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

  • Caleb J. Fan
  • Hung-Lun Chien
  • Matthew J. Weiss
  • Jin He
  • Christopher L. Wolfgang
  • John L. Cameron
  • Timothy M. Pawlik
  • Martin A. Makary
Article

Abstract

Background

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.

Methods

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.

Results

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).

Conclusions

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.

Keywords

MIS Medicare Bariatric Cholecystectomy Colectomy Hernia 

Minimally invasive surgery (MIS) is associated with less physiologic stress and immunologic burden, allowing for a faster functional recovery [1]. Benefits of MIS include less pain, shorter length of stay (LOS), lower complication rates, and reduced healthcare utilization [2, 3, 4]. The benefits of MIS are particularly relevant in the elderly population who generally has diminished physiologic reserve [5] and a higher prevalence of frailty [6]. For example, Antoniou et al. reported a decreased risk of mortality, morbidity, and cardiac and respiratory complications for patients over 65 years old who underwent laparoscopic colorectal surgery versus patients who underwent open colorectal surgery [7]. Data on peri- and post-operative outcomes have demonstrated that elderly patients benefit from MIS at least as much as non-elderly patients [3, 4].

Despite the clinical evidence, MIS is still underutilized in many settings and populations. Previous studies have suggested that utilization may vary due to a range of patient (e.g., elderly, obese, comorbid) and provider (e.g., general surgeons, rural, and teaching hospitals) factors [4]. Individuals over the age of 65 who are primarily covered by Medicare experience lower utilization of MIS for commonly performed operations such as cholecystectomy, colectomy, and hysterectomy [4, 8, 9]. Most reports that have noted a decreased morbidity with MIS in the elderly population have generally focused on an individual procedure [7, 10, 11, 12]. As such, we sought to examine post-operative clinical and economic outcomes of the MIS versus open approach among a much broader range of seven common surgical procedures in the Medicare population.

Materials and methods

Using the 2014 Medicare Provider Analysis and Review (MEDPAR) Inpatient Limited Data Set, patients undergoing open or minimally invasive (laparoscopic, thoracoscopic, or robotic) bariatric, cholecystectomy, colectomy, hysterectomy, inguinal hernia, thoracic, and ventral hernia procedures were identified using a DRG code and ICD-9 procedure code (Table 1). Patients needed to meet both DRG and ICD-9 code criteria to be selected for the study population. Specifically, robotic procedures were identified using laparoscopic ICD-9 codes accompanied by a robotic code (17.4x). Exclusion criteria included patients with in-hospital deaths, end-stage renal disease, paralysis, dementia, AIDS, and patients who left against medical advice. The excluded population comprised 4% of the Medicare population and was excluded in order to focus on a healthy population.

