by Judith Riess, Editor of Medical Training Magazine
In a very interesting study conducted by Michael A. Palese, M.D., Chairman of Urology, Mount Sinai Beth Israel, Director of Minimally Invasive Surgery, he found that robotic assisted laparoscopic surgery (RALS) has made its way to every surgical field. Studies have shown RALS to result in fewer deaths, shorter hospital stays, fewer complications, fewer transfusions, and more routine discharges. (2)
In order to better understand the benefits of investment in this technology, the Institute of Medicine set comparative analysis of RALS as a high priority, to better understand what the benefits are of this relatively new technology (1).
In Dr. Palese’s study, they characterized trends for RALS across all specialties in the period spanning 2009 to 2014. They highlighted six procedures in order to establish a comparison between patients and surgeons involved in RALS procedures and their non-RALS counterparts.
This study used data from the Statewide Planning and Research Cooperative System (SPARCS) as well as from the American Medical Association (AMA) Physician Masterfile. The SPARCS dataset is a New York State all payer database established in 1979, and compiled by the New York State Department of Health Office of Quality and Patient Safety. New York State law mandates the collection of certain data from all inpatient centers in the state of New York.
The SPARCS database provides a unique opportunity to examine inpatient physician trends due both to its completeness and the availability of a physician identifier that may then be linked to other resources. The AMA Physician Masterfile was established in 1906 and includes current and historical data for more than 1.4 million physicians, residents, and medical students in the United States.
The SPARCS database includes information on patient characteristics such as age, race, ethnicity, gender, and zip code. Up to 3 physicians, listed as “operating”, “attending”, and “other” are identified for each encounter, enabling the identification of associated physicians. The AMA Physician Masterfile provides information of a physician’s completed residencies, allowing verification of urology residency completion.
Prior to the commencement of this study, the study design was approved by the institutional review board of the Icahn School of Medicine at Mount Sinai. Using the SPARCS dataset, the study sample was collected for all inpatient procedures that were coded using an ICD-9 robotic modifier (ICD-9 17.4*). Since the ICD-9 robotic modifier codes were established in October2008, they set their period of interest from the start of 2009 to the end of 2014. Physician state license numbers associated with each encounter were recorded. The AMA Physician Masterfile was used to identify what residency or fellowship training each participating physician had completed. Additionally, six procedures that represented a large proportion of RALS cases in different fields were highlighted for comparison in patient and physician data: radical prostatectomy (RP) (ICD-9 60.5), hysterectomy (HM) (ICD-9 68.3, 68.4, 68.5, 68.6, 68.7, 68.9), total knee replacement (knee arthroplasty) (TKR) (ICD-9 81.54), single internal mammary coronary artery bypass (CAB) (ICD-9 36.15), partial nephrectomy (PN) (ICD-9 55.4), and rectal resection (RR) (ICD-9 48.6). Patient zip code was recorded and mapped to poverty rate as recorded in US Census Bureau Data.
Categorization of Encounters
Every encounter was categorized using two methodologies. In the first methodology, they categorized each encounter by the residency or fellowship completed by the operating physician. If the operating physician was ambiguous, they relied on the two other fields provided. This allowed them to categorize encounters without making assumptions about which specialty does which procedure. In the second methodology, they categorized each procedure into groups of practice: urological, gynecological, cardio-thoracic, general, otolaryngological, orthopedic, and uncategorized. This was provided for comparison.
Key Variables of Interest
The outcome variables most relevant to this study were the proportion of RALS cases handled by each category. The key independent variable is year. Comparative analysis on patient demographic data as well as comorbidity and primary payer data was completed to compare the differences between patients receiving RALS as opposed to non-RALS care. The number of comorbidities for each patient was determined for each encounter was derived using the Quan adaptation of Charlson comorbidity scoring algorithm (10). Physician demographics data was also compared.
