Medical Society Will Feature this First of a Kind Study of Roughly 64,000 Patients at MIS Week
NEW YORK – An analysis of robotic surgery case data from 2009 to 2014 on 63,725 patients found that the emergent surgery is reaching largely wealthy, white males, but in more areas of medicine. According to the study, minorities, women and those with lower incomes are left with fewer surgical options. The study will be featured at the MIS Week 2016 (SLS) annual meeting.
According to the authors at Mount Sinai Beth Israel Hospital, patients receiving robotic surgery care were found to be more likely young, male, white, and from a more affluent area than patients receiving non-robotic care. Surgeons involved in robotic surgery cases were more likely to be younger, male, and a non-foreign medical graduate, as compared to surgeons involved in non-robotic laparoscopic cases.
“These trends suggest that the benefits of robotic assisted laparoscopic surgery for both the surgeon and patient have not been distributed equally,” says Dr. Michael A. Palese, chairman, Department of Urology, Mount Sinai Beth Israel Hospital and the study lead, “We are concerned as the apparent division of care based on socioeconomic status suggests that economically disadvantaged persons may be subjected to inferior quality of care.”
The study surveys the evolving changes in inpatient medicine and across multiple specialties as it adapts to robotic technology. The first such study to assess changes in robotic assisted laparoscopic surgical cases over time and provide comparative analysis of both patients and surgeons involved in these procedures, across several specialties, it found that the quantity of the cases for each category rose during the period of 2009-2014, however, the rise was asymmetric across categories. The proportion of all robotic surgery cases decreased for urologists and gynecologists, while increasing for all other specialists, including orthopedic surgeons, otolaryngologists, cardio-thoracic surgeons and general surgeons.
Other specialities in medicine, such as ENT, orthopedics, and general surgery are new to robotic surgery and are just starting to incorporate the technology into their practices. The researchers believe this is the reason they are seeing an increase during the study period. “We expect that once the use of robotic surgery also becomes “saturated” in these specialities, says Palese, “we would also see the decline that we are seeing in urology and gynecology.”
Over the past three decades, robotic assisted laparoscopic surgery has made its way to every surgical field; however researchers discovered growth in non traditional specialties: “The decline in urologists and gynecologists performing robotic surgery during this study period is probably because these two specialties were the first to adopt robotic surgery in their practices and are probably seeing a further “sub-specialization” during the study period, says Palese. “It appears that certain urologists and gynecologists are only focusing on robotic surgery and the general urologist/gynecologist is forgoing the use of robotic surgery in their practices and leaving it to the sub-specialists.”
In order to better understand the benefits of investment in this technology, the Institute of Medicine set comparative analysis of this particular surgery as a high priority, to better understand what the benefits are of this relatively new technology. “Since then,” says Palese, “studies have shown it to result in fewer deaths, shorter hospital stays, complications, transfusions, and more routine discharges.”
In procedures that serve males and females, males were more likely to receive robotic surgery care than females. According to the authors, this trend and the other trends mentioned suggest that the benefits of robotics for both the surgeon and patient have not been distributed equally.
“While it can be difficult to have every surgical option available in every community, we need to do a better job of understanding these disparities,” said Dr. Paul Wetter, chairman of the Society of Laparoendoscopic Surgeons. “This is why surgical education needs to be a top priority in medicine, providing an understanding of the benefits and complexities around all forms of Minimally Invasive surgery, which are often underutilized including robotics.”
Robotic Assisted Laparoscopic Surgery (RALS) Frequencies
- Of the 63,725 robot cases analyzed, 29,464 (46.2%) were performed by a urologist, 617 (1.0%) by a otolaryngologist, 7,207 (11.3%) by a general surgeon, 4,217 (6.7%) by a cardio-thoracic surgeon, 17,739 (27.8%) by a gynecologist, 2,215 (3.5%) by an orthopedic surgeon, and 2,243 (3.5%) were uncategorized.
- The number of RALS cases handled by cardio-thoracic- trained surgeons per year rose from 197 (3.1% of all cases) to 1,159 (8.7%), general-trained surgeons from 198 (3.2%) to 2,559 (19.1%), orthopedic-trained surgeons from 55 (0.8%) to 985 (7.4%), otolaryngology-trained surgeons from 21 (0.3%) to 155 (1. 2%), urology-trained surgeons from 4,063 (64.8%) to 5,226 (39.1%), and gynecology-trained surgeons from 1,560 (24.9%) to 2,744 (20.5%). Linear regression of the number of cases by year for each specialty yields the following: for cardio-thoracic, 211 cases/year (180 to 243), for general, 491 (389 to 592), for gynecology, 294 (-88 to 675), for orthopedic, 176 (107 to 246), for otolaryngology, 26 (16 to 36), and for urology 186 (-12 to 385).
- While there was a significant increase in the number of RALS cases for orthopedic surgeons, otolaryngologists, cardio-thoracic surgeons and general surgeons. This increase is not seen for urologists and gynecologists.
- Looking at the highlighted procedures, we see that the proportion that are handed through RALS has increased universally.
- A number of less invasive alternatives have diffused into practice over the past decade for treatment.
- A declining reimbursement may be discouraging more invasive procedures, with their higher likelihood for complications, and encouraging non-invasive treatment.
By Race, Gender and Age:
- As stated previously, this study found that surgeons involved in RALS cases were more likely to be younger, male, and a non-FMG than surgeons who were involved in the non-RALS alternatives.
- Gender divides are well attested to in literature, with disparate treatment and varying priorities often cited as a root cause.
- Another reason may stem from the varying hospital accreditation practices for attainting RALS privileges or from gatekeepers of RALS training. This sort of gatekeeping can result in biased selection. These same factors may create the observed divide for FMGs as well.
- For age, the explaining factor may be greater access to RALS during training or higher willingness to take on the training after residency in order to attain RALS privileges. Also of note, there are exceptions to the generalization. Another exception was found in CAB where there was no difference in age between the RALS and non-RALS surgeons as well as higher likelihood for FMGs to be using RALS procedures.
- Patients receiving RALS care were more likely to be younger, white, and from a more affluent area, than patients receiving non-RALS care. For procedures where males and females receive care, males were more likely to receive RALS care than females. This result underscores the socioeconomic divisions that exist in the provision of RALS care. Previous studies have consistently shown better outcomes for RALS procedures
- Previous studies have seen similar socioeconomic divisions in the dispensation of other care widely regarded as superior, such as higher odds for utilization of radical prostatectomy as opposed to nephron-sparing PN as linked to lower socioeconomic status.
The main limitation of this study is that the SPARCS dataset only collects information from and was confined to New York State. New York, however, is the 3 rd largest state in terms of population and contains both urban and rural environments, a diversity of socioeconomic and ethnic backgrounds, and diversity of hospital types.
“These results have significant implications for surgeons planning for future practice, as well as hospital administrators adapting to rapid changes in medicine, because the trends are changing, says researcher Mark Finkelstein at the Icahn School of Medicine at Mount Sinai. Robotic surgery requires such significant capital investment, but we believe we will see more affordable and greater access to robotic surgery as more competition in robotic tools arrive.”