Compared with open surgical procedures, the use of laparoscopic surgery for some common conditions is associated with fewer complications, shorter length of stay, and lower hospital costs, researchers find.
The use of open incisions rather than less invasive surgical techniques results in complications such as such as infections in more than 4,000 patients annually, a Johns Hopkins surgeon reports.
"It's one of the greatest disparities in medicine, that roughly half of surgical patients are cut open, and roughly half are getting minimally invasive surgery, though minimally invasive techniques have lower infection and complication rates, lower lengths of stay, and lower use of postoperative pain medications," says Martin Makary, MD, professor of surgery at the Johns Hopkins University School of Medicine.
A paper by Makary and colleagues about their study findings was published was published Wednesday in JAMA Surgery.
Though similar types of hospitals with similar patient populations were compared, "radical variation" was found between the use of minimally invasive laparoscopic or keyhole surgery versus open procedures.
"How we triage patients hasn't been on the radar when discussions of improving quality of care in America are taking place," says Makary. "Yet the highest ticket item in medicine is surgery, and surgical admissions constitute half of all hospital admissions at the biggest hospitals in the country." Makary is an outspoken critic of poor healthcare quality.
He describes the variation as inexplicable considering the tremendous toll infections take. In pancreas surgery, his specialty, minimally invasive techniques cause infection in 1% of cases. Open procedures cause infection in 12%–15% of cases, Makary says.
"We're talking about the near elimination of one of the marker complications of surgery in American medicine," he says. "You have to ask, 'if there was a pill that reduced [surgical site infections] by this much, we'd ask 'why isn't everyone on this?'"
Makary emphasizes that not all patients who don't get minimally invasive surgery are candidates for that technique, but "most are."
His research, which follows a related study published last year in the British Medical Journal, used the 2010 National Inpatient Sample for patients undergoing three procedures: appendectomies, partial colectomies, and NS lung lobectomies, excluding those undergoing emergency or multiple operations. Hospitals were not identified by name, but were grouped by type, region, size, and whether they were urban or rural.
Researchers compared rates of surgeries using minimally invasive versus open techniques at similar hospitals, risk adjusting for demographics and patient mix.
The BMJ paper found enormous unexplained variation, Makary says. In the JAMA Surgery paper. researchers hypothesized how much savings could be achieved if surgeons at hospitals that more often used open surgical procedures increased their rates of minimally invasive procedures to the average of those hospitals that used them the most.
They estimated there would be 4,300 fewer complications, nearly 170,000 fewer hospital days, and $337 million in annual savings nationwide.
Fewer complications would save $688 per patient undergoing an appendectomy, $5,097 for each patient undergoing a colectomy, and $2,844 for patients undergoing a lobectomy, researchers calculated. Including other savings such as reduced lengths of stay, minimally invasive techniques amounted to $1,528, $7,507 and $6,209, respectively.
"One fifth of all hospitals nationally do all of their colon operations as open procedures, even though there's a randomized controlled trial published in the New England Journal of Medicine that's over 10 years old showing the superiority of the minimally invasive approach," Makary says.
Steven Schwaitzberg, MD, past president of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), which conducts training for physicians wanting to learn minimally invasive surgical techniques, agrees with Makary's view.
Schwaitzberg estimates that laparoscopic colectomies could be increased from 30% to 70% of all procedures. Laparoscopic hysterectomies, now as low as 10% of all such procedures, could be done for 75% of such operations. And liver operations performed with minimal incisions, now at between 10% to 20% of such procedures, could be increase to between 50% and 75%.
"We need energy and more training, and a coordinated effort with Medicare and other payers to incentivize and encourage doctors to learn these techniques," he says.
Barriers
Makary says there are reasons why hospitals and surgeons don't adopt these safer and less expensive strategies in greater numbers. One is that some doctors "never learned minimally invasive techniques." Another reason is awareness. The savings and complication rates for each are "off the radar for most hospital leaders. They're not aware of the opportunity to improve quality and reduce infections, or reduce readmissions."
More subtle pressures include the need for hospitals to retain general surgeons who are able to perform many types of surgeries well, but who don't specialize in minimally invasive surgical techniques, which require specialized training.
A related issue is that at some hospitals, surgeons' compensation is based on volume, so they tend not to refer to minimally invasive surgeons, and, Makary adds, they often compete with each other to for volume.
Patient informed consent is another impediment. Makary says most of the patients who go to Johns Hopkins for minimally invasive pancreas surgery report that when they inquired about it, "their doctors said [minimally invasive surgery] was dangerous, or experimental, or equivalent. I frequently meet people who say, 'my doctor never discussed the option.' For some of these people, we can only imagine they are not being given the option, or not told about it in a fair way."
"These are the issues that live in the operating room locker rooms and physician lounges, and they are heard in the side conversations at our annual meetings," he says.
Makary says minimally invasive strategies are not necessarily less expensive than open procedures, nor do they always require less time under anesthesia, although that is usually the case.
A Possible Solution
One solution is for healthcare systems to channel their patients toward "the best match for a surgeon for the best outcome" for their situation. "If someone is a candidate for a minimally invasive hysterectomy, why are they going to someone who only does it as an open procedure?" he asks.
The nation could also develop a system for hospitals to be transparent about their surgeons' track record, and reveal hospital names now in the de-identified database. "I've advocated for that transparency," Makary says.
Andrew Wright, MD, a surgeon and director of the Center for Videoendoscopic Surgery at the University of Washington Medical Center in Seattle, says some surgeons have resisted training because it requires extra equipment that adds costs, and there is concern that the procedures take longer.
Makary's study, however, "shows conclusively that not only does minimally invasive surgery cost less, it also is safer. Patients stay in the hospital for less time, they recover faster and have fewer complications" Wright says.