ROBOtic Care Outcomes Project for acute gallbladder pathology.

BACKGROUND: Robotic cholecystectomy is being increasingly used for patients with acute gallbladder disease who present to the emergency department, but clinical evidence is limited. We aimed to compare the outcomes of emergent laparoscopic and robotic cholecystectomies in a large real-world database. METHODS: Patients who received emergent laparoscopic or robotic cholecystectomies from 2020 to 2022 were identified from the Intuitive Custom Hospital Analytics database, based on deidentified extraction of electronic health record data from US hospitals. Conversion to open or subtotal cholecystectomy and complications were defined using ICD10 and/or CPT codes. Multivariate logistic regression with inverse probability treatment weighting (IPTW) was performed to compare clinical outcomes of laparoscopic versus robotic approach after balancing covariates. Cost analysis was performed with activity-based costing and adjustment for inflation. RESULTS: Of 26,786 laparoscopic and 3,151 robotic emergent cholecystectomy patients being included, 64% were female, 60% were ≥45 years, and 24% were obese. Approximately 5.5% patients presented with pancreatitis, and 4% each presenting with sepsis and biliary obstruction. After IPTW, distributions of all baseline covariates were balanced. Robotic cholecystectomy decreased odds of conversion to open (odds ratio, 0.68; 95% confidence interval, 0.49-0.93; p = 0.035), but increased odds of subtotal cholecystectomy (odds ratio, 1.64; 95% confidence interval, 1.03-2.60; p = 0.037). Surgical site infection, readmission, length of stay, hospital acquired conditions, bile duct injury or leak, and hospital mortality were similar in both groups. There was no significant difference in hospital cost. CONCLUSION: Robotic cholecystectomy has reduced odds of conversion to open and comparable complications, but increased odds of subtotal cholecystectomy compared with laparoscopic cholecystectomy for acute gallbladder diseases. Further work is required to assess the long-term implications of these differences. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Extremes of body mass index have significant impact on complications, readmissions, and utilization of post-acute services after primary total hip arthroplasty.

AIMS: High body mass index (BMI) is associated with increased rates of complications in primary total hip arthroplasty (THA), but less is known about its impact on cost. The effects of low BMI on outcomes and cost are less understood. This study evaluated the relationship between BMI, inpatient costs, complications, readmissions, and utilization of post-acute services. METHODS: A retrospective database analysis of 40,913 primary THAs performed between January 2013 and December 2017 in 29 hospitals was conducted. Operating time, length of stay (LOS), complication rate, 30-day readmission rate, inpatient cost, and utilization of post-acute services were measured and compared in relation to patient BMI. RESULTS: Mean operating time increased with BMI and for BMI > 50 kg/m2 was approximately twice that of BMI 10 kg/m2 to 15 kg/m2. Mean inpatient cost did not vary significantly with BMI. Mean total reimbursement was lowest for the lowest BMI cohort and increased with BMI. Mean LOS was greatest at the extremes of BMI (4.0 days for BMI 10 kg/m2 to 15 kg/m2; 3.75 days for BMI > 50 kg/m2) and twice that of normal BMI. Mean complication rates were greatest in the lowest BMI cohort (16% for BMI 10 kg/m2 to 15 kg/m2) and five times the mean rate of complications in the normal BMI cohorts. Furthermore, 30-day readmissions were greatest in the highest BMI cohort (10% for BMI > 50 kg/m2) and five times the rate for normal BMI patients. CONCLUSION: LOS, complications, and 30-day readmissions all increase at the extremes of BMI and appear to be greater than those of patients with normal BMI. The lowest BMI patients had the lowest payment for inpatient stay yet were at considerable risk for complications and readmission. Patients with extreme BMI should be counselled about their increased risk of complications for THA and nutritional status/obesity optimized preoperatively if possible. Cite this article: Bone Joint J 2020;102-B(7 Supple B):62-70.

Robotic-assisted versus laparoscopic unilateral inguinal hernia repair: a comprehensive cost analysis.

BACKGROUND: Cost-effectiveness of robotic-assisted surgery is still debatable. Robotic-assisted inguinal hernia repair has no clear clinical benefit over laparoscopic repair. We performed a comprehensive cost-analysis comparison between the two approaches for evaluation of their cost-effectiveness in a large healthcare system in the Western United States. METHODS: Health records in 32 hospitals were queried for procedural costs of inguinal hernia repairs between January 2015 and March 2017. Elective robotic-assisted or laparoscopic unilateral inguinal hernia repairs were included. Cost calculations were done using a utilization-based costing model. Total cost included: fixed cost, which comprises medical device and personnel costs, and variable cost, which comprises disposables and reusable instruments costs. Other outcome measures were length of stay (LOS), conversion to open, and operative times. Statistics were done using t test for continuous variables and χ2 test for categorical variables. A p-value < 0.05 was considered significant. RESULTS: A total of 2405 cases, 734 robotic-assisted (633 Primary: 101 recurrent) and 1671 laparoscopic (1471 Primary: 200 recurrent), were included. The average total cost was significantly higher (p < 0.001) in the robotic-assisted group ($5517) compared to the laparoscopic group ($3269). However, the average laparoscopic variable cost ($1105) was significantly higher (p < 0.001) than the robotic-assisted cost ($933). Whereas there was no significant difference between the two groups for LOS and conversion to open, average operative times were significantly higher in the robotic-assisted group (p < 0.001). Subgroup analysis for primary and recurrent inguinal hernias matched the overall results. CONCLUSIONS: Robotic-assisted inguinal hernia repair has a significantly higher cost and significantly longer operative times, compared to the laparoscopic approach. The study has shown that only fixed cost contributes to the cost difference between the two approaches. Medical device cost plus the longer operative times are the main factors driving the cost difference. Laparoscopic unilateral inguinal hernia repair is more cost-effective compared to a robotic-assisted approach.

Outcome comparisons between high-volume robotic and laparoscopic surgeons in a large healthcare system.

Robotic colorectal surgery has been performed for nearly a decade, but has been criticized for high cost. We sought to assess outcomes of colorectal operations performed by surgeons with higher experience in robotics and laparoscopy across a large health system. We performed a retrospective review of colon or rectal resections performed between January 2013 and May 2016 within the Providence Health and Services. Surgeons were only included if they performed 30 or more procedures with an approach per year. We assessed outcomes including operative time, hospital length of stay, complications, readmission, conversion to open rates and total direct costs. When comparing the two groups, robotics surgery had a decreased length of hospital stay, lower conversion rate, and longer operative time. There was no statistical difference between complications and rate of readmission. There was no statistically significant difference in total direct cost. These data do suggest that high volume robotic surgery can carry the benefit of a lower length of stay and lower conversion rate, while not incurring an increase in total cost, complication or readmissions.