BEST EVIDENCE TOPIC – ADULT CARDIAC
Interactive CardioVascular and Thoracic Surgery 20 (2015) 844–847 doi:10.1093/icvts/ivv038 Advance Access publication 10 March 2015
Cite this article as: Canale LS, Colafranceschi AS. Is robotic mitral valve surgery more expensive than its conventional counterpart? Interact CardioVasc Thorac Surg 2015;20:844–7.
Is robotic mitral valve surgery more expensive than its conventional counterpart? Leonardo Secchin Canale* and Alexandre Siciliano Colafranceschi Department of Cardiac Surgery, Pro Cardiaco Hospital, Rio de Janeiro, Brazil * Corresponding author. Department of Cardiac Surgery, 143 Dona Marian Street, A-12, Botafogo, Rio de Janeiro, RJ, Brazil. Tel: +55-21-999722605; fax: +55-21-999722605; e-mail: [email protected] (L. Canale). Received 10 April 2014; received in revised form 6 February 2015; accepted 12 February 2015
Abstract A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Is robotic mitral valve surgery more expensive than its conventional counterpart?’ Altogether 19 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There is a general impression in the surgical community that robotic operations might incur prohibitive additional costs. There is a paucity of data in the literature regarding cost analysis in cardiac robotic surgery. From the five studies, four were single institution experiences and one was a database inquiry study. These four studies showed that operational costs are higher for robotic cases but this was partially (one study) or completely (three studies) offset by lower postoperative costs. Overall hospital costs were similar between the two approaches in three studies and one study showed higher costs in the robotic group. Higher operating theatre (OT) costs were driven mainly by use of robotic instruments (approximately US$1500 per case) and longer OT times. Savings in postoperative care were driven by shorter length of hospital stay (on average 2 days fewer in robotic cases) and lower morbidity. If amortization cost, that is, the value of the initial capital investment on the robotic system divided by all operations performed, is included in this analysis, robotic approach becomes significantly more expensive by approximately US$3400 per case. The fifth study was a large national database inquiry in which robotic approach was found to be more expensive by US$600 per case excluding amortization cost and by US$3700 if amortization is included. We conclude that the total hospital cost of robotic mitral valve surgery is slightly higher than conventional sternotomy surgery. If amortization is taken into consideration, robotic cases are considerably more expensive. Keywords: Review • Mitral valve repair • Robotic • Costs • Cost-analysis
INTRODUCTION A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
THREE-PART QUESTION In [ patients undergoing robotic mitral valve surgery] are the [hospital costs] higher than in a [conventional sternotomy approach]?
CLINICAL SCENARIO Besides being a cardiac surgeon in your hospital, you are also in charge of a cost-saving programme for your department. The chairman is interested in starting a robotic cardiac programme focused on mitral valve (MV) surgery, and has the resources to purchase a surgical robot. He asks for your opinion regarding
differences in hospital costs between robotic approach and conventional sternotomy surgery. You resolve to check the literature yourself.
SEARCH STRATEGY Medline 1950 to March 2014 using the PUBMED interface [(mitral valve OR mitral valve prolapse OR mitral valve annuloplasty OR mitral valve repair OR mitral valve surgery) AND (robotics OR robotic surgery)] AND (costs OR cost OR cost analysis). Related articles and references were screened for suitable articles.
SEARCH OUTCOME Nineteen papers were found using the reported search. From these, five papers were identified. That provided the best evidence to answer the question. These are presented in Table 1.
