Under-Utilization of Minimally Invasive Surgery in Hospitals
Under-Utilization of Minimally Invasive Surgery in Hospitals
It has been well established that minimally invasive surgery is associated with lower complications and improved postoperative recovery. Despite these benefits, two standards of care remain in existence because patient candidacy and the choice of operations are often discretionary, based on surgeon preference. In the United States we found wide variation in the use of minimally invasive surgery by hospital after adjusting for differences in a hospital’s unique patient population. This study has important implications for quality improvement. Based on our findings, many hospitals have an opportunity to decrease surgical complications by increasing utilization of minimally invasive surgery.
Surgical site infection, a leading quality indicator in healthcare, is one important quality metric that is noticeably decreased with use of minimally invasive surgery. Surgical site infections occur in 8-15% of open colorectal operations at an estimated cost of $1398 per patient secondary to prolonged hospitalization, wound care, and wound complications. In addition, the presence of a surgical site infection during a hospitalization is a leading risk factor for hospital readmission after colon surgery (odds ratio 1.18, 95% confidence interval 1.08 to 1.29). Hospitals have struggled to find innovative ways to decrease surgical site infections and there is a paucity of interventions with an established benefit beyond current practices. However, one intervention that is often overlooked is minimally invasive surgery. The decreased incision size associated with laparoscopy results in less subcutaneous dead space and thus a lower risk of bacterial contamination. A 2005 Cochrane review of 25 randomized controlled trials concluded that laparoscopic colectomy was associated with a 0.56 risk ratio of surgical site infections compared with open surgery. Similarly, a 2009 Cochrane review of 34 randomized controlled trials concluded that laparoscopic hysterectomy was associated with a 0.31 risk ratio of surgical site infections compared with open surgery. In our analysis using Agency for Healthcare Research and Quality patient safety indicators for surgical care, we noted fewer wound, infectious, thrombotic, pulmonary, and mortality complications associated with minimally invasive surgery. Based on our findings, increased hospital utilization of minimally invasive surgery at many US hospitals represents a tremendous opportunity to prevent surgical site infection events.
We found that rural hospitals were less likely to perform minimally invasive surgery for three of the four procedures studied (appendectomy, colectomy, and hysterectomy, the fourth being lobe lobectomy). This disparity may be due to the broad range of surgical services some surgeons in rural areas are required to provide and a scarcity of surgical specialists in such areas with advanced skills in minimally invasive surgery. Alternatively, the disparity may be a function of a lack of patient awareness about surgical options, decreased competition for patients, or a lack of minimally invasive surgery equipment, staff, or support in rural areas. Other hospital characteristics showed no association or an irregular pattern of association with utilization of minimally invasive surgery. For instance, large hospital size was not associated with use with the exception of hysterectomy carried out laparascopically. Teaching status was associated with high utilization of minimally invasive surgery for hysterectomy, low utilization for colectomy, and no association for appendectomy or lung lobectomy, indicating no pattern of association across procedure types. By geographic region, the north east was associated with low utilization of minimally invasive appendectomy, the south was associated with high utilization of minimally invasive appendectomy and colectomy, and the Midwest was associated with low utilization of minimally invasive lung lobectomy. Regional variations that we observed may be due to more extensive specialty specific training in minimally invasive surgery in some areas. Moreover, hospital and regional attitudes towards minimally invasive surgery may vary, with some areas having a more minimally invasive surgery culture and others a more open surgery culture.
One reason that hospitals may be underperforming minimally invasive surgery is variability in appropriate training in residency and fellowship. Residents and fellows learn in an apprenticeship model, yet for many, the surgeons they learn from may lack advanced skills in minimally invasive surgery. In a survey of US obstetric and gynecology residency programs in 2006, only 69% had formal laparoscopy training. In a national survey of colorectal surgeons in 2009, lack of adequate operative time and formal training were the main reasons cited by the surgeons for not offering laparoscopic colon resections. Owing to this lack of exposure to minimally invasive surgery, training programs are beginning to implement formal education in this type of surgery during residency. In one general surgery program where a one month intensive advanced training program in minimally invasive surgery was implemented, 70% of postgraduate residents who had undergone the training believed that it was essential to their current practice. One strategy that hospitals may consider in managing surgeons who cannot or choose not to acquire skills for performing minimally invasive surgery is to create a division of labor where patients who are not candidates for minimally invasive surgery are cared for by these surgeons. Increased standardization of competencies in minimally invasive surgery in surgical residency is needed to tackle wide variations in training.
