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Attitudes and Beliefs Regarding the Utility of Robotically Assisted Gynecologic Surgery Among Practicing Gynecologists Jason D. Wright, Greta B. Raglan, Jay Schulkin, Michael F. Fialkow
Introduction Robotically assisted surgery is now widely used for a variety of procedures (Barbash and Glied, 2010). The technology relies on a surgical robot that allows an operating surgeon to manipulate minimally invasive instrumentation through a remote consul (Maeso et al., 2010). While initially developed for prostatectomy, the technology is now often used for the performance of gynecologic procedures including hysterectomy (Paraiso et al., 2011; Rosero et al., 2013; Wright et al., 2013a; Wright et al., 2012, 2014). Despite the availability of robotically assisted surgery, the appropriate use of the technology remains controversial (Steege and Einarsson, 2014; Weissman and Zinner, 2013; Rardin, 2014). Proponents of robotic-assisted surgery suggest that the technology facilitates access to minimally invasive surgery, allows completion of more technically challenging procedures by a minimally invasive approach, and enhances surgeon ergonomics (Rardin, 2014; Wright et al., 2013). In contrast, previous work has largely been unable to demonstrate improved patient outcomes with robotic-assisted surgery, and many studies have found that the technology is associated with substantially greater costs than laparoscopy (Rosero et al., 2013; Wright et al., 2012; Wright et al., 2013a; Wright et al., 2014; Liu et al., 2012; Woelk et al., 2013; Paraiso et al., 2013; Sarlos et al., 2010; Sarlos et al., 2012). Furthermore, several studies have suggested that marketing, often not based on data, of roboticassisted surgery is prominent (Jin et al., 2011; Schiavone et al., 2012). Given the controversy surrounding the appropriate use of robotic-assisted surgery
Abstract: While use of robotic-assisted surgery has increased rapidly, little is known about the attitudes and beliefs of practicing gynecologists regarding the utility of the technology. We surveyed a large sample of gynecologists to examine their attitudes and beliefs about the benefits, utility, and factors driving use of robotic-assisted gynecologic surgery. A 51item survey was mailed to 600 fellows or junior fellows of the American College of Obstetricians and Gynecologists. The survey included questions on use of robotic surgery, decisionmaking, and beliefs regarding the technology. Responses were stratified based on whether the respondent used robotic surgery or not. A total of 310 responses were received including 27.8% who used robotic surgery in their practices. Hysterectomy was the most commonly performed procedure. Opinions about the use and effectiveness of robotic procedures varied based on whether an individual was a robot user. Eighty-two percentage of robot users and 21% of nonrobot users believed robotic surgery provided benefits over laparoscopic (p , .0001). Among both groups, the ability to increase access to minimally invasive surgery and marketing were believed to be the greatest drivers of use of robotic surgery. Attitudes and beliefs about the effectiveness of robotic gynecologic surgery are highly variable among clinicians.
in gynecology, we sought to examine the attitudes of obstetricians and gynecologists (OB/GYNS) toward the technology. Specifically, we surveyed a large sample of practicing (OB/GYNS) to determine their patterns of use, preferences, and attitudes toward robotically assisted gynecologic surgery.
Keywords robotic procedures obstetrics and gynecology minimally invasive surgery
Methods A mailing including a cover letter, survey, and prepaid return envelope was sent to 600 Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists (the College). Participants
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were members of the Collaborative Ambulatory Research Network (CARN), a group of fellows who voluntarily participate in four to six surveys annually without compensation. Those who did not respond were sent up to three reminder mailings. This study was approved by the Institutional Review Board at Indiana University. Participants completed a 6-page questionnaire with 51-items, which covered a range of topics including: robotic procedures, decision-making under uncertainty, consultation and preferred interventions for periviable patients, work experiences, and demographics. Robotic questions asked whether physicians perform robotic surgery, about their experiences using robotics, and their institutional practices regarding robotic surgery. Items pertaining to other topics are reported elsewhere. Demographic questions asked about participants’ age, sex, race, medical specialty and subspecialty, number of years out of residency, practice setting, and location. Practice state was also collected to enable the assessment of geographic practice variation. Survey items were pretested on OB/GYN physicians at Indiana University Hospital. The data were analyzed using a personal computer-based software package (Stata/ SE 10.0 for MAC. StataCorp LP College Station, Texas). Group differences in responses on continuous measures were assessed with student’s t test analyses. Group differences on categorical measures were assessed with x2 tests. A p value of ,.05 was considered statistically significant.
