Outcomes comparison of robotic-assisted versus laparoscopic and open surgery for patients undergoing rectal cancer resection with concurrent stoma creation.

BACKGROUND: Despite widespread adoption of robotic-assisted surgery (RAS) in rectal cancer resection, there remains limited knowledge of its clinical advantage over laparoscopic (Lap) and open (OS) surgery. We aimed to compare clinical outcomes of RAS with Lap and OS for rectal cancer. METHODS: We identified all patients aged ≥ 18 years who had elective rectal cancer resection requiring temporary or permanent stoma formation from 1/2013 to 12/2020 from the PINC AI™ Healthcare Database. We completed multivariable logistic regression analysis accounting for hospital clustering to compare ileostomy formation between surgical approaches. Next, we built inverse probability of treatment-weighted analyses to compare outcomes for ileostomy and permanent colostomy separately. Outcomes included postoperative complications, in-hospital mortality, discharge to home, reoperation, and 30-day readmission. RESULTS: A total of 12,787 patients (OS: 5599 [43.8%]; Lap: 2872 [22.5%]; RAS: 4316 [33.7%]) underwent elective rectal cancer resection. Compared to OS, patients who had Lap (OR 1.29, p < 0.001) or RAS (OR 1.53, p < 0.001) were more likely to have an ileostomy rather than permanent colostomy. In those with ileostomy, RAS was associated with fewer ileus (OR 0.71, p < 0.001) and less bleeding (OR 0.50, p < 0.001) compared to Lap. In addition, RAS was associated with lower anastomotic leak (OR 0.25, p < 0.001), less bleeding (OR 0.51, p < 0.001), and fewer blood transfusions (OR 0.70, p = 0.022) when compared to OS. In those patients who had permanent colostomy formation, RAS was associated with fewer ileus (OR 0.72, p < 0.001), less bleeding (OR 0.78, p = 0.021), lower 30-day reoperation (OR 0.49, p < 0.001), and higher discharge to home (OR 1.26, p = 0.013) than Lap, as well as OS. CONCLUSION: Rectal cancer patients treated with RAS were more likely to have an ileostomy rather than a permanent colostomy and more enhanced recovery compared to Lap and OS.

One-year healthcare costs after robotic-assisted and laparoscopic partial and radical nephrectomy: a cohort study.

OBJECTIVE: Despite the wide-spread adoption of robotic-assisted surgery (RAS), the cost-benefit implications for partial (PN) and radical nephrectomy (RN) versus laparoscopic surgery (Lap) is not well established. We sought to examine the trend of adoption and 1-year healthcare expenditure of PN and RN, and compare 1-year expenditures of RAS versus Lap for PN and RN. PATIENTS AND METHODS: This cohort study used the MerativeTM MarketScan® Databases between 2013 and 2020. A total of 5,353 patients with kidney cancer undergoing PN (2,980, 55.7%) or RN (2,373, 44.3%). We compared open-conversion, length of stay (LOS), index expenditure, 1-year healthcare expenditure and utilization, and missed work-days between RAS and Lap for PN and RN. RESULTS: Adoption of PN increased overtime (47.0% to 55.8%), mainly driven by robotic PN increase. Among PN, RAS had lower open-conversion, shorter LOS and lower index expenditure than Lap. Among RN, RAS had shorter LOS, and similar open-conversion and index expenditures. During 1-year post-discharge, RAS had lower hospital outpatient visits (IRR = 0.92, 95% CI = 0.85, 0.99, p = 0.029) and office-based visits (IRR = 0.91, 95% CI = 0.86, 0.96, p = 0.002) for PN, translating to a 1-day less (95% CI = 0.25, 1.75, p = 0.008) missed from work for RAS. Following RN, RAS had lower 1-year readmission than Lap (O.R = 0.72, 95% CI = 0.55, 0.94, p = 0.018). RAS and Lap had comparable 1-year post-discharge expenditures for both PN (mean difference, MD = -$475, 95% CI = -$4362, $3412, p = 0.810) and RN (MD = -$4,204, 95% CI = -$13,837, $5430, p = 0.404). CONCLUSION: At index surgery, RAS was associated with shorter LOS for both PN and RN, and lower open-conversion and expenditures for PN. RAS and Lap had comparable 1-year total expenditures, despite lower healthcare visits for RAS.

Comparison of 1-Year Health Care Expenditures and Utilization Following Minimally Invasive vs Open Nephrectomy.