Some patients who are candidates for minimally invasive surgery are not informed of an option before undergoing open surgery. Comprehensive shared decision making tools to properly inform patients about the options of minimally invasive and open surgery are needed. A Cochrane review of 86 studies on shared decision making showed that patients with decision aids have increased knowledge and more accurate risk perception and are more likely to choose less invasive options. In one study, the researchers found that among 201 patients with newly diagnosed clinical stage I or II breast cancer, those given a decision aid were more likely to chose breast conserving therapy over mastectomy. Furthermore, hospital utilization of laparoscopy is easily measured and should accompany publically reported surgical outcomes for a hospital to better inform patients. Transparency of hospital rates of minimally invasive surgery could create incentives for hospitals to achieve rates of minimally invasive surgery consistent with best practices and to optimize their surgical outcomes. Rates of minimally invasive surgery should be evaluated in the context of national benchmarks. Such transparency could increase the appropriate application of minimally invasive surgery to patient care and decrease variation through increased accountability. A 2012 study of utilization of percutaneous coronary intervention procedures found that public reporting was associated with a 5% reduction in procedures performed, with no difference in patient outcomes, suggesting the impact of public reporting to incentivize more appropriate care. We submit that a hospital’s propensity adjusted observed to predicted ratio of minimally invasive surgery be used as one additional quality measure in surgical care.
This study has some important limitations. Administrative claims data can have incomplete coding, particularly of pre-existing conditions. However, large series have shown optimal patient outcomes in high risk populations for minimally invasive appendectomy, colectomy, and hysterectomy. Additionally, the propensity score predictions are based on current practice and may not reflect the optimal utilization rate of minimally invasive surgery. Another limitation is the lack of information available in the database for physician factors, such as laparoscopic training and experience that may influence the choice of procedure. This study focused on hospital utilization of minimally invasive surgery, but further research is needed to determine the clinician level factors that influence utilization of minimally invasive surgery. Selection bias of patients is not accounted for and may detract from the observed difference in surgical complications.
Many hospitals in the United States have low utilization of minimally invasive surgery while many others have high utilization. Hospital utilization of minimally invasive surgery by procedure may be a meaningful process measure in healthcare to complement existing and maturing outcome measures of surgical care. Important ways to deal with this disparity may be more standardized postgraduate training, training of surgeons currently in practice, transparency of hospital rates of utilization of minimally invasive surgery, and better information for patients.
Discussion
Disparity in Quality
It has been well established that minimally invasive surgery is associated with lower complications and improved postoperative recovery. Despite these benefits, two standards of care remain in existence because patient candidacy and the choice of operations are often discretionary, based on surgeon preference. In the United States we found wide variation in the use of minimally invasive surgery by hospital after adjusting for differences in a hospital’s unique patient population. This study has important implications for quality improvement. Based on our findings, many hospitals have an opportunity to decrease surgical complications by increasing utilization of minimally invasive surgery.
Implications for Reduction in Surgical Site Infection
Surgical site infection, a leading quality indicator in healthcare, is one important quality metric that is noticeably decreased with use of minimally invasive surgery. Surgical site infections occur in 8-15% of open colorectal operations at an estimated cost of $1398 per patient secondary to prolonged hospitalization, wound care, and wound complications. In addition, the presence of a surgical site infection during a hospitalization is a leading risk factor for hospital readmission after colon surgery (odds ratio 1.18, 95% confidence interval 1.08 to 1.29). Hospitals have struggled to find innovative ways to decrease surgical site infections and there is a paucity of interventions with an established benefit beyond current practices. However, one intervention that is often overlooked is minimally invasive surgery. The decreased incision size associated with laparoscopy results in less subcutaneous dead space and thus a lower risk of bacterial contamination. A 2005 Cochrane review of 25 randomized controlled trials concluded that laparoscopic colectomy was associated with a 0.56 risk ratio of surgical site infections compared with open surgery. Similarly, a 2009 Cochrane review of 34 randomized controlled trials concluded that laparoscopic hysterectomy was associated with a 0.31 risk ratio of surgical site infections compared with open surgery. In our analysis using Agency for Healthcare Research and Quality patient safety indicators for surgical care, we noted fewer wound, infectious, thrombotic, pulmonary, and mortality complications associated with minimally invasive surgery. Based on our findings, increased hospital utilization of minimally invasive surgery at many US hospitals represents a tremendous opportunity to prevent surgical site infection events.