Results Three hundred ten College members responded to the survey for a total response rate of 51.7%. Respondents with practices not involving gynecologic surgery, such as maternal fetal medicine specialists, were excluded leaving 263 respondents for analysis. Among respondents, 27.8% reported using the surgical robot in their practices. Nonrobot users tended to be older and have been in practice longer than those
who use the robot. Nonusers were also more likely to be general gynecologists. Table 1 outlines other demographic characteristics of the respondents. There was no association between either practice type or practice location and use of the surgical robot. Of those who perform robotic surgery, the largest proportion (57.1%) began using the robot between 2009 and 2011, and 91.8% underwent training with the manufacturer. All respondents who use the robot perform robotic hysterectomies, with decreasing proportions performing adnexal surgery (88.6%), myomectomy (74.3%), and colpopexy (22.9%). Forty percent of respondents perform fewer than a quarter of their cases robotically, and nearly 67.1% use the robot for less than half of their cases. Only 12.9% of practitioners perform greater than 75% of their cases using the robot. Only one respondent reported performing more than 10 robotic procedures per month. Most respondents (85.7%) perform five or fewer robotic cases per month, and the remainder performs 10 or fewer. Most respondents who use the robot (68.6%) believe they are doing more minimally invasive surgery because of the robot, and the same percentage believe that it does not take longer than traditional laparoscopy. The majority (94.3%) believe that fewer than 10% of their cases require conversion to open, and 61.4% believe that robot surgery does take longer than open surgery. Opinions about the use and effectiveness of robotic procedures varied based on whether an individual was a robot user or a nonuser (Table 2). Eighty-two percentage of robot users and 21% of nonrobot users believed robotic surgery provided benefits over laparoscopic (p , .0001). A high percentage of both groups believed robotic surgery offered benefits over laparotomy. When asked the most important factor driving demand for robotic surgery, robot users reported the ability to increase use of minimally invasive surgery (56%) and marketing (22%); nonrobot users described marketing (64%) and ability to increase minimally invasive
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Table 1. Respondent Demographics Respondents Mean age (SD) Sex (% female) Mean years in practice (SD) Race White/caucasian Black/African Am Hispanic/Latino Asian/Pacific Isl Other/more than one Primary medical specialty Generalist Gynecology only Other Practice setting Solo practice Obstetrics/Gynecology group Multispecialty Health Maintenence Organization (HMO) University Other Practice location Urban/inner city Urban/noninner city Suburban Town 5–50K Rural ,5,000 Other *
Overall
Robot Users
Nonusers
n = 262 53.7 (8.9) 52.6% 21.8 (9.3)
n = 73 49.7 (7.5) 56.2% 18.1 (7.7)
n = 189 55.2 (8.9) 51.3% 23.4 (9.5)
88.4% 4.1% 3.4% 4.1% 2.6%
84.7% 8.3% 2.8% 4.2% 2.8%
89.9% 2.7% 3.7% 3.7% 2.7%
77.3% 16.7% 5.9%
71.2% 15.1% 13.7%
80.1% 15.8% 4.1%
16.% 47.6% 15.2% 3.7%
9.6% 58.9% 12.3% 2.7%
19.4% 43.4% 16.3% 4.1%
10.0% 6.7%
12.3% 4.1%
9.2% 7.7%
16.5% 29.0% 34.6% 17.3% 1.5% 1.1%
18.1% 27.8% 36.1% 15.3% 1.4% 1.4%
16.0% 129.4% 34.0% 18.0% 1.6% 1.0%
p ,.001* .56 ,.001* .243
,.001*
.173
.987
p , .01.
surgery (25%) (p , .0001). Among robot users, 41% reported that they would still use the surgical robot if outcomes were similar to laparoscopy but robotic surgery was more expensive. When asked if changes in reimbursement policy would change practice patterns, we found that 23.3% of robotic surgery users would switch to laparoscopy if reimbursement was reduced by 10%–20% and 40.8% would use laparoscopy if reimbursement for a robotic procedure declined by 20%–35%. Among robot nonusers, the corresponding numbers were 63.6% and 64.9%, respectively. Many robot users (45.8%) and most nonusers (80.4%) believed robotic surgery took longer than
laparoscopy, whereas a majority of both groups thought robotic surgery took longer than laparotomy.
Discussion Our findings suggest that attitudes and beliefs about the effectiveness of robotic gynecologic surgery are highly variable among practicing gynecologists. Not surprisingly, the most important factor associated with these attitudes is whether the physician uses robotic surgery; gynecologists who use robotic surgical technology have much more favorable attitudes toward the procedures than gynecologists who do not perform robotic surgery.
