According to published research, surgical complications are a substantial burden in the United States, costing an estimated $25 billion annually and accounting for many readmissions. However, studies show that complications can be reduced by using minimally invasive surgery for select candidates for these operations. Potential benefits include lower of surgical site infection (SSI) rates, decreased pain, and shorter hospitalizations. Data suggest that this is the case for laparoscopic procedures for appendectomy as well as minimally invasive colectomy, hysterectomy, and lung lobectomy. “There is strong evidence showing that minimally invasive surgery has better patient outcomes when compared with traditional open procedures for many common operations,” says Martin A. Makary, MD, MPH.
In some cases, hospitals and surgeons may only perform open surgery, meaning many patients who are candidates for minimally invasive surgery may only be offered open surgery. “We have extensive data supporting the use of minimally invasive surgery, but the choice of surgery often comes down to surgeon preference,” Dr. Makary says. “It’s likely that there is wide variation in the use of minimally invasive surgery throughout the country, but few studies have explored this issue. By measuring if there are disparities in the use of minimally invasive surgery, we may be able to identify opportunities to decrease surgical complications.”
A Nationwide Analysis
In BMJ, Dr. Makary and colleagues analyzed records of a nationwide inpatient sample database from the AHRQ. The study group determined use rates and patterns of four common surgical procedures: laparoscopic appendectomy, partial colectomy, total abdominal hysterectomy, and thorascopic lung lobectomy. The authors noted that laparoscopic appendectomy, partial colectomy, and total abdominal hysterectomy were supported by Cochrane reviews that suggest there are benefits to patients by using a minimally invasive approach. They also looked at thorascopic lung lobectomy, a procedure for which the benefits of a minimally invasive operation versus an open procedure are less established. The data set was robust, including information on patients discharged from more than 1,000 hospitals from 45 states in 2010.
According to the study results, the average hospital utilization of minimally invasive surgery was 71% for appendectomy, about 28% for colectomy, 13% for hysterectomy, and 32% for lung lobectomy. Overall, surgical complications were less common with minimally invasive surgery when compared with open surgery (Table). In addition, hospitals located in urban settings, those that were larger, and those that were identified as teaching institutions had higher utilization rates of minimally invasive surgery. Urban hospitals were more than four times as likely as rural hospitals to perform laparoscopic appendectomies and colectomies and 15 times more likely to perform minimally invasive hysterectomies.
“The use of minimally invasive surgery was highly variable for each procedure type,” says Dr. Makary. “There were noticeable disparities between the actual and predicted use of these types of surgery. These disparities may be due to the broad range of surgical services that some surgeons in rural areas are required to provide.” The scarcity of surgical specialists with advanced skills in minimally invasive surgery in these geographic regions also appears to contribute to the observed disparities.
The study team’s findings suggest that many hospitals have an opportunity to decrease surgical complications by increasing their use of minimally invasive surgery. “For example,” Dr. Makary says, “SSIs are a leading quality indicator in healthcare. In our analysis, the rate of SSIs was noticeably lower when minimally invasive surgery was used.” The study found that minimally invasive procedures were associated with fewer wounds and infections as well as lower rates of thrombotic and pulmonary complications and mortality.
The disparity in appropriateness of operations offered between hospitals has important implications for training, informed consent, and patient empowerment with data transparency, according to the study. “To deal with these disparities, efforts should be made to standardize the training and education of surgeons,” Dr. Makary says. “It may behoove hospitals to create a division of labor in which patients who aren’t candidates for minimally invasive surgery can receive these procedures through referral to other specialists capable of performing these surgeries.”
Dr. Makary adds that hospitals should also be transparent about their rates of utilization of minimally invasive surgery so that patients are well informed when making decisions. “Some candidates for minimally invasive surgery are never told about these options and follow the surgeon’s preference by undergoing open surgery,” he says. “We need comprehensive shared decision-making tools so that we properly inform patients about their range of options. Such transparency could potentially increase the appropriate use of minimally invasive surgery, decrease variation, and enhance patient outcomes.”
Readings & Resources (click to view)
Cooper M, Hutfless S, Segev D, et al. Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review. BMJ. 2014;349:g4198. Available at: http://www.bmj.com/content/bmj/349/bmj.g4198.full.pdf.
Southgate E, Vousden N, Karthikesalingam A, et al. Laparoscopic vs open appendectomy in older patients. Arch Surg. 2012;147:557-562.
Woodham B, Cox M, Eslick G. Evidence to support the use of laparoscopic over open appendicectomy for obese individuals: a meta-analysis. Surg Endosc. 2012;26:2566-2570.
Martin R, Kehdy F, Allen J. Formal training in advanced surgical technologies enhances the surgical residency. Am J Surg. 2005;190:244-248.
Kiran R, El-Gazzaz G, Vogel J, Remzi F. Laparoscopic approach significantly reduces surgical site infections after colorectal surgery: data from national surgical quality improvement program. J Am Coll Surg. 2010;211:232-238.
Overview of the Agency for Healthcare Research and Quality Patient Safety Indicators. 2013. Available at: www.qualityindicators.ahrq.gov/Modules/psi_resources.aspx.