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Minimally invasive versus open surgery in the Medicare population: a comparison of post-operative and economic outcomes



Despite strong evidence demonstrating the clinical and economic benefits of minimally invasive surgery (MIS), utilization of MIS in the Medicare population is highly variable and tends to be lower than in the general population. We sought to compare the post-operative and economic outcomes of MIS versus open surgery for seven common surgical procedures in the Medicare population.


Using the 2014 Medicare Provider Analysis and Review Inpatient Limited Data Set, patients undergoing bariatric, cholecystectomy, colectomy, hysterectomy, inguinal hernia, thoracic, and ventral hernia procedures were identified using DRG and ICD-9 codes. Adjusting for patient demographics and comorbidities, the odds of complication and all-cause 30-day re-admission were compared among patients undergoing MIS versus open surgery stratified by operation type. A generalized linear model was used to calculate the estimated difference in length of stay (LOS), Medicare claim cost, and Medicare reimbursement.


Among 233,984 patients, 102,729 patients underwent an open procedure versus 131,255 who underwent an MIS procedure. The incidence of complication after MIS was lower for 5 out of the 7 procedures examined (OR 0.36–0.69). Re-admission was lower for MIS for 6 out of 7 procedures (OR 0.43–0.87). MIS was associated with shorter LOS for 6 procedures (point estimate range 0.35–2.47 days shorter). Medicare claim costs for MIS were lower for 4 (range $3010.23–$4832.74 less per procedure) and Medicare reimbursements were lower for 3 (range $841.10–$939.69 less per procedure).


MIS benefited Medicare patients undergoing a range of surgical procedures. MIS was associated with fewer complications and re-admissions as well as shorter LOS and lower Medicare costs and reimbursements versus open surgery. MIS may represent a better quality and cost proposition in the Medicare population.

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  1. Novitsky YW, Litwin DE, Callery MP (2004) The net immunologic advantage of laparoscopic surgery. Surg Endosc 18:1411–1419

    Article  PubMed  CAS  Google Scholar 

  2. da Luz Moreira A, Kiran RP, Kirat HT, Remzi FH, Geisler DP, Church JM, Garofalo T, Fazio VW (2010) Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs. Surg Endosc 24:1280–1286

    Article  PubMed  Google Scholar 

  3. Cooper MA, Hutfless S, Segev DL, Ibrahim A, Lyu H, Makary MA (2014) Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review. BMJ 349:g4198

    Article  PubMed  PubMed Central  Google Scholar 

  4. Keller DS, Parikh N, Senagore AJ (2017) Predicting opportunities to increase utilization of laparoscopy for colon cancer. Surg Endosc 31:1855–1862

    Article  PubMed  Google Scholar 

  5. Chesney T, Acuna SA (2015) Do elderly patients have the most to gain from laparoscopic surgery? Ann Med Surg 4:321–323

    Article  Google Scholar 

  6. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP (2010) Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 210:901–908

    Article  PubMed  Google Scholar 

  7. Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA (2015) Laparoscopic colorectal surgery confers lower mortality in the elderly: a systematic review and meta-analysis of 66,483 patients. Surg Endosc 29:322–333

    Article  PubMed  Google Scholar 

  8. Dua A, Aziz A, Desai SS, McMaster J, Kuy S (2014) National trends in the adoption of laparoscopic cholecystectomy over 7 years in the United States and impact of laparoscopic approaches stratified by age. Minim Invasive Surg 2014:635461

    PubMed  PubMed Central  Google Scholar 

  9. Gruber K, Soliman AS, Schmid K, Rettig B, Ryan J, Watanabe-Galloway S (2015) Disparities in the utilization of laparoscopic surgery for colon cancer in rural Nebraska: a call for placement and training of rural general surgeons. J Rural Health 31:392–400

    Article  PubMed  PubMed Central  Google Scholar 

  10. Kannan U, Reddy VS, Mukerji AN, Parithivel VS, Shah AK, Gilchrist BF, Farkas DT (2015) Laparoscopic vs open partial colectomy in elderly patients: insights from the American College of Surgeons: National Surgical Quality Improvement Program database. World J Gastroenterol 21:12843–12850

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  11. Bogani G, Cromi A, Uccella S, Serati M, Casarin J, Pinelli C, Ghezzi F (2014) Perioperative and long-term outcomes of laparoscopic, open abdominal, and vaginal surgery for endometrial cancer in patients aged 80 years or older. Int J Gynecol Cancer 24:894–900