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Table 2. Opinions of Robot Users Versus Nonusers Survey Question Content Percentage of procedures performed laparoscopically? ,25% 25-50% 51-75% .75% N/A Believe robotic assistance provides benefit over laparoscopy? Yes No Uncertain Believe robotic assistance provides benefit over laparotomy? Yes No Uncertain What is the most important factor driving use of robotic surgery? Patient demand Marketing Improved outcomes compared to other modalities Increased ability to use minimally invasive surgery Hospital demand If outcomes of laparoscopy and robotic surgery were similar but robotics was more expensive would you perform a procedure robotically? Yes No If reimbursement for a robotic procedure was 10%–20% less than for a laparoscopic procedure would you be more likely to perform the procedure laparoscopically? Yes No If reimbursement for a robotic procedure was 20%–35% less than for a laparoscopic procedure would you be more likely to perform the procedure laparoscopically? Yes No Has marketing influenced your decision to perform procedures robotically? Yes No
Robot Users (n = 73)
Nonusers (n = 189)
p .005*
13.9% 16.7% 22.2% 47.2% 0%
20.9% 20.9% 23.0% 26.7% 8.6%
82.2% 11.0% 6.9%
21.0% 45.2% 33.9%
5.96% 2.7% 1.4%
73.1% 11.8% 14.5%
8.3% 22.2% 12.5%
5.1% 63.8% 22.3%
55.6%
24.9%
1.4%
4.0%
40.9% 59.1%
4.7% 95.3%
23.3% 76.7%
63.6% 36.4%
,.001*
,.001*
,.001*
,.001*
,.001*
.001*
40.8% 59.2%
64.9% 35.1%
24.7% 75.3%
8.0% 92.0%
,.001*
(Continued)
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Table 2. (Continued) Survey Question Content
Robot Users (n = 73)
Do you believe a robotic procedure generally takes longer to perform than a similar procedure performed laparoscopically? Yes No Uncertain Do you believe a robotic procedure generally takes longer to perform than a similar procedure performed by laparotomy? Yes No Uncertain Is there a robotics team in the Operating Room at your institution? Yes No Is there a robotics expert at your facility? Yes No Do you expect graduates of residency programs to have proficiency in robotic surgery? Yes No Would a graduate of a residency program with competence in robotic surgery be more appealing for your practice? Yes No *
Nonusers (n = 189)
,.001*
45.8% 45.8% 8.4%
80.4% 6.0% 13.6%
64.4% 31.5% 4.1%
78.0% 8.8% 13.2%
94.5% 5.5%
66.5% 33.5%
66.7% 33.3%
58.2% 41.8%
,.001*
,.001*
.175
.065
51.4% 48.6%
38.7% 61.3%
61.6% 38.4%
33.7% 66.3%
p , .01.
Despite the rapid uptake of robotic surgery, previous studies have often been unable to demonstrate improved effectiveness for the procedures compared with laparoscopy. Two recent prospective trials comparing laparoscopic and roboticassisted hysterectomy for benign gynecologic disease both noted that perioperative outcomes and morbidity were similar for the two modalities; however, operative times were significantly longer for the robotic-assisted procedures (Paraiso et al., 2013; Sarlos et al., 2012). Similarly, an observational study that compared outcomes at hospitals throughout the United States found that morbidity and mortality were similar for the two operations, whereas
p
the cost of robotic-assisted hysterectomy was substantially greater (Wright et al., 2013a). Although these data question the efficacy of robotic-assisted gynecologic surgery, more than 80% of respondents to our survey who used robotic surgery reported that they believed the procedures provided clinical benefit over laparoscopy. Among gynecologists who did not use robotic surgery, only 21% believed that robotic-assisted surgery was beneficial compared to laparoscopy. Almost all survey participants believed that robotic-assisted surgery provided benefits compared to laparotomy. The ability of robotic surgery to increase use of minimally invasive surgical options has been suggested as a major
,.001*
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benefit for the technology. In gynecology, although laparoscopic hysterectomy has been used since the 1990s, uptake was slow. A recent population-based analysis demonstrated that uptake of robotic surgery since 2006 has been rapid and may have allowed women who would otherwise have required laparotomy to undergo a minimally invasive procedure (Wright et al., 2013a). Of note, at hospitals that did not perform robotic surgery, this study found an increase in the use of laparoscopy (Wright et al., 2013). Among practitioners in our survey, we noted that more than 50% of those who performed robotically assisted surgery believed that the technology afforded the opportunity for more women to undergo minimally invasive surgery. Marketing of robotic assisted surgery to patients, physicians, and hospitals has been pervasive (Jin et al., 2011; Schiavone et al., 2012). This marketing has come not only from industry but also from physicians and hospitals (Jin et al., 2011; Schiavone et al., 2012). A recent review of hospital Web sites noted that marketing of robotically assisted gynecologic surgery was widespread (Schiavone et al., 2012). Furthermore, many of the Web sites used stock images and texts from the manufacturer, whereas few sites described undesirable attributes of robotic surgery, and many of the claims made were not based on data (Schiavone et al., 2012). The current data suggest that many physicians believe that marketing is the most important driver of use of robotic surgery. In our cohort, nearly two-thirds of nonrobot users responded that marketing was the most important factor driving use of robotic surgery, whereas over one-fifth of robot users responded similarly. A major concern surrounding the rapid dissemination of robotic surgery stems from the high costs associated with many procedures. An analysis of more than 20 types of procedures noted that roboticassisted operations were on average 13% more expensive than nonrobotic alternatives (Babash and Glied, 2010). Similar findings have been found in gynecology. An analysis of robotically assisted hysterectomy for benign gynecologic diseases,
