Under-Utilization of Minimally Invasive Surgery in Hospitals
Under-Utilization of Minimally Invasive Surgery in Hospitals
Table 1 lists the percentage of hospitals in the low, medium, and high categories for utilization of minimally invasive surgery by hospital location, size, teaching status, region, and financial type. Out of the 1051 hospitals in the nationwide inpatient sample database, the inclusion criteria for our analysis were met by 596 hospitals for appendectomy, 541 hospitals for colectomy, 499 hospitals for hysterectomy, and 208 hospitals for lung lobectomy. The mean hospital utilization of minimally invasive surgery was 71.0% (423/596) for appendectomy, 28.4% for colectomy (154/541), 13.0% (64/499) for hysterectomy, and 32.0% (66/208) for lung lobectomy. Hospital utilization of minimally invasive surgery varied widely for all four procedures, with a significant increase in utilization from the low to medium third hospitals and from the medium to high third hospitals (mean utilization by third for appendectomy: low 40.9% (81/199), medium 78.8% (n=156), high 93.1% (n=185), P<0.001; colectomy: low 6.7% (12/180), medium 29.0% (n=52), high 49.8% (n=90), P<0.001; hysterectomy: low 0.0% (0/166), medium 6.2% (n=10), high 33.6% (n=56), P<0.001; lung lobectomy: low 3.6% (3/69), medium 26.7% (n=18), high 65.7% (n=45), P<0.001). Some hospitals had zero utilization of minimally invasive surgery for the four procedures: appendectomy 1.6% (9/596), colectomy 11.5% (62/541), hysterectomy 35% (174/499), and lung lobectomy 15.9% (33/208). Conversely, greater than 75% utilization of minimally invasive surgery was observed in hospitals: appendectomy 56.4% (336/596), colectomy 0.7% (4/541), hysterectomy 1.6% (8/499), and lung lobectomy 8.2% (17/208).
There was sharp discordance between a hospital's observed and predicted proportion of procedures performed using minimally invasive surgery (Figure). The range of the actual to predicted ratio of utilization was 0-1.49 for appendectomy, 0-3.88 for colectomy, 0-6.68 for hysterectomy, and 0-2.51 for lung lobectomy.
(Enlarge Image)
Figure 1.
Percentage of procedures performed using minimally invasive surgery (MIS) by hospital. Hospitals are ranked in increasing order from lowest to highest observed to predicted ratio of MIS utilization. Each point represents one hospital. For predicted values, error bars are 95% confidence intervals. *Case mix adjusted (predicted rate). Each diamond represents one hospital
For the Agency for Healthcare Research and Quality patient safety indicators, the overall complication rates for minimally invasive surgery compared with open surgery were, respectively: appendectomy: 3.94% (1439/36 513) v 7.90% (958/12?123), P<0.001; colectomy: 13.8% (1689/12 242) v 35.8% (8837/24 687), P<0.001; hysterectomy: 4.69% (270/5757) v 6.64% (1988/29 940), P<0.001; and lung lobectomy: 17.1% (367/2145) v 25.4% (971/3824), P<0.05. Using a risk adjusted model, individual complications for each procedure were either decreased or no different with the minimally invasive surgery approach, with most exhibiting a decrease ( Table 2 ).
High utilization of minimally invasive surgery was associated with urban location (appendectomy: odds ratio 4.66, 95% confidence interval 1.17 to 18.5; colectomy: 4.59, 1.04 to 20.3; hysterectomy: 15.0, 2.98 to 75.0), large hospital size (hysterectomy: 8.70, 1.62 to 46.8), teaching hospital (hysterectomy: 5.41, 1.27 to 23.1), Midwest region (appendectomy: 7.85, 1.26 to 49.1), south region (appendectomy: 21.0, 3.79 to 117; colectomy: 10.0, 1.83 to 54.7), and west region (appendectomy: 9.33, 1.48 to 58.8, Table 3 ). Low utilization of minimally invasive surgery was associated with teaching hospital (colectomy: odds ratio 0.19, 95% confidence interval 0.05 to 0.76), Midwest region (lung lobectomy: 0.02, 0.001 to 0.31), private not for profit hospitals (appendectomy: 0.16, 0.03 to 0.84), and government hospitals (appendectomy: 0.08, 0.01 to 0.60).