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
845
L.S. Canale and A.S. Colafranceschi / Interactive CardioVascular and Thoracic Surgery
Table 1: Best evidence papers Author, date and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Suri et al. (2013), Mayo Clin Proc, USA [2]
185 propensity-matched pairs (370 patients) undergoing mitral valve repair for degenerative disease
Overall costs of each surgical episode (from date of admission to discharge)
Similar total costs for robotic and open cases: US$32 144 vs US$31 838 (P = 0.32)
On average, robotic cases had higher procedural costs that were offset by reduced ICU and postoperative costs
Major components of the overall costs (procedure costs and overall costs)
Operating theatre (OT) cost higher for robotic cases: US$11 234 vs US$8474 (P < 0.001)
Observational prospective cohort (level 3 evidence)
Postoperative costs lower in robotic cases: US$4595 vs US$8663, P < 0.001 Shorter median LOS in robotic group: 3.5 days vs 5.3 days (P < 0.001) All mitral valve surgeries (between June 2005 and June 2008) in one hospital. Total 147 patients (107 robotic, 40 conventional)
Observational retrospective review (level 4 evidence)
Total cost of each operation (operative and postoperative components)
Similar costs overall between robotic and conventional surgery: US$18 503 vs US$17 879. P = 0.176
Hospital and ICU LOS
Robotic operative procedure costs were higher than conventional surgery: US$12 328 vs US$9755. P < 0.001 Postoperative costs were lower in robotic cases: US$6174 vs US$8124. P < 0.001
Higher operative costs in the robotic group were driven by the robotic instruments costs (US$1597 per case) and robotic drapping material (US$383 per case) If one includes the additional costs of the investment on the robotic system (approximately US $2800 per case), total costs for robotic cases become US$3444 higher than conventional cases (P = 0.004)
Robotic group had shorter ICU stay (37 h vs 45 h, P = 0.002) and shorter hospital LOS (6.47 days vs 8.76 days, P = 0.001) Morgan et al. (2005), J Card Surg, USA [4]
Mitral valve repair in 20 patients (10 robotic approach, 10 conventional)
Total effective cost from surgery until discharge
Observational retrospective review (level 4 evidence) Intraoperative and postoperative cost components
Similar overall costs between robotic and conventional cases (US$14 538 vs US$13 894. P = 0.539) Higher operative costs in robotic cases (US$10 999 vs US$9507. P = 0.029). The main drivers for this difference were OT time and supplies
The main driver for higher operative cost was OT time. This was reduced over time The small sample size in this study might have limited the ability to find differences in postoperative costs
Similar postoperative costs for robotic and conventional cases (US$3539 vs US$4387. P = 0.173) If amortization costs are included (US$2800 per surgery) robotic approach becomes significantly more expensive by US$3400
Continued
BEST EVIDENCE TOPIC
Kam et al. (2010), Heart Lung Circ, Australia [3]
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L.S. Canale and A.S. Colafranceschi / Interactive CardioVascular and Thoracic Surgery
Table 1: (Continued) Author, date and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Mihaljevic et al. (2014), JAMA, USA [5]
Compared 473 robotic MV repair operations with 3 other approaches using propensity-matched analysis
Cost of care
Robotic procedure cost 36.9% more than sternotomy
Benefit of care
Robotic hospital cost was 18.1% higher than sternotomy approach (including the investment cost)
Mini sternotomy and mini thoracotomy groups had similar costs and similar time to return to work when compared with full sternotomy
Clinical cohort study (level 4 evidence)
Robotic approach was the least invasive option but also the most expensive
Patients submitted to robotic surgery returned to work 2 weeks earlier than sternotomy patients Barbash et al. (2010), N Engl J Med, USA [6] Database inquiry (level 4 evidence)
Database inquiry on all mitral valve operations (total 14 191) performed in the USA in the year 2007 through the Healthcare Cost and Utilization Project
Mean cost per mitral valve surgery
Mean cost per surgery was US$45 914
Large database study including all mitral valve operations in 2007
Difference in costs for robotic operations compared with conventional approach including and excluding amortization costs