Hospital Factors
We found that rural hospitals were less likely to perform minimally invasive surgery for three of the four procedures studied (appendectomy, colectomy, and hysterectomy, the fourth being lobe lobectomy). This disparity may be due to the broad range of surgical services some surgeons in rural areas are required to provide and a scarcity of surgical specialists in such areas with advanced skills in minimally invasive surgery. Alternatively, the disparity may be a function of a lack of patient awareness about surgical options, decreased competition for patients, or a lack of minimally invasive surgery equipment, staff, or support in rural areas. Other hospital characteristics showed no association or an irregular pattern of association with utilization of minimally invasive surgery. For instance, large hospital size was not associated with use with the exception of hysterectomy carried out laparascopically. Teaching status was associated with high utilization of minimally invasive surgery for hysterectomy, low utilization for colectomy, and no association for appendectomy or lung lobectomy, indicating no pattern of association across procedure types. By geographic region, the north east was associated with low utilization of minimally invasive appendectomy, the south was associated with high utilization of minimally invasive appendectomy and colectomy, and the Midwest was associated with low utilization of minimally invasive lung lobectomy. Regional variations that we observed may be due to more extensive specialty specific training in minimally invasive surgery in some areas. Moreover, hospital and regional attitudes towards minimally invasive surgery may vary, with some areas having a more minimally invasive surgery culture and others a more open surgery culture.
Opportunities for Training
One reason that hospitals may be underperforming minimally invasive surgery is variability in appropriate training in residency and fellowship. Residents and fellows learn in an apprenticeship model, yet for many, the surgeons they learn from may lack advanced skills in minimally invasive surgery. In a survey of US obstetric and gynecology residency programs in 2006, only 69% had formal laparoscopy training. In a national survey of colorectal surgeons in 2009, lack of adequate operative time and formal training were the main reasons cited by the surgeons for not offering laparoscopic colon resections. Owing to this lack of exposure to minimally invasive surgery, training programs are beginning to implement formal education in this type of surgery during residency. In one general surgery program where a one month intensive advanced training program in minimally invasive surgery was implemented, 70% of postgraduate residents who had undergone the training believed that it was essential to their current practice. One strategy that hospitals may consider in managing surgeons who cannot or choose not to acquire skills for performing minimally invasive surgery is to create a division of labor where patients who are not candidates for minimally invasive surgery are cared for by these surgeons. Increased standardization of competencies in minimally invasive surgery in surgical residency is needed to tackle wide variations in training.
Implications for Transparency
Some patients who are candidates for minimally invasive surgery are not informed of an option before undergoing open surgery. Comprehensive shared decision making tools to properly inform patients about the options of minimally invasive and open surgery are needed. A Cochrane review of 86 studies on shared decision making showed that patients with decision aids have increased knowledge and more accurate risk perception and are more likely to choose less invasive options. In one study, the researchers found that among 201 patients with newly diagnosed clinical stage I or II breast cancer, those given a decision aid were more likely to chose breast conserving therapy over mastectomy. Furthermore, hospital utilization of laparoscopy is easily measured and should accompany publically reported surgical outcomes for a hospital to better inform patients. Transparency of hospital rates of minimally invasive surgery could create incentives for hospitals to achieve rates of minimally invasive surgery consistent with best practices and to optimize their surgical outcomes. Rates of minimally invasive surgery should be evaluated in the context of national benchmarks. Such transparency could increase the appropriate application of minimally invasive surgery to patient care and decrease variation through increased accountability. A 2012 study of utilization of percutaneous coronary intervention procedures found that public reporting was associated with a 5% reduction in procedures performed, with no difference in patient outcomes, suggesting the impact of public reporting to incentivize more appropriate care. We submit that a hospital’s propensity adjusted observed to predicted ratio of minimally invasive surgery be used as one additional quality measure in surgical care.
Limitations of This Study
This study has some important limitations. Administrative claims data can have incomplete coding, particularly of pre-existing conditions. However, large series have shown optimal patient outcomes in high risk populations for minimally invasive appendectomy, colectomy, and hysterectomy. Additionally, the propensity score predictions are based on current practice and may not reflect the optimal utilization rate of minimally invasive surgery. Another limitation is the lack of information available in the database for physician factors, such as laparoscopic training and experience that may influence the choice of procedure. This study focused on hospital utilization of minimally invasive surgery, but further research is needed to determine the clinician level factors that influence utilization of minimally invasive surgery. Selection bias of patients is not accounted for and may detract from the observed difference in surgical complications.
Conclusions
Many hospitals in the United States have low utilization of minimally invasive surgery while many others have high utilization. Hospital utilization of minimally invasive surgery by procedure may be a meaningful process measure in healthcare to complement existing and maturing outcome measures of surgical care. Important ways to deal with this disparity may be more standardized postgraduate training, training of surgeons currently in practice, transparency of hospital rates of utilization of minimally invasive surgery, and better information for patients.
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