The cost of conversion in robotic and laparoscopic colorectal surgery
- 404 Downloads
Conversion from minimally invasive to open colorectal surgery remains common and costly. Robotic colorectal surgery is associated with lower rates of conversion than laparoscopy, but institutions and payers remain concerned about equipment and implementation costs. Recognizing that reimbursement reform and bundled payments expand perspectives on cost to include the entire surgical episode, we evaluated the role of minimally invasive conversion in total payments.
This is an observational study from a linked data registry including clinical data from the Michigan Surgical Quality Collaborative and payment data from the Michigan Value Collaborative between July 2012 and April 2015. We evaluated colorectal resections initiated with open and minimally invasive approaches, and compared reported risk-adjusted and price-standardized 30-day episode payments and their components.
We identified 1061 open, 1604 laparoscopic, and 275 robotic colorectal resections. Adjusted episode payments were significantly higher for open operations than for minimally invasive procedures completed without conversion ($19,489 vs. $15,518, p < 0.001). The conversion rate was significantly higher with laparoscopic than robotic operations (15.1 vs. 7.6%, p < 0.001). Adjusted episode payments for minimally invasive operations converted to open were significantly higher than for those completed by minimally invasive approaches ($18,098 vs. $15,518, p < 0.001). Payments for operations completed robotically were greater than those completed laparoscopically ($16,949 vs. $15,250, p < 0.001), but the difference was substantially decreased when conversion to open cases was included ($16,939 vs. $15,699, p = 0.041).
Episode payments for open colorectal surgery exceed both laparoscopic and robotic minimally invasive options. Conversion to open surgery significantly increases the payments associated with minimally invasive colorectal surgery. Because conversion rates in robotic colorectal operations are half of those in laparoscopy, the excess expenditures attributable to robotics are attenuated by consideration of the cost of conversions.
KeywordsColorectal Minimally invasive Cost Robotic Laparoscopic
Complaince with ethical standards
Dr. Cleary reports personal fees from Intuitive Surgical, outside the submitted work. Mr. Mullard reports grants from Blue Cross Blue Shield of Michigan, during the conduct of the study. Dr. Regenbogen is supported by the American Society of Colon and Rectal Surgeons Career Development Award CDG-015, National Institute on Aging Grants for Early Medical/Surgical Specialists Transition to Aging Research R03-AG047860, and National Institute on Aging K08-AG047252. Ms. Ferraro and Dr. Regenbogen have nothing to disclose.
- 2.Jordan J, Dowson H, Gage H, Jackson D, Rockall T (2014) Laparoscopic versus open colorectal resection for cancer and polyps: a cost-effectiveness study. CEOR 6:414–422Google Scholar
- 3.Silva-Velazco J, Dietz DW, Stocchi L, Costedio M, Gorgun E, Kalady MF, Kessler H, Lavery IC, Remzi FH (2016) Considering value in rectal cancer surgery: an analysis of costs and outcomes on the open, laparoscopic, and robotic approach for proctectomy. Ann Surg. doi: 10.1097/SLA0000000000001815 Google Scholar
- 24.Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AMH, Heath RM, Brown JM, for the MRC CLASICC trial group (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multi-centre, randomized trial. Lancet 365:1718–1726CrossRefPubMedGoogle Scholar
- 27.Fleshman J, Sargent DJ, Green E, Anvari M, Stryker SJ, Beart RW Jr, Hellinger M, Flanagan R Jr, Peters W, Nelson H, Clinical Outcomes of Surgical Therapy Study Group (2007) Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST study group trial. Ann Surg 246:655–664CrossRefPubMedGoogle Scholar
- 28.Pfeifer J, Wexner SD, Reissman O, Bernstein M, Nogueras JJ, Singh S, Weiss E (1995) Laparoscopic versus open colon surgery. Costs and outcome. Surg Endosc 12:1322–1326Google Scholar
- 36.Morelli L, Guadagni S, Lorenzoni V, DiFranco G, Cobuccio L, Palmeri M, Caprili G, D’Isidoro C, Moglia A, Ferrari V, DiCandio G, Mosca F, Turchetti G (2016) Robot-assisted versus laparoscopic rectal resection for cancer in a single surgeon’s experience: a cost analysis covering the initial 50 robotic cases with the daVinci Si. Int J Colorectal Dis 31:1639–1648CrossRefPubMedGoogle Scholar