Results
Table 1 lists the percentage of hospitals in the low, medium, and high categories for utilization of minimally invasive surgery by hospital location, size, teaching status, region, and financial type. Out of the 1051 hospitals in the nationwide inpatient sample database, the inclusion criteria for our analysis were met by 596 hospitals for appendectomy, 541 hospitals for colectomy, 499 hospitals for hysterectomy, and 208 hospitals for lung lobectomy. The mean hospital utilization of minimally invasive surgery was 71.0% (423/596) for appendectomy, 28.4% for colectomy (154/541), 13.0% (64/499) for hysterectomy, and 32.0% (66/208) for lung lobectomy. Hospital utilization of minimally invasive surgery varied widely for all four procedures, with a significant increase in utilization from the low to medium third hospitals and from the medium to high third hospitals (mean utilization by third for appendectomy: low 40.9% (81/199), medium 78.8% (n=156), high 93.1% (n=185), P<0.001; colectomy: low 6.7% (12/180), medium 29.0% (n=52), high 49.8% (n=90), P<0.001; hysterectomy: low 0.0% (0/166), medium 6.2% (n=10), high 33.6% (n=56), P<0.001; lung lobectomy: low 3.6% (3/69), medium 26.7% (n=18), high 65.7% (n=45), P<0.001). Some hospitals had zero utilization of minimally invasive surgery for the four procedures: appendectomy 1.6% (9/596), colectomy 11.5% (62/541), hysterectomy 35% (174/499), and lung lobectomy 15.9% (33/208). Conversely, greater than 75% utilization of minimally invasive surgery was observed in hospitals: appendectomy 56.4% (336/596), colectomy 0.7% (4/541), hysterectomy 1.6% (8/499), and lung lobectomy 8.2% (17/208).
There was sharp discordance between a hospital's observed and predicted proportion of procedures performed using minimally invasive surgery (Figure). The range of the actual to predicted ratio of utilization was 0-1.49 for appendectomy, 0-3.88 for colectomy, 0-6.68 for hysterectomy, and 0-2.51 for lung lobectomy.
(Enlarge Image)
Figure 1.
Percentage of procedures performed using minimally invasive surgery (MIS) by hospital. Hospitals are ranked in increasing order from lowest to highest observed to predicted ratio of MIS utilization. Each point represents one hospital. For predicted values, error bars are 95% confidence intervals. *Case mix adjusted (predicted rate). Each diamond represents one hospital
For the Agency for Healthcare Research and Quality patient safety indicators, the overall complication rates for minimally invasive surgery compared with open surgery were, respectively: appendectomy: 3.94% (1439/36 513) v 7.90% (958/12?123), P<0.001; colectomy: 13.8% (1689/12 242) v 35.8% (8837/24 687), P<0.001; hysterectomy: 4.69% (270/5757) v 6.64% (1988/29 940), P<0.001; and lung lobectomy: 17.1% (367/2145) v 25.4% (971/3824), P<0.05. Using a risk adjusted model, individual complications for each procedure were either decreased or no different with the minimally invasive surgery approach, with most exhibiting a decrease ( Table 2 ).
High utilization of minimally invasive surgery was associated with urban location (appendectomy: odds ratio 4.66, 95% confidence interval 1.17 to 18.5; colectomy: 4.59, 1.04 to 20.3; hysterectomy: 15.0, 2.98 to 75.0), large hospital size (hysterectomy: 8.70, 1.62 to 46.8), teaching hospital (hysterectomy: 5.41, 1.27 to 23.1), Midwest region (appendectomy: 7.85, 1.26 to 49.1), south region (appendectomy: 21.0, 3.79 to 117; colectomy: 10.0, 1.83 to 54.7), and west region (appendectomy: 9.33, 1.48 to 58.8, Table 3 ). Low utilization of minimally invasive surgery was associated with teaching hospital (colectomy: odds ratio 0.19, 95% confidence interval 0.05 to 0.76), Midwest region (lung lobectomy: 0.02, 0.001 to 0.31), private not for profit hospitals (appendectomy: 0.16, 0.03 to 0.84), and government hospitals (appendectomy: 0.08, 0.01 to 0.60).
Source...