MINIMALLY INVASIVE PROCTECTOMY: THE ROBOTIC APPROACH IS ASSOCIATED WITH HIGHER AGGREGATE COSTS OF CARE
Emanuel Eguia*1, Patrick Sweigert1, Majid Afshar1, Joshua Eberhardt1, Marc Singer1, PAUL KUO2, Marshall S. Baker1
1Surgery, Loyola University Medical Center, Maywood, IL; 2Surgery, University of Southern Florida, Tampa, FL
BACKGROUND
The use of robotic-assisted surgery for patients undergoing proctectomy is becoming more common. Few studies compare clinical outcomes and costs for robotic proctectomy to those for the open and laparoscopic approaches to proctectomy.
METHODS
We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective low anterior resection (LAR) and abdominal perineal resection (APR) in FL, IA, MA, WI, MD, NY, and WA between 2013 and 2014. Multivariable regression (MVR) was used to evaluate the association between surgical approach (open proctectomy (OAP) vs. laparoscopic (LAP) vs. robotic-assisted (RAP)) and rates of postoperative complication, overall lengths of stay (LOS) and aggregate costs of care including all readmissions to 90 days following the index procedure. Candidate variables were determined a priori using best variable subsets and included: age, gender, insurance, race, Charlson comorbidity index (CCI), LOS, and hospital volume broken to terciles (low: <73 colectomy/year; moderate: 73-155 colectomy/year; high volume: 155 colectomy/year).
RESULTS
3,187 patients underwent elective proctectomy; 2,207 (69%) underwent LAR, and 980 (31%) underwent APR. 533 (17%) underwent RAP, 480 (15%) LAP, and 2,174 (68%) OAP.
On univariate analysis, patients undergoing RAP were more likely to be privately insured (53% vs. 36% vs. 41%; p<.01) and to undergo a proximal diversion during an LAR than those undergoing either an LAP or OAP (32% vs. 5% vs. 12%; p<.01). Patients undergoing RAP and LAP had statistically shorter LOS than patients undergoing OAP (6 days vs. 6 days vs. 7 days; p<.01) but patients undergoing RAP had higher aggregate costs of care than those undergoing either LAP or OAP ($27,000 vs. $25,000 vs. $24,000; p<.01). There were no statistical differences between cohorts in age, CCI or gender.
On MVR adjusting for age, gender, comorbidity, hospital volume, insurance status and whether or not patients underwent concomitant proximal diversion during an LAR, there were no significant differences between treatment cohorts in rates of postoperative complication (PE, MI, UTI, DVT, Wound Infection, Pneumonia, Other Sepsis or Renal Failure), rates of readmission, LOS and postoperative mortality. When evaluating adjusted aggregate costs of care including readmissions to 90 days and adjusting for hospital volume, aggregate costs were, however, consistently higher for patients undergoing RAP relative to those undergoing either LAP or OAP (Table 1).
CONCLUSION
Postoperative clinical outcomes for RAP are statistically identical to those for LAP and OAP, but the aggregate costs associated with RAP are significantly higher independent of hospital volume. These findings suggest the LAP provides postoperative clinical results comparable to RAP but is a more cost-effective approach to proctectomy.
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