for instance, found that robotic-assisted hysterectomy was over $2,000 more costly than either open or laparoscopic alternatives (Wright et al., 2013a). Similar findings have been noted for robotically assisted hysterectomy for endometrial cancer (Wright et al., 2012). Of greater concern is that even after surgeons gain technical proficiency and hospitals have performed a high number of procedures, the cost of robotic-assisted gynecologic surgery remains higher (Wright et al., 2014). Among respondents to our survey, nonusers of the surgical robot overwhelmingly responded that they would not use the technology if it was more costly but no more effective than other surgical approaches. Interestingly, among users of robotic surgery, 59% stated that they would not use robotic surgery if it was more costly but did not improve outcomes. Given the cost concerns for roboticassisted surgery, some proposals have called for restructuring the reimbursement system for unproven interventions (Pearson and Bach, 2010). In essence, these initiatives either reduce physician or hospital reimbursement or pass costs to patients when a more costly procedure without increased effectiveness is used in lieu of a lower cost alternative. Among robotic gynecologic surgeons, we noted that 23% of physicians would perform a procedure laparoscopically instead of using robotic-assistance if reimbursement were reduced by 10-20%. Similarly, 41% of respondents would perform the operation laparoscopically if reimbursement were lowered by 20%–35%. These findings suggest that alternative reimbursement strategies may be a way to promote cost savings for gynecologic surgery. Furthermore, these data are helpful for organizations to understand factors influencing physician use of robotic technology. We recognize a number of important limitations. Although our survey was associated with a relatively high response rate from a range of general gynecologists and subspecialists, these data may not be representative of all gynecologists in the United States. The College has, however, previously undertaken a number of similar
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research surveys, and these studies include representative clinicians from across the country (England et al., 2014; Raglan et al., 2014; Wright et al., 2013b). Regardless, this instrument provides a framework for further studies to examine physician attitudes associated with novel technologies and surgical innovation. Second, our study may be underpowered to detect differences in attitudes and practice patterns. There was little a priori data describing how pelvic surgeons perceived robotic-assisted surgery and thus our data were meant to be descriptive and hypothesis generating. Third, our data are based on self-report, and we are unable to confirm actual use and volume of use of robotic surgery. Finally, we attempted to include questions directed at discerning attitudes toward commonly cited drivers of robotic surgery. Undoubtedly, other patient, physician, and systems factors influence the choice to offer and use robotically assisted gynecologic surgery. In conclusion, our findings suggest that beliefs and attitudes regarding the utility and effectiveness of robotic-assisted gynecologic surgery are highly variable. Practitioners who do not use the technology are more skeptical of the benefits of the procedures, particularly when compared to laparoscopy. Further work to explore whether and how physician attitudes influence outcomes and large-scale studies to define the role of robotically assisted surgery in gynecology would be beneficial.
Acknowledgments This article was supported by Grant no. UA6MC19010 from the Maternal and Child Health Bureau (Title V, Social Security Act, Health Resources and Services Administration, and Department of Health and Human Services [DHHS]). The authors would like to thank Jason Dana for his contributions to this project.
References Barbash, G.I., & Glied, S.A. New technology and health care costs—the case of robot-assisted surgery. New Engl J Med 2010;363:701–704.
England, L.J., Anderson, B.L., & Tong, V.T., et al. Screening practices and attitudes of obstetrician-gynecologists toward new and emerging tobacco products. Am J Obstet Gynecol 2014;211:695.e1–7. Jin, L.X., Ibrahim, A.M., & Newman, N.A., et al. Robotic surgery claims on United States hospital websites. J Healthc Qual 2011;33: 48–52. Liu, H., Lu, D., & Wang, L., et al. Robotics surgery for benign gynaecological disease. Cochrane Database Syst Rev 2012. published online. doi: 10.1002/14651858.CD008978. pub2. Maeso, S., Reza, M., & Mayo, J.A., et al. Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis. Ann Surg 2010;252:254–262. Paraiso, M.F., Jelovsek, J.E., & Frick, A., et al. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol 2011;118: 1005–1013. Paraiso, M.F., Ridgeway, B., & Park, A.J., et al. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. Am J Obstet Gynecol 2013;208:368.e1–e7. Pearson, S.D., & Bach, P.B. How Medicare could use comparative effectiveness research in deciding on new coverage and reimbursement. Health Aff (Millwood) 2010; 29:1796–1804. Raglan, G.B., Margolis, B., Paulus, R.A., & Schulkin, J. Electronic health record adoption among Obstetrician/Gynecologists in the United States: physician practices and satisfaction. J Healthc Qual 2014. epub ahead of print. doi:10.1111/jhq.12072. Rardin, C.R. The debate over robotics in benign gynecology. Am J Obstet Gynecol 2014;210: 418–422. Rosero, E.B., Kho, K.A., & Joshi, G.P., et al. Comparison of robotic and laparoscopic hysterectomy for benign gynecologic disease. Obstet Gynecol 2013;122:778–786. Sarlos, D., Kots, L., Stevanovic, N., & Schaer, G. Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and and cost analyses of a matched case-control study. Eur J Obstet Gynecol Reprod Biol 2010;150:92–96. Sarlos, D., Kots, L., & Stevanovic, N., et al. Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol 2012;120:601–611. Schiavone, M.B., Kuo, E.C., & Naumann, R.W., et al. The commercialization of robotic surgery: unsubstantiated marketing of gynecologic surgery by hospitals. Am J Obstet Gynecol 2012;207:174.e1–7. Steege, J.F., & Einarsson, J.I. Robotics in benign gynecologic surgery: where should we go? Obstet Gynecol 2014;123:1–2.