Importance: Given the widespread adoption and clinical benefits of minimally invasive surgery approaches (MIS) in partial nephrectomy (PN) and radical nephrectomy (RN), assessment of long-term cost implications is relevant. Objective: To compare health care utilization and expenditures within 1 year after MIS and open surgery (OS). Design, Setting, and Participants: This cohort study was conducted using a US commercial claims database between 2013 and 2018. A total of 5104 patients aged 18 to 64 years who underwent PN or RN for kidney cancer and were continuously insured for 180 days before and 365 days after surgery were identified. An inverse probability of treatment weighting analysis was performed to examine differences in costs and use of health care services. Exposures: Surgical approach (MIS or OS). Main Outcomes and Measures: Outcomes assessed included 1-year total health care expenditure, health care utilizations, and estimated days missed from work. Results: Of the 5104 patients, 2639 had PN (2008 MIS vs 631 OS) and 2465 had RN (1816 MIS vs 649 OS) and most were male (PN: 1657 [62.8%]; RN: 399 [63.1%]) and between 55 and 64 years of age (PN: 1034 [51.3%]; RN: 320 [55.7%]). Patients who underwent MIS had lower index hospital length of stay compared with OS (mean [95% CI] for PN: 2.45 [2.37-2.53] vs 3.78 [3.60-3.97] days; P < .001; for RN: 2.82 [2.73-2.91] vs 4.62 [4.41-4.83] days; P < .001), and lower index expenditure for RN ($28 999 [$28 243-$29 796] vs $31 977 [$30 729-$33 329]; P < .001). For PN, index expenditure was lower for OS than MIS (mean [95% CI], $27 480 [$26 263-$28 753] vs $30 380 [$29614-$31 167]; P < .001). Patients with MIS had lower 1-year postdischarge readmission rate (PN: 15.1% vs 21.5%; odds ratio [OR], 0.65; 95% CI, 0.52-0.82; P < .001; RN: 15.6% vs 18.9%; OR, 0.79; 95% CI, 0.63-1.00; P = .05), and fewer hospital outpatient visits (mean [95% CI] for PN: 4.69 [4.48-4.90] vs 5.25 [4.84-5.66]; P = .01; RN: 5.50 [5.21-5.80] vs 6.71 [6.12-7.30]; P < .001) than those with OS. For RN, MIS was associated with 1.47 fewer missed workdays (95% CI, 0.57-2.38 days; P = .001). The reduction in health care use in MIS was associated with lower or similar total cumulative expenditures compared with OS (mean difference [95% CI] for PN: $331 [-$3250 to $3912]; P = .85; for RN: -$11 265 [-$17 065 to -$5465]; P < .001). Conclusions and Relevance: In this cohort study, MIS was associated with lower or similar total cumulative expenditure than OS in the period 1 year after discharge from the index surgery. These findings suggest that downstream expenditures and resource utilization should be considered when evaluating surgical approach for nephrectomy.

A national database propensity score-matched comparison of minimally invasive and open colectomy for long-term opioid use.

BACKGROUND: Opioid dependence is a public health crisis and surgery is a risk factor for long-term opioid use. Though minimally invasive surgery (MIS) is associated with less perioperative pain, demonstrating an association with less long-term opioid use would be another reason to justify adoption of minimally invasive techniques. We compared the rates for long-term opioid prescriptions among patients in a large national database who underwent minimally invasive and open colectomy. METHODS: Using the MarketScan Database, we retrospectively analyzed patients undergoing colon resection for benign and malignant diseases between 2013 and 2017. Among opioid-naïve patients who had ≥ 1 opioid prescriptions filled perioperatively (30 days before surgery to 14 days after discharge), propensity score matching was applied for group comparisons [open (OS) versus MIS, and laparoscopic (LS) versus robotic-assisted surgery (RS)]. The primary outcome was long-term opioid use defined as the proportion of patients with ≥ 1 long-term opioid prescriptions filled 90-180 days after discharge. Risks factors for long-term opioid use were assessed using logistic regression. RESULTS: Among the 5413 matched pairs in the MIS versus OS cohorts, MIS significantly reduced long-term opioid use of 'any opioids' (13.3% vs. 20.9%), schedule II/III opioids (11.7% vs. 19.2%), and high-dose opioids (4.3% vs. 7.7%; all p < 0.001). Among the 1195 matched pairs in the RS versus LS cohorts, RS was associated with less high-dose opioids (2.1% vs. 3.8%, p = 0.015) 90-180 days after discharge. Other risk factors for long-term opioid use included younger age, benign indications, tobacco use, mental health conditions, and > 6 Charlson comorbidities. CONCLUSION: Minimally invasive colectomy is associated with a significant reduction in long-term opioid use when compared to OS. Robotic-assisted colectomy was associated with less high-dose opioids compared to LS. Increasing adoption of minimally invasive surgery for colectomy and including RS, where appropriate, may decrease long-term opioid use.

Shared decision making, satisfaction with care and medication adherence among patients with diabetes.

OBJECTIVES: We examined factors associated with shared decision making and whether shared decision-making (SDM) was associated with satisfaction with care or with adherence to anti-diabetic medication. METHODS: A retrospective study was conducted using 2011-2014 Medical Expenditure Panel Survey (MEPS) data. Inclusion criteria were 18 years or older and visit to a usual source of care during the prior 12 months. Exclusion criteria were reported cognitive limitation, proxy response, less than two prescription fills, or missing data on study variables. SDM was assessed using seven MEPS items. Satisfaction with care was assessed using a single MEPS item 12 months after SDM measurement. Adherence was assessed using Medication Possession Ratio in 12 months after SDM measurement. RESULTS: The weighted sample of 797 respondents represented 15.6 million with diabetes. Being older, male, or uninsured were associated with low SDM. High SDM was associated with higher satisfaction (p < 0.0001). SDM was not associated with adherence. CONCLUSIONS: Patients with higher SDM were more satisfied with their healthcare. We did not find association between SDM and adherence to antidiabetic medication. PRACTICE IMPLICATIONS: Involvement in SDM is encouraged to improve patient satisfaction. Providers may consider age, sex and insurance status in facilitating communications to improve SDM.