Table 1

DRG and ICD-9 codes for minimally invasive and open procedures

Procedure

DRG Code: description

Minimally invasive ICD-9 code: description

Open ICD-9 code: description

Bariatric

326: Stomach, esophageal & duodenal proc w MCC

327: Stomach, esophageal & duodenal proc w CC

328: Stomach, esophageal & duodenal proc w/o CC/MCC

619: O.R. procedures for obesity w MCC

620: O.R. procedures for obesity w CC

621: O.R. procedures for obesity w/o CC/MCC

4438: Laparoscopic gastroenterostomy

4382: Laparoscopic vertical (sleeve) gastrectomy

4439: Other gastroenterostomy without gastrectomy

4389: Open and other partial gastrectomy

Cholecystectomy

414: Cholecystectomy except by laparoscope w/o c.d.e. w MCC

415: Cholecystectomy except by laparoscope w/o c.d.e. w CC

416: Cholecystectomy except by laparoscope w/o c.d.e. w/o CC/MCC

417: Laparoscopic cholecystectomy w/o c.d.e. w MCC

418: Laparoscopic cholecystectomy w/o c.d.e. w CC

419: Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC

5123: Laparoscopic cholecystectomy

5124: Laparoscopic partial cholecystectomy

5122: Cholecystectomy

5121: Other partial cholecystectomy

Colectomy

329: Major small & large bowel procedures w MCC

330: Major small & large bowel procedures w CC

331: Major small & large bowel procedures w/o CC/MCC

1731: Laparoscopic multiple segmental resection of large intestine

1732: Laparoscopic cecectomy

1733: Laparoscopic right hemicolectomy

1734: Laparoscopic resection of transverse colon

1735: Laparoscopic left hemicolectomy

1736: Laparoscopic sigmoidectomy

1739: Other laparoscopic partial excision of large intestine

4581: Laparoscopic total intra-abdominal colectomy

4571: Open and other multiple segmental resection of large intestine

4572: Open and other cecectomy

4573: Open and other right hemicolectomy

4574: Open and other resection of transverse colon

4575: Open and other left hemicolectomy

4576: Open and other sigmoidectomy

4579: Other and unspecified partial excision of large intestine

4582: Open total intra-abdominal colectomy

Hysterectomy

734: Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC

735: Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC

736: Uterine & adnexa proc for ovarian or adnexal malignancy w MCC

737: Uterine & adnexa proc for ovarian or adnexal malignancy w CC

738: Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MCC

739: Uterine, adnexa proc for non-ovarian/adnexal malignancy w MCC

740: Uterine, adnexa proc for non-ovarian/adnexal malignancy w CC

741: Uterine, adnexa proc for non-ovarian/adnexal malignancy w/o CC/MCC

742: Uterine & adnexa proc for non-malignancy w CC/MCC

743: Uterine & adnexa proc for non-malignancy w/o CC/MCC

6831: Laparoscopic supracervical hysterectomy

6841: Laparoscopic total abdominal hysterectomy

6851: Laparoscopically assisted vaginal hysterectomy

6861: Laparoscopic radical abdominal hysterectomy

6839: Other and unspecified subtotal abdominal hysterectomy

6849: Other and unspecified total abdominal hysterectomy

6859: Other and unspecified vaginal hysterectomy

6869: Other and unspecified radical abdominal hysterectomy

Inguinal hernia

350: Inguinal & femoral hernia procedures w MCC

351: Inguinal & femoral hernia procedures w CC

352: Inguinal & femoral hernia procedures w/o CC/MCC

1711: Laparoscopic repair of direct inguinal hernia with graft or prosthesis

1712: Laparoscopic repair of indirect inguinal hernia with graft or prosthesis

1713: Laparoscopic repair of inguinal hernia with graft or prosthesis, not otherwise specified

1721: Laparoscopic bilateral repair of direct inguinal hernia with graft or prosthesis

1722: Laparoscopic bilateral repair of indirect inguinal hernia with graft or prosthesis

1723: Laparoscopic bilateral repair of inguinal hernia, one direct and one indirect, with graft or prosthesis

1724: Laparoscopic bilateral repair of inguinal hernia with graft or prosthesis, not otherwise specified

5303: Other and open repair of direct inguinal hernia with graft or prosthesis

5304: Other and open repair of indirect inguinal hernia with graft or prosthesis

5305: Repair of inguinal hernia with graft or prosthesis, not otherwise specified

5314: Other and open bilateral repair of direct inguinal hernia with graft or prosthesis

5315: Other and open bilateral repair of indirect inguinal hernia with graft or prosthesis

5316: Other and open bilateral repair of inguinal hernia, one direct and one indirect, with graft or prosthesis

5317: Bilateral inguinal hernia repair with graft or prosthesis, not otherwise specified

Ventral hernia

353: Hernia procedures except inguinal & femoral w MCC

354: Hernia procedures except inguinal & femoral w CC

355: Hernia procedures except inguinal & femoral w/o CC/MCC

5362: Laparoscopic incisional hernia repair with graft or prosthesis

5363: Other laparoscopic repair of other hernia of anterior abdominal wall with graft or prosthesis

5361: Other open incisional hernia repair with graft or prosthesis

5369: Other and open repair of other hernia of anterior abdominal wall with graft or prosthesis

Thoracic

163: Major chest procedures w MCC

164: Major chest procedures w CC

165: Major chest procedures w/o CC/MCC

3220: Thoracoscopic excision of lesion or tissue of lung

3230: Thoracoscopic segmental resection of lung

3241: Thoracoscopic lobectomy of lung

3229: Other local excision or destruction of lesion or tissue of lung

3239: Other and unspecified segmental resection of lung

3249: Other lobectomy of lung

CC complication or comorbidity, c.d.e. common duct exploration, MCC major complication or comorbidity, proc procedure, rad radical