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Weissman, J.S., & Zinner, M. Comparative effectiveness research on robotic surgery. J Am Med Assoc 2013;309:721–722. Woelk, J.L., Casiano, E.R., & Weaver, A.L., et al. The learning curve of robotic hysterectomy. Obstet Gynecol 2013;121:87–95. Wright, J.D., Burke, W.M., & Wilde, E.T., et al. Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer. J Clin Oncol 2012;30:783–791. Wright, J.D., Ananth, C.V., & Lewin, S.N., et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. J Am Med Assoc 2013a;309:689–698.
Wright, J.D., Silver, R.M., & Bonanno, C., et al. Practice patterns and knowledge of obstetricians and gynecologists regarding placenta accrete. J Maternal Fetal Neonatal Med 2013b;26:1602–1609. Wright, J.D., Ananth, C.V., & Tergas, A.I., et al. An economic analysis of robotically assisted hysterectomy. Obstet Gynecol 2014;123: 1038–1048. The authors declare no conflict of interest. For more information on this article, contact Jason D. Wright at [email protected].
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Attitudes and Beliefs Regarding the Utility of Robotically Assisted Gynecologic Surgery Among Practicing Gynecologists Jason D. Wright, Greta B. Raglan, Jay Schulkin, Michael F. Fialkow
Introduction Robotically assisted surgery is now widely used for a variety of procedures (Barbash and Glied, 2010). The technology relies on a surgical robot that allows an operating surgeon to manipulate minimally invasive instrumentation through a remote consul (Maeso et al., 2010). While initially developed for prostatectomy, the technology is now often used for the performance of gynecologic procedures including hysterectomy (Paraiso et al., 2011; Rosero et al., 2013; Wright et al., 2013a; Wright et al., 2012, 2014). Despite the availability of robotically assisted surgery, the appropriate use of the technology remains controversial (Steege and Einarsson, 2014; Weissman and Zinner, 2013; Rardin, 2014). Proponents of robotic-assisted surgery suggest that the technology facilitates access to minimally invasive surgery, allows completion of more technically challenging procedures by a minimally invasive approach, and enhances surgeon ergonomics (Rardin, 2014; Wright et al., 2013). In contrast, previous work has largely been unable to demonstrate improved patient outcomes with robotic-assisted surgery, and many studies have found that the technology is associated with substantially greater costs than laparoscopy (Rosero et al., 2013; Wright et al., 2012; Wright et al., 2013a; Wright et al., 2014; Liu et al., 2012; Woelk et al., 2013; Paraiso et al., 2013; Sarlos et al., 2010; Sarlos et al., 2012). Furthermore, several studies have suggested that marketing, often not based on data, of roboticassisted surgery is prominent (Jin et al., 2011; Schiavone et al., 2012). Given the controversy surrounding the appropriate use of robotic-assisted surgery
Abstract: While use of robotic-assisted surgery has increased rapidly, little is known about the attitudes and beliefs of practicing gynecologists regarding the utility of the technology. We surveyed a large sample of gynecologists to examine their attitudes and beliefs about the benefits, utility, and factors driving use of robotic-assisted gynecologic surgery. A 51item survey was mailed to 600 fellows or junior fellows of the American College of Obstetricians and Gynecologists. The survey included questions on use of robotic surgery, decisionmaking, and beliefs regarding the technology. Responses were stratified based on whether the respondent used robotic surgery or not. A total of 310 responses were received including 27.8% who used robotic surgery in their practices. Hysterectomy was the most commonly performed procedure. Opinions about the use and effectiveness of robotic procedures varied based on whether an individual was a robot user. Eighty-two percentage of robot users and 21% of nonrobot users believed robotic surgery provided benefits over laparoscopic (p , .0001). Among both groups, the ability to increase access to minimally invasive surgery and marketing were believed to be the greatest drivers of use of robotic surgery. Attitudes and beliefs about the effectiveness of robotic gynecologic surgery are highly variable among clinicians.
in gynecology, we sought to examine the attitudes of obstetricians and gynecologists (OB/GYNS) toward the technology. Specifically, we surveyed a large sample of practicing (OB/GYNS) to determine their patterns of use, preferences, and attitudes toward robotically assisted gynecologic surgery.
Keywords robotic procedures obstetrics and gynecology minimally invasive surgery
Methods A mailing including a cover letter, survey, and prepaid return envelope was sent to 600 Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists (the College). Participants
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were members of the Collaborative Ambulatory Research Network (CARN), a group of fellows who voluntarily participate in four to six surveys annually without compensation. Those who did not respond were sent up to three reminder mailings. This study was approved by the Institutional Review Board at Indiana University. Participants completed a 6-page questionnaire with 51-items, which covered a range of topics including: robotic procedures, decision-making under uncertainty, consultation and preferred interventions for periviable patients, work experiences, and demographics. Robotic questions asked whether physicians perform robotic surgery, about their experiences using robotics, and their institutional practices regarding robotic surgery. Items pertaining to other topics are reported elsewhere. Demographic questions asked about participants’ age, sex, race, medical specialty and subspecialty, number of years out of residency, practice setting, and location. Practice state was also collected to enable the assessment of geographic practice variation. Survey items were pretested on OB/GYN physicians at Indiana University Hospital. The data were analyzed using a personal computer-based software package (Stata/ SE 10.0 for MAC. StataCorp LP College Station, Texas). Group differences in responses on continuous measures were assessed with student’s t test analyses. Group differences on categorical measures were assessed with x2 tests. A p value of ,.05 was considered statistically significant.