This study surveys the evolving changes in inpatient medicine and across several specialties as it adapts to robotic technology. To their knowledge, this is the first such study to chart changes in RALS cases over time and provide comparative analysis of both patients and surgeons involved in these procedures, across several specialties. This study found that the quantity of RALS cases for each category rose during the period of interest, however, the rise was asymmetric across categories. The proportion of all RALS cases decreased for urologists and gynecologists, while increasing for all other surgeons. In general, surgeons involved in RALS cases were more likely to be younger, male, and a non-foreign medical graduate (FMG), as compared to surgeons involved in non-RALS cases. Patients receiving RALS care were more likely to be young, male, white, and from a more affluent area, than patients receiving non-RALS care.
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. This is likely due to their earlier adoption of RALS technique in urology and gynecology. One study, for example, noted the proportion of radical prostatectomy cases rose from 10% to 68% in the two year period spanning 2007 to 2009.(3) Interestingly, this study picks up right where the other study dropped off, showing the rise continue, albeit at a slower rate, to 85.5%. The clear domination of RALS in radical prostatectomy makes it unique among procedures and its rapid adoption underlies how quickly technology can drastically change practice, an observation mirrored in many fields that are similarly adapting to new technologies. The lack of a significant rise in the number of RALS cases for both urologists and gynecologists, may suggest that uptake of RALS in urology and gynecology has reached a saturation point, where all procedures for which RALS is advantageous have already come to utilize it. This conclusion may be complicated by influences on the general number of procedures being done and so require comparative analysis of RALS against non-RALS cases on a procedure-by-procedure basis as was done in this study. It is clear, however, that a majority of RALS cases are no longer handled by urologists, instead, while urologists still handle a plurality of these cases, RALS cases are increasingly spread across many specialties.
Looking at the highlighted procedures, we see that the proportion that are handed through RALS has increased universally. The most dramatic changes are seen in RR and PN. In RR, especially, we see the steady rise in the proportion of RALS cases from a negligible proportion to 20.0%. This trend is seen despite the decreases in the quantity of procedures seen in HM, RP, and CAB.
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.
Robotic assisted laparoscopic surgery (RALS) cases are diversifying. While previously a majority of RALS cases were handled by urologists and gynecologists, general, orthopedic, cardio-thoracic, and otolaryngological surgeons have begun performing a significant proportion of RALS cases. In general, surgeons involved in RALS cases were more likely to be younger, male, and a non-foreign medical graduate, as compared to surgeons involved in non-RALS cases. Patients receiving RALS care were more likely to be young, white, and from a more affluent area, than patients receiving non-RALS care. In procedures that serve males and females, males were more likely to receive RALS care than females. These trends suggest that the benefits of RALS for both the surgeon and patient have not been distributed equally. These results have implications for surgeons planning for future practice and hospital administrators adapting to the rapidly changing medical landscape. RALS requires significant capital investments and should be weighed as part of a strategic plan for future growth.
- IOM (Institute of Medicine): Initial National Priorities for Comparative Effectiveness Research [Internet]. Washington, D.C.: National Academies Press; 2009. Available from: http://www.nap.edu/catalog/12648
- Anderson JE, Chang DC, Parsons JK, et al.: The first national examination of outcomes and trends in robotic surgery in the United States. [Internet]. J Am Coll Surg 2012; 215:107–14; discussion 114–6Available from: http://dx.doi.org/10.1016/j.jamcollsurg.2012.02.005
- Dasgupta P, Kirby RS: The current status of robot-assisted radical prostatectomy.[Internet]. Asian J Androl 2009; 11:90–3Available from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3735203&tool=pmcentrez&rendertype=abstract
Dr. Palese and his research assistant, Dr. Finkelstein will be discussing this study and future studies at Minimally Invasive Surgery Week. August 31-September 3, 2016 at 3PM Thursday, Sept. 1 at the Poster Town Hall at Westin Copley Plaza, Boston, Massachusetts, USA .
Dr. Palese is a world recognized surgeon and scholar who is also a leader in the development of new treatments and technologies. He performed the first robotic radical nephrectomy, robotic partial nephrectomy, robotic donor nephrectomy, robotic nephro-ureterectomy, robotic adrenalectomy, and robotic ureteral reimplant & reconstruction at The Mount Sinai Medical Center in New York City. He holds several patents for the design of novel surgical devices.