Perioperative Outcomes and Trends in the Use of Robotic Colectomy for Medicare Beneficiaries From 2010 Through 2016

Abstract

IMPORTANCE The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice. OBJECTIVE To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings. DESIGN, SETTING, AND PARTICIPANTS This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019. EXPOSURES Receipt of robotic colectomy. MAIN OUTCOMES AND MEASURES Incidence of postoperative medical and surgical complications and length of stay. RESULTS A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients]). CONCLUSIONS AND RELEVANCE While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.

Is robotic utilization associated with increased minimally invasive colorectal surgery rates? Surgeon-level evidence

“…The slope for year of surgery represents the average annual change in proportional use of robotic surgery. If the slope averaged over all years was positive, surgeons were classified as having IRU, whereas surgeons who did not have a positive average slope were classified as having non-IRU [22]. For example, if a surgeon had 1 year of increased proportional use of robotic surgery, 1 year of decreased proportional use of robotics but a smaller percentile change than the increase, and then otherwise stable usage, then the overall slope would still remain positive and this surgeon would be considered to have IRU.…”

American Board of Surgery Statement on Assessment and Robotic Surgery

“…In general surgery, the data for better outcomes for patients undergoing robotic surgery are not available. The most recent data on robotic colectomy among Medicare patients from 2010 to 2016 was analyzed by Sheets et al 10 The authors found no difference in the complication rates between robotic and laparoscopic colectomy. They also found that robotic colectomies replaced a higher proportion of MIS laparoscopic surgeries rather than high risk open procedures.…”

Cost drivers of locally advanced rectal cancer treatment—An analysis of a leading healthcare insurer

“…Currently, robot‐assisted approaches are an evolving surgical tool and technique within the field of colorectal surgery 7–9 . Despite multiple favorable preliminary reports with regard to surgical ease, quality, and outcomes, recent results from a landmark multicenter randomized controlled trial failed to demonstrate a substantial benefit 10–12 .…”