Change in cost for using robotic approach (without amortization cost)— additional US$600 per case
This study analysed cost alone, without investigating differences in morbidity, recovery time and length of hospital stay
Change in cost for using robotic approach (including amortization cost)— additional US$3700 per case
Robust conclusions due to a large number of cases
RESULTS Suri et al. [2] studied 185 propensity-matched pairs of conventional MV repair surgery and robotic approach surgery in patients with degenerative disease. Outcomes studied were total hospital costs with its main components (operative and postoperative) and intensive care unit (ICU) and hospital length of stay (LOS). Robotic approach led to shorter hospital LOS (3.5 vs 5.3 days, P < 0.001). Total hospital costs were similar between both approaches (robotic: US$32 144, conventional: US$31 838, P = 0.32). Operative costs were higher for robotic cases—US$11 234 vs US$8474 (P < 0.001). On the other hand, postoperative costs were lower in the robotic cases—US$4595 vs US$8663 (P < 0.001). Kam et al. [3] in Australia studied all MV repair operations performed between June 2005 and June 2008 in one hospital system, and compared operative costs and LOS. The study included 107 robotic and 40 conventional cases. Robotic cases had shorter ICU stay (37 vs 45 h, P = 0.002) and hospital LOS (6.47 vs 8.76 days, P = 0.001). Robotic operative procedures had higher costs than conventional surgery (US$12 328 vs US$9755, P < 0.001) but postoperative costs were lower (US$6174 vs US$8124, P < 0.001). All in all, total costs were similar between both groups (US$18 503 vs US$17 879, P = 0.176). Morgan et al. [4] compared the costs of their first 10 robotic MV repair with 10 conventional operations. Similar overall costs between robotic and conventional cases were observed (US$14 538 vs US$13 894, P = 0.539). Operative costs were higher for robotic cases (US$10 999 vs US$9507, P = 0.029). Postoperative costs were
lower in the robotic group (US$3539 vs US$4387, P = 0.173) compensating the increased operative costs. When the costs from amortization of the robotic system were included (US$2800), the robotic approach became significantly more expensive than the sternotomy approach by US$3444. Mihaljevic et al. [5] retrospectively compared MV repair performed by robotic approach (473 patients) with three other options (ministernotomy, mini right thoracotomy, conventional sternotomy) by creating propensity-matched groups. The study considered not only instrument costs but also capitalization of the system and societal benefits of time to return to work. When compared with full sternotomy (227 patients), the robotic approach resulted in higher procedural costs by 36.9%, which were partially offset by reduced postoperatory costs (19.1% lower). Resulting difference was an increase in hospital costs of 18.1%. Patients submitted to robotic operations returned to work 2 weeks earlier than those submitted to full sternotomy approach. Barbash et al. in 2010 [6] performed a database inquiry on 14 191 MV repair operations (robotic and non-robotic) performed in the USA in 2007 through the Healthcare Cost and Utilization Project. MV repair was one of them. Although the authors did not define the exact number of operations performed robotically (only the overall number), they did report the extra hospital cost of robotically assisted MV repair over conventional approach with and without the amortization extra cost. According to this study, a total of 14 191 MV repairs (robotically and non-robotically) were performed in the USA in 2007. The overall mean cost was US$45 914. Robotic surgery consumed an extra US$600 per case
L.S. Canale and A.S. Colafranceschi / Interactive CardioVascular and Thoracic Surgery
CLINICAL BOTTOM LINE Robotic MV repair has slightly higher overall hospital costs when compared with a conventional sternotomy approach. Studies consistently show that the operative procedure is more costly in robotic cases—driven by usage of robotic material and longer OT time, which is partially offset by lower costs in the postoperative
period—driven by shorter LOS and lower morbidity. When the amortization cost is included in the calculation, robotic MV surgery becomes significantly more expensive than conventional surgery although these costs will vary widely depending on caseload and sharing of the system. Conflict of interest: none declared.