Five outcomes were examined in this study: complication rate, all-cause 30-day re-admission, patient LOS, Medicare claim cost, and Medicare reimbursement. A complication was defined with the Healthcare Cost and Utilization Project (HCUP) Clinical Classifications Software category label of “complications of surgical procedures or medical care.” Claim cost was estimated following HCUP developed methodology. We utilized individual hospital department cost-to-charge ratios derived from annual Centers for Medicare and Medicaid Services cost reports to calculate the cost for each inpatient stay (https://www.hcup-us.ahrq.gov/reports/methods/2011_04.pdf). We used the MEDPAR Medicare Payment Amount variable in claim records to calculate the average reimbursement to institutional providers.

Adjusting for patient demographics, comorbidities, and Charlson Comorbidity Index (CCI) score (Table 2) using a multivariable generalized linear model, the odds of complication and re-admission were calculated to compare patients undergoing the MIS versus open approach. For LOS, the estimated differences in days were calculated, and for Medicare claim cost and reimbursement, the estimated differences in US dollars were calculated. Generalized estimating equations were used for all outcomes to adjust for hospital clustering. A p value of < 0.05 was defined as significant.

Table 2

Patient demographics and Charlson Comorbidity Index Score

Procedure

Bariatric

Cholecystectomy

Colectomy

Hysterectomy

Inguinal Hernia

Thoracic

Ventral Hernia

Procedure type

Open

MIS

Open

MIS

Open

MIS

Open

MIS

Open

MIS

Open

MIS

Open

MIS

N

2784

17,476

8733

58,002

46,894

27,418

18,352

6447

5366

948

10,514

17,830

10,086

3134

Age category

<65

30%

65%

18%

18%

12%

10%

29%

25%

8%

11%

13%

12%

26%

23%

65–84

61%

35%

70%

69%

74%

80%

68%

71%

66%

68%

84%

85%

68%

71%

>84

9%

0%

12%

13%

14%

10%

3%

4%

26%

21%

3%

3%

6%

6%

Gender

Male

40%

26%

57%

47%

42%

43%

0%

0%

79%

75%

51%

47%

37%

35%

Female

60%

74%

43%

53%

58%

57%

100%

100%

21%

25%

49%

53%

63%

65%

Race

White

80%

78%

84%

84%

86%

87%

77%

82%

84%

87%

88%

88%

87%

89%

Black

13%

16%

9%

8%

9%

8%

15%

11%

10%

9%

7%

7%

8%

7%

Other

7%

6%

7%

8%

5%

5%

8%

7%

6%

4%

5%

5%

5%

4%

Medicare status

Normal

70%

35%

82%

82%

88%

90%

71%

75%

92%

89%

87%

88%

74%

77%

Disabled

30%

65%

18%

18%

12%

10%

29%

25%

8%

11%

13%

12%

26%

23%

MSDRG

DRG w/o CC/MCC

22%

75%

26%

33%

17%

40%

51%

62%

43%

45%

23%

37%

46%

49%

DRG with CC

40%

21%

44%

43%

49%

48%

21%

16%

44%

41%

54%

48%

43%

42%

DRG with MCC

38%

4%

30%

24%

34%

12%

28%

22%

13%

14%

23%

15%

11%

9%

Mean CCI Score

3.03

1.19

1.56

1.28

2.77

2.33

2.21

1.96

1.36

1.11

4.01

3.42

1.16

1.12

MSDRG Medicare Severity Diagnosis-Related Group, DRG Diagnosis-Related Group, CC complication or comorbidity, MCC major complication or comorbidity

The MEDPAR Inpatient Limited Data Set includes 100% inpatient utilization of Medicare fee-for-service members. The data are released by Centers for Medicare and Medicaid Services annually and contain healthcare insurance claim fields from the standard UB04 Inpatient Claim Form. The data management and analysis were conducted using SAS software, Version 9.4.

Results

Among 233,984 patients, 102,729 patients underwent an open procedure while 131,255 patients underwent a minimally invasive procedure. Regardless of the procedure, utilization of MIS was greater in the general population than in the Medicare population (Fig. 1). Medicare patients undergoing bariatric, cholecystectomy, and thoracic procedures were most likely to undergo an MIS rather than an open procedure with MIS utilization of 86, 87, and 63%, respectively. For all procedure types except one, the majority of patients were between the ages of 65 and 84 and white with a normal Medicare status. However, the majority of patients who underwent a minimally invasive bariatric procedure were less than the age of 65 and white with a disabled Medicare status (Table 2). Within each procedure type, mean CCI score did not greatly differ among patients who underwent MIS versus open surgery except for patients undergoing a bariatric procedure: 1.19 versus 3.03.