Results Three hundred ten College members responded to the survey for a total response rate of 51.7%. Respondents with practices not involving gynecologic surgery, such as maternal fetal medicine specialists, were excluded leaving 263 respondents for analysis. Among respondents, 27.8% reported using the surgical robot in their practices. Nonrobot users tended to be older and have been in practice longer than those
who use the robot. Nonusers were also more likely to be general gynecologists. Table 1 outlines other demographic characteristics of the respondents. There was no association between either practice type or practice location and use of the surgical robot. Of those who perform robotic surgery, the largest proportion (57.1%) began using the robot between 2009 and 2011, and 91.8% underwent training with the manufacturer. All respondents who use the robot perform robotic hysterectomies, with decreasing proportions performing adnexal surgery (88.6%), myomectomy (74.3%), and colpopexy (22.9%). Forty percent of respondents perform fewer than a quarter of their cases robotically, and nearly 67.1% use the robot for less than half of their cases. Only 12.9% of practitioners perform greater than 75% of their cases using the robot. Only one respondent reported performing more than 10 robotic procedures per month. Most respondents (85.7%) perform five or fewer robotic cases per month, and the remainder performs 10 or fewer. Most respondents who use the robot (68.6%) believe they are doing more minimally invasive surgery because of the robot, and the same percentage believe that it does not take longer than traditional laparoscopy. The majority (94.3%) believe that fewer than 10% of their cases require conversion to open, and 61.4% believe that robot surgery does take longer than open surgery. Opinions about the use and effectiveness of robotic procedures varied based on whether an individual was a robot user or a nonuser (Table 2). Eighty-two percentage of robot users and 21% of nonrobot users believed robotic surgery provided benefits over laparoscopic (p , .0001). A high percentage of both groups believed robotic surgery offered benefits over laparotomy. When asked the most important factor driving demand for robotic surgery, robot users reported the ability to increase use of minimally invasive surgery (56%) and marketing (22%); nonrobot users described marketing (64%) and ability to increase minimally invasive
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Table 1. Respondent Demographics Respondents Mean age (SD) Sex (% female) Mean years in practice (SD) Race White/caucasian Black/African Am Hispanic/Latino Asian/Pacific Isl Other/more than one Primary medical specialty Generalist Gynecology only Other Practice setting Solo practice Obstetrics/Gynecology group Multispecialty Health Maintenence Organization (HMO) University Other Practice location Urban/inner city Urban/noninner city Suburban Town 5–50K Rural ,5,000 Other *
Overall
Robot Users
Nonusers
n = 262 53.7 (8.9) 52.6% 21.8 (9.3)
n = 73 49.7 (7.5) 56.2% 18.1 (7.7)
n = 189 55.2 (8.9) 51.3% 23.4 (9.5)
88.4% 4.1% 3.4% 4.1% 2.6%
84.7% 8.3% 2.8% 4.2% 2.8%
89.9% 2.7% 3.7% 3.7% 2.7%
77.3% 16.7% 5.9%
71.2% 15.1% 13.7%
80.1% 15.8% 4.1%
16.% 47.6% 15.2% 3.7%
9.6% 58.9% 12.3% 2.7%
19.4% 43.4% 16.3% 4.1%
10.0% 6.7%
12.3% 4.1%
9.2% 7.7%
16.5% 29.0% 34.6% 17.3% 1.5% 1.1%
18.1% 27.8% 36.1% 15.3% 1.4% 1.4%
16.0% 129.4% 34.0% 18.0% 1.6% 1.0%
p ,.001* .56 ,.001* .243
,.001*
.173
.987
p , .01.
surgery (25%) (p , .0001). Among robot users, 41% reported that they would still use the surgical robot if outcomes were similar to laparoscopy but robotic surgery was more expensive. When asked if changes in reimbursement policy would change practice patterns, we found that 23.3% of robotic surgery users would switch to laparoscopy if reimbursement was reduced by 10%–20% and 40.8% would use laparoscopy if reimbursement for a robotic procedure declined by 20%–35%. Among robot nonusers, the corresponding numbers were 63.6% and 64.9%, respectively. Many robot users (45.8%) and most nonusers (80.4%) believed robotic surgery took longer than
laparoscopy, whereas a majority of both groups thought robotic surgery took longer than laparotomy.