REFERENCES [1] Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–9. [2] Suri RM, Thompson JE, Burkhart HM, Huebner M, Borah BJ, Li Z et al. Improving affordability through innovation in the surgical treatment of mitral valve disease. Mayo Clin Proc 2013;88:1075–84. [3] Kam JK, Cooray SD, Kam JK, Smith JA, Almeida AA. A cost-analysis study of robotic versus conventional mitral valve repair. Heart Lung Circ 2010;19: 413–8. [4] Morgan JA, Thornton BA, Peacock JC, Hollingsworth KW, Smith CR, Oz MC et al. Does robotic technology make minimally invasive cardiac surgery too expensive? A hospital cost analysis of robotic and conventional techniques. J Card Surg 2005;20:246–51. [5] Mihaljevic T, Koprivanac M, Kelava M, Goodman A, Jarrett C, Williams SJ et al. Value of robotically assisted surgery for mitral valve disease. JAMA Surg 2014;149:679–86. [6] Barbash GI, Glied SA. New technology and health care costs—the case of robot-assisted surgery. N Engl J Med 2010;363:701–4. [7] Nayeemuddin M, Daley SC, Ellsworth P. Modifiable factors to decrease the cost of robotic-assisted procedures. AORN J 2013;98:343–52.
BEST EVIDENCE TOPIC
if amortization was not considered and an additional US$3700 if amortization was included. This study did not include an investigation on postoperative morbidity or LOS. Only the study by Mihaljevic compared robotic costs with nonrobotic minimally invasive approaches. Again they found that robotic approach was costlier than minithoracotomy (20.7% higher) and upper mini sternotomy options (32.1% higher). On the other hand, these other minimally invasive approaches had no benefit on time to return to work when compared with full sternotomy. In these five articles, amortization was calculated in a hypothetic situation where the robotic system was used exclusively for cardiac cases. The final result is an amortization cost of approximately US$2700 per case. In real life, though, many hospitals share one robotic system among different specialities, increasing its use and its cost-effectiveness. In such a situation, the amortization cost per surgery may be reduced to US$800 to US$900 per case when 300 patients are operated per year during a 7-year period [7].
847
Interactive CardioVascular and Thoracic Surgery 20 (2015) 844–847 doi:10.1093/icvts/ivv038 Advance Access publication 10 March 2015
Cite this article as: Canale LS, Colafranceschi AS. Is robotic mitral valve surgery more expensive than its conventional counterpart? Interact CardioVasc Thorac Surg 2015;20:844–7.
Is robotic mitral valve surgery more expensive than its conventional counterpart? Leonardo Secchin Canale* and Alexandre Siciliano Colafranceschi Department of Cardiac Surgery, Pro Cardiaco Hospital, Rio de Janeiro, Brazil * Corresponding author. Department of Cardiac Surgery, 143 Dona Marian Street, A-12, Botafogo, Rio de Janeiro, RJ, Brazil. Tel: +55-21-999722605; fax: +55-21-999722605; e-mail: [email protected] (L. Canale). Received 10 April 2014; received in revised form 6 February 2015; accepted 12 February 2015
Abstract A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was ‘Is robotic mitral valve surgery more expensive than its conventional counterpart?’ Altogether 19 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There is a general impression in the surgical community that robotic operations might incur prohibitive additional costs. There is a paucity of data in the literature regarding cost analysis in cardiac robotic surgery. From the five studies, four were single institution experiences and one was a database inquiry study. These four studies showed that operational costs are higher for robotic cases but this was partially (one study) or completely (three studies) offset by lower postoperative costs. Overall hospital costs were similar between the two approaches in three studies and one study showed higher costs in the robotic group. Higher operating theatre (OT) costs were driven mainly by use of robotic instruments (approximately US$1500 per case) and longer OT times. Savings in postoperative care were driven by shorter length of hospital stay (on average 2 days fewer in robotic cases) and lower morbidity. If amortization cost, that is, the value of the initial capital investment on the robotic system divided by all operations performed, is included in this analysis, robotic approach becomes significantly more expensive by approximately US$3400 per case. The fifth study was a large national database inquiry in which robotic approach was found to be more expensive by US$600 per case excluding amortization cost and by US$3700 if amortization is included. We conclude that the total hospital cost of robotic mitral valve surgery is slightly higher than conventional sternotomy surgery. If amortization is taken into consideration, robotic cases are considerably more expensive. Keywords: Review • Mitral valve repair • Robotic • Costs • Cost-analysis
INTRODUCTION A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
THREE-PART QUESTION In [ patients undergoing robotic mitral valve surgery] are the [hospital costs] higher than in a [conventional sternotomy approach]?