Fig. 1

General versus Medicare population utilization of MIS in 2014

The incidence of complications following MIS was markedly lower for 5 out of the 7 procedures examined; interestingly, complications were more common following MIS versus open surgery for inguinal hernias. All-cause 30-day re-admissions were lower following MIS versus open surgery for 6 out of 7 procedures. In addition, MIS was associated with a shorter LOS for six procedures. Medicare claim costs for MIS were also lower for four procedures; however, claim costs were greater following MIS versus open surgery for inguinal hernias. Finally, Medicare reimbursements for MIS were lower for three procedures (Table 3).

Table 3

Clinical and economic outcomes for seven common surgical procedures performed by the minimally invasive versus open approach

 

Complication rate (OR)

[95% CI]

Re-admission rate (OR)

[95% CI]

LOS (days)

[95% CI]

Claim cost (dollars)

[95% CI]

Reimbursement (dollars)

[95% CI]

Bariatric

0.38 [0.31, 0.47]***

0.43 [0.35, 0.54]***

− 1.74 [− 2.24, − 1.24]***

− 4169.24 [− 5653.9, − 2684.59]***

− 878.24 [− 1661.64, − 94.84]*

Cholecystectomy

0.36 [0.34, 0.39]***

0.87 [0.81, 0.93]***

0.57 [− 1.52, 2.66]

− 4832.74 [− 8137.71, − 1527.76]**

158.33 [− 929.36, 1246.03]

Colectomy

0.49 [0.47, 0.51]***

0.61 [0.58, 0.64]***

− 2.47 [− 3.97, − 0.97]**

− 3010.23 [− 3284.01, − 2736.44]***

− 841.10 [− 1002.08, − 680.12]***

Hysterectomy

0.63 [0.56, 0.7]***

0.63 [0.55, 0.71]***

− 1.45 [− 1.56, − 1.35]***

83.96 [− 269.96, 437.88]

− 208.37 [− 439.86, 23.13]

Inguinal hernia

1.56 [1.29, 1.88]***

1.03 [0.82, 1.31]

− 0.35 [− 0.57, − 0.13]**

1614.12 [971.13, 2257.1]***

− 156.56 [− 414.72, 101.59]

Thoracic

0.69 [0.64, 0.74]***

0.84 [0.78, 0.92]***

− 1.40 [− 1.53, − 1.27]***

− 3970.12 [− 4474.07, − 3466.16]***

− 939.69 [− 1254.57, − 624.80]***

Ventral hernia

0.91 [0.81, 1.02]

0.69 [0.60, 0.80]***

− 0.77 [− 0.91, − 0.64]***

− 77.17 [− 566.21, 411.88]

− 158.54 [− 345.97, 28.90]

*p value < 0.05

**p value < 0.01

***p value < 0.0001

Discussion

Benefits of MIS

The clinical and economic benefits of MIS in the general population have been documented in the literature. MIS is associated with lower post-operative complication rates [13, 14], re-admission [14], mortality [13], healthcare costs [13, 14], and shorter LOS [13]. Few studies have compared outcomes after the MIS versus open approach in the Medicare population, however. Most of these past studies have been limited as these reports focused exclusively on a particular procedure. For example, these studies demonstrated that in the Medicare population, laparoscopic cholecystectomy was associated with lower mortality and re-admissions rates [15]. In addition, laparoscopic colectomy was associated with lower mortality and fewer complications [16], and laparoscopic hysterectomy was associated with fewer surgical site complications and medical complications [17].

The current study provides a comprehensive review of Medicare data for seven different surgical procedures and clearly demonstrates the post-operative clinical and economic benefits of MIS. The majority of the procedures analyzed were associated with lower complication and re-admission rates, shorter LOS, and lower claim costs for MIS. In particular, this study provides new data on minimally invasive versus open outcomes for bariatric, hysterectomy, inguinal hernia, and ventral hernia procedures, which have not been thoroughly studied in the Medicare population. These results have critical implications for encouraging MIS utilization in the Medicare and especially, the elderly population.