Discussion Our findings suggest that attitudes and beliefs about the effectiveness of robotic gynecologic surgery are highly variable among practicing gynecologists. Not surprisingly, the most important factor associated with these attitudes is whether the physician uses robotic surgery; gynecologists who use robotic surgical technology have much more favorable attitudes toward the procedures than gynecologists who do not perform robotic surgery.
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Table 2. Opinions of Robot Users Versus Nonusers Survey Question Content Percentage of procedures performed laparoscopically? ,25% 25-50% 51-75% .75% N/A Believe robotic assistance provides benefit over laparoscopy? Yes No Uncertain Believe robotic assistance provides benefit over laparotomy? Yes No Uncertain What is the most important factor driving use of robotic surgery? Patient demand Marketing Improved outcomes compared to other modalities Increased ability to use minimally invasive surgery Hospital demand If outcomes of laparoscopy and robotic surgery were similar but robotics was more expensive would you perform a procedure robotically? Yes No If reimbursement for a robotic procedure was 10%–20% less than for a laparoscopic procedure would you be more likely to perform the procedure laparoscopically? Yes No If reimbursement for a robotic procedure was 20%–35% less than for a laparoscopic procedure would you be more likely to perform the procedure laparoscopically? Yes No Has marketing influenced your decision to perform procedures robotically? Yes No
Robot Users (n = 73)
Nonusers (n = 189)
p .005*
13.9% 16.7% 22.2% 47.2% 0%
20.9% 20.9% 23.0% 26.7% 8.6%
82.2% 11.0% 6.9%
21.0% 45.2% 33.9%
5.96% 2.7% 1.4%
73.1% 11.8% 14.5%
8.3% 22.2% 12.5%
5.1% 63.8% 22.3%
55.6%
24.9%
1.4%
4.0%
40.9% 59.1%
4.7% 95.3%
23.3% 76.7%
63.6% 36.4%
,.001*
,.001*
,.001*
,.001*
,.001*
.001*
40.8% 59.2%
64.9% 35.1%
24.7% 75.3%
8.0% 92.0%
,.001*
(Continued)
5
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Table 2. (Continued) Survey Question Content
Robot Users (n = 73)
Do you believe a robotic procedure generally takes longer to perform than a similar procedure performed laparoscopically? Yes No Uncertain Do you believe a robotic procedure generally takes longer to perform than a similar procedure performed by laparotomy? Yes No Uncertain Is there a robotics team in the Operating Room at your institution? Yes No Is there a robotics expert at your facility? Yes No Do you expect graduates of residency programs to have proficiency in robotic surgery? Yes No Would a graduate of a residency program with competence in robotic surgery be more appealing for your practice? Yes No *
Nonusers (n = 189)
,.001*
45.8% 45.8% 8.4%
80.4% 6.0% 13.6%
64.4% 31.5% 4.1%
78.0% 8.8% 13.2%
94.5% 5.5%
66.5% 33.5%
66.7% 33.3%
58.2% 41.8%
,.001*
,.001*
.175
.065
51.4% 48.6%
38.7% 61.3%
61.6% 38.4%
33.7% 66.3%
p , .01.
Despite the rapid uptake of robotic surgery, previous studies have often been unable to demonstrate improved effectiveness for the procedures compared with laparoscopy. Two recent prospective trials comparing laparoscopic and roboticassisted hysterectomy for benign gynecologic disease both noted that perioperative outcomes and morbidity were similar for the two modalities; however, operative times were significantly longer for the robotic-assisted procedures (Paraiso et al., 2013; Sarlos et al., 2012). Similarly, an observational study that compared outcomes at hospitals throughout the United States found that morbidity and mortality were similar for the two operations, whereas
p
the cost of robotic-assisted hysterectomy was substantially greater (Wright et al., 2013a). Although these data question the efficacy of robotic-assisted gynecologic surgery, more than 80% of respondents to our survey who used robotic surgery reported that they believed the procedures provided clinical benefit over laparoscopy. Among gynecologists who did not use robotic surgery, only 21% believed that robotic-assisted surgery was beneficial compared to laparoscopy. Almost all survey participants believed that robotic-assisted surgery provided benefits compared to laparotomy. The ability of robotic surgery to increase use of minimally invasive surgical options has been suggested as a major
,.001*
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benefit for the technology. In gynecology, although laparoscopic hysterectomy has been used since the 1990s, uptake was slow. A recent population-based analysis demonstrated that uptake of robotic surgery since 2006 has been rapid and may have allowed women who would otherwise have required laparotomy to undergo a minimally invasive procedure (Wright et al., 2013a). Of note, at hospitals that did not perform robotic surgery, this study found an increase in the use of laparoscopy (Wright et al., 2013). Among practitioners in our survey, we noted that more than 50% of those who performed robotically assisted surgery believed that the technology afforded the opportunity for more women to undergo minimally invasive surgery. Marketing of robotic assisted surgery to patients, physicians, and hospitals has been pervasive (Jin et al., 2011; Schiavone et al., 2012). This marketing has come not only from industry but also from physicians and hospitals (Jin et al., 2011; Schiavone et al., 2012). A recent review of hospital Web sites noted that marketing of robotically assisted gynecologic surgery was widespread (Schiavone et al., 2012). Furthermore, many of the Web sites used stock images and texts from the manufacturer, whereas few sites described undesirable attributes of robotic surgery, and many of the claims made were not based on data (Schiavone et al., 2012). The current data suggest that many physicians believe that marketing is the most important driver of use of robotic surgery. In our cohort, nearly two-thirds of nonrobot users responded that marketing was the most important factor driving use of robotic surgery, whereas over one-fifth of robot users responded similarly. A major concern surrounding the rapid dissemination of robotic surgery stems from the high costs associated with many procedures. An analysis of more than 20 types of procedures noted that roboticassisted operations were on average 13% more expensive than nonrobotic alternatives (Babash and Glied, 2010). Similar findings have been found in gynecology. An analysis of robotically assisted hysterectomy for benign gynecologic diseases,