CLINICAL SCENARIO Besides being a cardiac surgeon in your hospital, you are also in charge of a cost-saving programme for your department. The chairman is interested in starting a robotic cardiac programme focused on mitral valve (MV) surgery, and has the resources to purchase a surgical robot. He asks for your opinion regarding
differences in hospital costs between robotic approach and conventional sternotomy surgery. You resolve to check the literature yourself.
SEARCH STRATEGY Medline 1950 to March 2014 using the PUBMED interface [(mitral valve OR mitral valve prolapse OR mitral valve annuloplasty OR mitral valve repair OR mitral valve surgery) AND (robotics OR robotic surgery)] AND (costs OR cost OR cost analysis). Related articles and references were screened for suitable articles.
SEARCH OUTCOME Nineteen papers were found using the reported search. From these, five papers were identified. That provided the best evidence to answer the question. These are presented in Table 1.
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
845
L.S. Canale and A.S. Colafranceschi / Interactive CardioVascular and Thoracic Surgery
Table 1: Best evidence papers Author, date and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Suri et al. (2013), Mayo Clin Proc, USA [2]
185 propensity-matched pairs (370 patients) undergoing mitral valve repair for degenerative disease
Overall costs of each surgical episode (from date of admission to discharge)
Similar total costs for robotic and open cases: US$32 144 vs US$31 838 (P = 0.32)
On average, robotic cases had higher procedural costs that were offset by reduced ICU and postoperative costs
Major components of the overall costs (procedure costs and overall costs)
Operating theatre (OT) cost higher for robotic cases: US$11 234 vs US$8474 (P < 0.001)
Observational prospective cohort (level 3 evidence)
Postoperative costs lower in robotic cases: US$4595 vs US$8663, P < 0.001 Shorter median LOS in robotic group: 3.5 days vs 5.3 days (P < 0.001) All mitral valve surgeries (between June 2005 and June 2008) in one hospital. Total 147 patients (107 robotic, 40 conventional)
Observational retrospective review (level 4 evidence)
Total cost of each operation (operative and postoperative components)
Similar costs overall between robotic and conventional surgery: US$18 503 vs US$17 879. P = 0.176
Hospital and ICU LOS
Robotic operative procedure costs were higher than conventional surgery: US$12 328 vs US$9755. P < 0.001 Postoperative costs were lower in robotic cases: US$6174 vs US$8124. P < 0.001
Higher operative costs in the robotic group were driven by the robotic instruments costs (US$1597 per case) and robotic drapping material (US$383 per case) If one includes the additional costs of the investment on the robotic system (approximately US $2800 per case), total costs for robotic cases become US$3444 higher than conventional cases (P = 0.004)
Robotic group had shorter ICU stay (37 h vs 45 h, P = 0.002) and shorter hospital LOS (6.47 days vs 8.76 days, P = 0.001) Morgan et al. (2005), J Card Surg, USA [4]
Mitral valve repair in 20 patients (10 robotic approach, 10 conventional)
Total effective cost from surgery until discharge
Observational retrospective review (level 4 evidence) Intraoperative and postoperative cost components
Similar overall costs between robotic and conventional cases (US$14 538 vs US$13 894. P = 0.539) Higher operative costs in robotic cases (US$10 999 vs US$9507. P = 0.029). The main drivers for this difference were OT time and supplies
The main driver for higher operative cost was OT time. This was reduced over time The small sample size in this study might have limited the ability to find differences in postoperative costs
Similar postoperative costs for robotic and conventional cases (US$3539 vs US$4387. P = 0.173) If amortization costs are included (US$2800 per surgery) robotic approach becomes significantly more expensive by US$3400
Continued
BEST EVIDENCE TOPIC
Kam et al. (2010), Heart Lung Circ, Australia [3]