Interestingly, the incidence of complications and claim costs were higher for inguinal hernias performed using an MIS approach. These results were consistent with other data in the literature. In 2003, a Cochrane review reported that operative complications were more frequent for the laparoscopic versus open group with regard to visceral and vascular injuries [18]. While the reason for this is likely multifactorial, the increase in complications with MIS for hernia repair may be due to the learning curve associated with the procedure. The current study did not specifically examine diffusion of technical skills, but a surgeon may be technically safer at performing a certain operation or approach versus another. On the other hand, there may have been other benefits of the MIS approach that were not captured by this study such as a quicker return to activities of daily living and a lower rate of paresthesias [19]. As such, the data may suggest that a division of labor should be employed by hospitals when triaging patients to a surgeon depending on the type of operation that is best suited for the patient.

Underutilization of MIS in the Medicare population

Despite the clear benefits of MIS in the Medicare population, MIS utilization in the Medicare population is still less than in the general population. Although the adoption of laparoscopic cholecystectomy has increased over the years, elderly patients consistently lag behind younger patients in the utilization rates of laparoscopic cholecystectomy [8]. One reason for this disparity is a lingering ideology that older patients do not tolerate gas insufflation safely. This rationale dominated the early days of laparoscopy and has subsequently been proven untrue except in rare cases of pulmonary hypertension or heart failure [20]. In the absence of severe cardiopulmonary symptoms, older patients should be approached in the same way younger patients are approached. That is, most candidate patients without severe cardiopulmonary symptoms should be considered for a laparoscopic approach when feasible with the exception of procedures in select patient populations where outcomes are equivalent (e.g., high-risk patients undergoing inguinal hernia surgery). The discrepancy in laparoscopic utilization among older and younger patients could also be due to a perception that there are longer operative times associated with laparoscopy, which requires the patient to be sedated and on the operating table for a longer period of time. Many operations are often performed faster using laparoscopy [21, 22, 23], however, and given that elderly patients have a lower physiologic reserve, the benefits of laparoscopy such as fewer post-operative complications, shorter LOS, and decreased post-operative pain may be augmented in older patients [5].

Limitations

There were a few limitations to this study. Although many factors were adjusted for including age, gender, race, Medicare status, and CCI, we were not able to adjust for previous procedures. Previous surgical procedures could have affected the difficulty of the procedure and could have been associated with selection for an open versus a minimally invasive approach. In addition, we were unable to adjust for the acuity of the procedure performed, which may have also had an affect on approach selection as well. We were also unable to parse out the distribution of ventral hernias in the study (e.g., primary versus incisional versus epigastric).

In this study, claim costs were estimated using cost-to-charge ratios, which are not reflective of true costs. Thus, we included Medicare reimbursement data, which are more reflective of direct costs to the healthcare system. Finally, robotic procedures are frequently under-coded in large datasets; however, they are usually more expensive than laparoscopic procedures and have similar clinical outcomes. If robotic procedures were under-coded in this study, the cost differences between open and MIS procedures were underestimated as well.

Conclusions

The benefits of MIS extend to the Medicare population. Use of MIS was associated with lower complication and re-admission rates, Medicare costs and reimbursements, as well as shorter LOS. These results suggest that laparoscopy is underutilized in older patients. Better, more appropriate adoption of MIS in older patients supports Medicare’s objective of improved quality and higher-value care.

Notes

Acknowledgements

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.

Funding

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

Compliance with ethical standards

Disclosures

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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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Caleb J. Fan
    • 1
  • Hung-Lun Chien
    • 2
  • Matthew J. Weiss
    • 3
  • Jin He
    • 3
  • Christopher L. Wolfgang
    • 3
  • John L. Cameron
    • 3
  • Timothy M. Pawlik
    • 4
  • Martin A. Makary
    • 3
  1. 1.Department of Otolaryngology, Head and Neck SurgeryIcahn School of Medicine at Mount SinaiNew YorkUSA
  2. 2.Minimally Invasive Therapies GroupMedtronic Inc.MansfieldUSA
  3. 3.Department of SurgeryThe Johns Hopkins UniversityBaltimoreUSA
  4. 4.Department of SurgeryThe Ohio State University Wexner Medical CenterColumbusUSA

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