients who had preoperative chemoradiotherpy. There is also a trend towards better outcome in anastomotic leak rates, circumferential margin positivity and perseveration of autonomic function, but there was no clear statistical significance to support this from the currently available data.

CONCLUSION

The use of robotic approach seems to be capable of addressing most of the shortcomings of the standard laparoscopic surgery. The technique has proved its safety profile in both colonic and rectal surgery. However, the cost involved may restrict its use to patients with challenging rectal cancer and in specialist centres.

Optimizing cost and short-term outcomes for elderly patients in laparoscopic colonic surgery

BACKGROUND

Elderly patients often are regarded as high-risk for major abdominal surgery because of a lack of functional reserve and associated medical comorbidities. The goal of this study was to compare the cost of care and short-term outcomes of elderly and nonelderly patients undergoing laparoscopic colectomy. Our hypothesis was that elderly patients managed with laparoscopic colorectal surgery and an enhanced recovery protocol (ERP) can realize the same benefits of lower hospital length of stay (LOS) without increasing hospital costs or readmission rates.

METHODS

Review of a prospective database identified all patients that underwent an elective laparoscopic colectomy from 2009 to 2012. Patients were stratified into elderly (≥70 years old) and nonelderly (<70 years old) cohorts. The main outcome measures were discharge disposition, hospital costs, hospital LOS, and 30-day readmission rates between the laparoscopic and open groups.

RESULTS

A total of 302 nonelderly (66%) and 153 elderly (34%) patients were included in the analysis. The elderly cohort had significantly higher comorbidities than the nonelderly group. There were no mortalities. Operative variables (procedure time, blood loss, and intraoperative complications) were similar. At discharge, significantly more elderly patients required temporary nursing or home care. There were no significant differences in short-term outcomes of LOS, 30-day readmission rates, or costs for the episode of care between the two groups.

CONCLUSIONS

Combining laparoscopic colectomy with an ERP is cost-effective and results in similar short-term outcomes for the elderly and nonelderly patients. Despite higher comorbidities, elderly patients realized the same benefits of shorter LOS with similar hospital costs and readmission rates.

Systematic review of single-incision laparoscopic colonic surgery

BACKGROUND

Randomized clinical trials (RCTs) have shown multiport laparoscopic surgery to be safe compared with open surgery in elective colonic disease. Single-incision laparoscopic surgery (SILS) represents the latest advance in laparoscopic surgery. The aim of this systematic review was to establish the safety and complication profile of colonic SILS.

METHODS

The search was performed in October 2011 using PubMed, MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. Search terms were 'colorectal', 'colon', 'colectomy', 'rectal' and single incision/port/trocar/site/scar. Only pure single-incision laparoscopic colonic surgery for benign and malignant colonic disease was included. Primary outcomes were the early postoperative complication profiles of colonic SILS. Secondary outcomes were duration of operation, lymph node yields, conversion rate and duration of hospital stay.

RESULTS

Colonic SILS data were compared with data from a Cochrane review on the short-term outcomes of laparoscopic colonic surgery and four main RCTs on laparoscopic colonic surgery. Median operating times and time to first bowel motion for colonic SILS were comparable with those for laparoscopic colonic surgery. The median lymph node retrieval for malignant disease achieved with SILS was acceptable. Evidence for a reduction in postoperative pain with SILS was conflicting. There was no significant reduction in length of hospital stay with SILS. Most patients selected for colonic SILS had a low body mass index, non-bulky tumours and were operated on by experienced laparoscopic surgeons. There was significant heterogeneity in study group characteristics, indications for surgery, research methodology, operative techniques and follow-up time.

CONCLUSION

Colonic SILS should be restricted to highly selected patients; operations should be performed by experienced laparoscopic surgeons, with critical appraisal of clinical outcomes.