846
L.S. Canale and A.S. Colafranceschi / Interactive CardioVascular and Thoracic Surgery
Table 1: (Continued) Author, date and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Mihaljevic et al. (2014), JAMA, USA [5]
Compared 473 robotic MV repair operations with 3 other approaches using propensity-matched analysis
Cost of care
Robotic procedure cost 36.9% more than sternotomy
Benefit of care
Robotic hospital cost was 18.1% higher than sternotomy approach (including the investment cost)
Mini sternotomy and mini thoracotomy groups had similar costs and similar time to return to work when compared with full sternotomy
Clinical cohort study (level 4 evidence)
Robotic approach was the least invasive option but also the most expensive
Patients submitted to robotic surgery returned to work 2 weeks earlier than sternotomy patients Barbash et al. (2010), N Engl J Med, USA [6] Database inquiry (level 4 evidence)
Database inquiry on all mitral valve operations (total 14 191) performed in the USA in the year 2007 through the Healthcare Cost and Utilization Project
Mean cost per mitral valve surgery
Mean cost per surgery was US$45 914
Large database study including all mitral valve operations in 2007
Difference in costs for robotic operations compared with conventional approach including and excluding amortization costs
Change in cost for using robotic approach (without amortization cost)— additional US$600 per case
This study analysed cost alone, without investigating differences in morbidity, recovery time and length of hospital stay
Change in cost for using robotic approach (including amortization cost)— additional US$3700 per case
Robust conclusions due to a large number of cases
RESULTS Suri et al. [2] studied 185 propensity-matched pairs of conventional MV repair surgery and robotic approach surgery in patients with degenerative disease. Outcomes studied were total hospital costs with its main components (operative and postoperative) and intensive care unit (ICU) and hospital length of stay (LOS). Robotic approach led to shorter hospital LOS (3.5 vs 5.3 days, P < 0.001). Total hospital costs were similar between both approaches (robotic: US$32 144, conventional: US$31 838, P = 0.32). Operative costs were higher for robotic cases—US$11 234 vs US$8474 (P < 0.001). On the other hand, postoperative costs were lower in the robotic cases—US$4595 vs US$8663 (P < 0.001). Kam et al. [3] in Australia studied all MV repair operations performed between June 2005 and June 2008 in one hospital system, and compared operative costs and LOS. The study included 107 robotic and 40 conventional cases. Robotic cases had shorter ICU stay (37 vs 45 h, P = 0.002) and hospital LOS (6.47 vs 8.76 days, P = 0.001). Robotic operative procedures had higher costs than conventional surgery (US$12 328 vs US$9755, P < 0.001) but postoperative costs were lower (US$6174 vs US$8124, P < 0.001). All in all, total costs were similar between both groups (US$18 503 vs US$17 879, P = 0.176). Morgan et al. [4] compared the costs of their first 10 robotic MV repair with 10 conventional operations. Similar overall costs between robotic and conventional cases were observed (US$14 538 vs US$13 894, P = 0.539). Operative costs were higher for robotic cases (US$10 999 vs US$9507, P = 0.029). Postoperative costs were
lower in the robotic group (US$3539 vs US$4387, P = 0.173) compensating the increased operative costs. When the costs from amortization of the robotic system were included (US$2800), the robotic approach became significantly more expensive than the sternotomy approach by US$3444. Mihaljevic et al. [5] retrospectively compared MV repair performed by robotic approach (473 patients) with three other options (ministernotomy, mini right thoracotomy, conventional sternotomy) by creating propensity-matched groups. The study considered not only instrument costs but also capitalization of the system and societal benefits of time to return to work. When compared with