    Article  PubMed  Google Scholar 

  12. Southgate E, Vousden N, Karthikesalingam A, Markar SR, Black S, Zaidi A (2012) Laparoscopic vs open appendectomy in older patients. Arch Surg 147:557–562

    Article  PubMed  Google Scholar 

  13. Banka G, Woodard G, Hernandez-Boussard T, Morton JM (2012) Laparoscopic vs open gastric bypass surgery: differences in patient demographics, safety, and outcomes. Arch Surg 147:550–556

    Article  PubMed  Google Scholar 

  14. Ecker BL, Kuo LE, Simmons KD, Fischer JP, Morris JB, Kelz RR (2016) Laparoscopic versus open ventral hernia repair: longitudinal outcomes and cost analysis using statewide claims data. Surg Endosc 30:906–915

    Article  PubMed  Google Scholar 

  15. Samkoff JS, Wu B (1995) Laparoscopic and open cholecystectomy outcomes in Medicare beneficiaries in member states of the Large State PRO Consortium. Am J Med Qual 10:183–189

    Article  PubMed  CAS  Google Scholar 

  16. Sheetz KH, Norton EC, Birkmeyer JD, Dimick JB (2017) Provider experience and the comparative safety of laparoscopic and open colectomy. Health Serv Res 52:56–73

    Article  PubMed  Google Scholar 

  17. Wright JD, Neugut AI, Wilde ET, Buono DL, Tsai WY, Hershman DL (2012) Use and benefits of laparoscopic hysterectomy for stage I endometrial cancer among Medicare beneficiaries. J Oncol Pract 8:e89–e99

    Article  PubMed  PubMed Central  Google Scholar 

  18. McCormack K, Scott NW, Go PM, Ross S, Grant AM (2003) Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003:CD001785

    Google Scholar 

  19. Wu JJ, Way JA, Eslick GD, Cox MR (2017) Transabdominal pre-peritoneal versus open repair for primary unilateral inguinal hernia: a meta-analysis. World J Surg.

    Article  PubMed  Google Scholar 

  20. Atkinson TM, Giraud GD, Togioka BM, Jones DB, Cigarroa JE (2017) Cardiovascular and ventilatory consequences of laparoscopic surgery. Circulation 135:700–710

    Article  PubMed  Google Scholar 

  21. Xiong H, Wang J, Jia Y, Ye C, Lu Y, Chen C, Shen J, Chen Y, Zhao W, Wang L, Zhou J (2017) Laparoscopic surgery versus open resection in patients with gastrointestinal stromal tumors: an updated systematic review and meta-analysis. Am J Surg.

    Article  PubMed  Google Scholar 

  22. Soliani G, De Troia A, Portinari M, Targa S, Carcoforo P, Vasquez G, Fisichella PM, Feo CV (2017) Laparoscopic versus open incisional hernia repair: a retrospective cohort study with costs analysis on 269 patients. Hernia 21:609–618

    Article  PubMed  CAS  Google Scholar 

  23. Fan CJ, Hirose K, Walsh CM, Quartuccio M, Desai NM, Singh VK, Kalyani RR, Warren DS, Sun Z, Hanna MN, Makary MA (2017) Laparoscopic total pancreatectomy with islet autotransplantation and intraoperative islet separation as a treatment for patients with chronic pancreatitis. JAMA Surg 152:550–556

    Article  PubMed  PubMed Central  Google Scholar 

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The authors acknowledge Mr. and Mrs. John Rodda and The Rodda Family Partnership, LTD, for their generous support of this research study at Johns Hopkins.


The authors acknowledge the funding support provided by Mr. and Mrs. John Rodda and The Rodda Family Partnership, LTD.

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Correspondence to Caleb J. Fan.

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Mr. Hung-Lun Chien is an employee of Medtronic, Inc. Drs. Caleb J. Fan, Matthew J. Weiss, Jin He, Christopher L. Wolfgang, John L. Cameron, Timothy M. Pawlik, and Martin A. Makary have no conflicts of interest or financial ties to disclose.

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Fan, C.J., Chien, HL., Weiss, M.J. et al. Minimally invasive versus open surgery in the Medicare population: a comparison of post-operative and economic outcomes. Surg Endosc 32, 3874–3880 (2018).

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  • MIS
  • Medicare
  • Bariatric
  • Cholecystectomy
  • Colectomy
  • Hernia