for instance, found that robotic-assisted hysterectomy was over $2,000 more costly than either open or laparoscopic alternatives (Wright et al., 2013a). Similar findings have been noted for robotically assisted hysterectomy for endometrial cancer (Wright et al., 2012). Of greater concern is that even after surgeons gain technical proficiency and hospitals have performed a high number of procedures, the cost of robotic-assisted gynecologic surgery remains higher (Wright et al., 2014). Among respondents to our survey, nonusers of the surgical robot overwhelmingly responded that they would not use the technology if it was more costly but no more effective than other surgical approaches. Interestingly, among users of robotic surgery, 59% stated that they would not use robotic surgery if it was more costly but did not improve outcomes. Given the cost concerns for roboticassisted surgery, some proposals have called for restructuring the reimbursement system for unproven interventions (Pearson and Bach, 2010). In essence, these initiatives either reduce physician or hospital reimbursement or pass costs to patients when a more costly procedure without increased effectiveness is used in lieu of a lower cost alternative. Among robotic gynecologic surgeons, we noted that 23% of physicians would perform a procedure laparoscopically instead of using robotic-assistance if reimbursement were reduced by 10-20%. Similarly, 41% of respondents would perform the operation laparoscopically if reimbursement were lowered by 20%–35%. These findings suggest that alternative reimbursement strategies may be a way to promote cost savings for gynecologic surgery. Furthermore, these data are helpful for organizations to understand factors influencing physician use of robotic technology. We recognize a number of important limitations. Although our survey was associated with a relatively high response rate from a range of general gynecologists and subspecialists, these data may not be representative of all gynecologists in the United States. The College has, however, previously undertaken a number of similar
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research surveys, and these studies include representative clinicians from across the country (England et al., 2014; Raglan et al., 2014; Wright et al., 2013b). Regardless, this instrument provides a framework for further studies to examine physician attitudes associated with novel technologies and surgical innovation. Second, our study may be underpowered to detect differences in attitudes and practice patterns. There was little a priori data describing how pelvic surgeons perceived robotic-assisted surgery and thus our data were meant to be descriptive and hypothesis generating. Third, our data are based on self-report, and we are unable to confirm actual use and volume of use of robotic surgery. Finally, we attempted to include questions directed at discerning attitudes toward commonly cited drivers of robotic surgery. Undoubtedly, other patient, physician, and systems factors influence the choice to offer and use robotically assisted gynecologic surgery. In conclusion, our findings suggest that beliefs and attitudes regarding the utility and effectiveness of robotic-assisted gynecologic surgery are highly variable. Practitioners who do not use the technology are more skeptical of the benefits of the procedures, particularly when compared to laparoscopy. Further work to explore whether and how physician attitudes influence outcomes and large-scale studies to define the role of robotically assisted surgery in gynecology would be beneficial.
Acknowledgments This article was supported by Grant no. UA6MC19010 from the Maternal and Child Health Bureau (Title V, Social Security Act, Health Resources and Services Administration, and Department of Health and Human Services [DHHS]). The authors would like to thank Jason Dana for his contributions to this project.
References Barbash, G.I., & Glied, S.A. New technology and health care costs—the case of robot-assisted surgery. New Engl J Med 2010;363:701–704.
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Weissman, J.S., & Zinner, M. Comparative effectiveness research on robotic surgery. J Am Med Assoc 2013;309:721–722. Woelk, J.L., Casiano, E.R., & Weaver, A.L., et al. The learning curve of robotic hysterectomy. Obstet Gynecol 2013;121:87–95. Wright, J.D., Burke, W.M., & Wilde, E.T., et al. Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer. J Clin Oncol 2012;30:783–791. Wright, J.D., Ananth, C.V., & Lewin, S.N., et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. J Am Med Assoc 2013a;309:689–698.
Wright, J.D., Silver, R.M., & Bonanno, C., et al. Practice patterns and knowledge of obstetricians and gynecologists regarding placenta accrete. J Maternal Fetal Neonatal Med 2013b;26:1602–1609. Wright, J.D., Ananth, C.V., & Tergas, A.I., et al. An economic analysis of robotically assisted hysterectomy. Obstet Gynecol 2014;123: 1038–1048. The authors declare no conflict of interest. For more information on this article, contact Jason D. Wright at [email protected].