full sternotomy (227 patients), the robotic approach resulted in higher procedural costs by 36.9%, which were partially offset by reduced postoperatory costs (19.1% lower). Resulting difference was an increase in hospital costs of 18.1%. Patients submitted to robotic operations returned to work 2 weeks earlier than those submitted to full sternotomy approach. Barbash et al. in 2010 [6] performed a database inquiry on 14 191 MV repair operations (robotic and non-robotic) performed in the USA in 2007 through the Healthcare Cost and Utilization Project. MV repair was one of them. Although the authors did not define the exact number of operations performed robotically (only the overall number), they did report the extra hospital cost of robotically assisted MV repair over conventional approach with and without the amortization extra cost. According to this study, a total of 14 191 MV repairs (robotically and non-robotically) were performed in the USA in 2007. The overall mean cost was US$45 914. Robotic surgery consumed an extra US$600 per case
L.S. Canale and A.S. Colafranceschi / Interactive CardioVascular and Thoracic Surgery
CLINICAL BOTTOM LINE Robotic MV repair has slightly higher overall hospital costs when compared with a conventional sternotomy approach. Studies consistently show that the operative procedure is more costly in robotic cases—driven by usage of robotic material and longer OT time, which is partially offset by lower costs in the postoperative
period—driven by shorter LOS and lower morbidity. When the amortization cost is included in the calculation, robotic MV surgery becomes significantly more expensive than conventional surgery although these costs will vary widely depending on caseload and sharing of the system. Conflict of interest: none declared.
REFERENCES [1] Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–9. [2] Suri RM, Thompson JE, Burkhart HM, Huebner M, Borah BJ, Li Z et al. Improving affordability through innovation in the surgical treatment of mitral valve disease. Mayo Clin Proc 2013;88:1075–84. [3] Kam JK, Cooray SD, Kam JK, Smith JA, Almeida AA. A cost-analysis study of robotic versus conventional mitral valve repair. Heart Lung Circ 2010;19: 413–8. [4] Morgan JA, Thornton BA, Peacock JC, Hollingsworth KW, Smith CR, Oz MC et al. Does robotic technology make minimally invasive cardiac surgery too expensive? A hospital cost analysis of robotic and conventional techniques. J Card Surg 2005;20:246–51. [5] Mihaljevic T, Koprivanac M, Kelava M, Goodman A, Jarrett C, Williams SJ et al. Value of robotically assisted surgery for mitral valve disease. JAMA Surg 2014;149:679–86. [6] Barbash GI, Glied SA. New technology and health care costs—the case of robot-assisted surgery. N Engl J Med 2010;363:701–4. [7] Nayeemuddin M, Daley SC, Ellsworth P. Modifiable factors to decrease the cost of robotic-assisted procedures. AORN J 2013;98:343–52.
BEST EVIDENCE TOPIC
if amortization was not considered and an additional US$3700 if amortization was included. This study did not include an investigation on postoperative morbidity or LOS. Only the study by Mihaljevic compared robotic costs with nonrobotic minimally invasive approaches. Again they found that robotic approach was costlier than minithoracotomy (20.7% higher) and upper mini sternotomy options (32.1% higher). On the other hand, these other minimally invasive approaches had no benefit on time to return to work when compared with full sternotomy. In these five articles, amortization was calculated in a hypothetic situation where the robotic system was used exclusively for cardiac cases. The final result is an amortization cost of approximately US$2700 per case. In real life, though, many hospitals share one robotic system among different specialities, increasing its use and its cost-effectiveness. In such a situation, the amortization cost per surgery may be reduced to US$800 to US$900 per case when 300 patients are operated per year during a 7-year period [7].
847
