Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4198 (Published 08 July 2014) Cite this as: BMJ 2014;349:g4198
- Michol A Cooper, surgical resident1,
- Susan Hutfless, assistant professor of medicine2,
- Dorry L Segev, associate professor of surgery1,
- Andrew Ibrahim, surgical resident1,
- Heather Lyu, surgical resident1,
- Martin A Makary, professor of surgery1, professor of health policy and management2
- 1Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- 2Departments of Health Policy, Management and Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Correspondence to: M Makary Department of Surgery, Johns Hopkins Hospital, Halsted 610, 600 N Wolfe St, Baltimore, MD 21287, USA mmakary1{at}jhmi.edu
- Accepted 17 June 2014
Abstract
Objective To determine casemix adjusted hospital level utilization of minimally invasive surgery for four common surgical procedures (appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy) in the United States.
Design Retrospective review.
Setting United States.
Participants Nationwide inpatient sample database, United States 2010.
Methods For each procedure, a propensity score model was used to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, hospitals were categorized into thirds (low, medium, and high) based on their actual to predicted proportion of utilization of minimally invasive surgery.
Main outcome measures The primary outcome measures were the actual and predicted proportion of procedures performed with minimally invasive surgery. Secondary outcome measures included surgical complications and hospital characteristics.
Results Mean hospital utilization of minimally invasive surgery was 71.0% (423/596) for appendectomy (range 40.9-93.1% (244-555)), 28.4% (154/541) for colectomy (6.7-49.8% (36/541-269/541)), 13.0% (65/499) for hysterectomy (0.0-33.6% (0/499-168/499)), and 32.0% (67/208) for lung lobectomy (3.6-65.7% (7.5/208-137/208)). Utilization of minimally invasive surgery was highly variable for each procedure type. There was noticeable discordance between actual and predicted utilization of the surgery (range of actual to predicted ratio for appendectomy 0-1.49; colectomy 0-3.88; hysterectomy 0-6.68; lung lobectomy 0-2.51). Surgical complications were less common with minimally invasive surgery compared with open surgery, respectively: overall rate for appendectomy 3.94% (1439/36 513) v 7.90% (958/12 123), P<0.001; for colectomy: 13.8% (1689/12 242) v 35.8% (8837/24 687), P<0.001; for hysterectomy: 4.69% (270/5757) v 6.64% (1988/29 940), P<0.001; and for lung lobectomy: 17.1% (367/2145) v 25.4% (971/3824), P<0.05. High utilization of minimally invasive surgery was associated with urban location (appendectomy: odds ratio 4.66, 95% confidence interval 1.17 to 18.5; colectomy: 4.59, 1.04 to 20.3; hysterectomy: 15.0, 2.98 to 75.0), large hospital size (hysterectomy: 8.70, 1.62 to 46.8), teaching hospital (hysterectomy: 5.41, 1.27 to 23.1), Midwest region (appendectomy: 7.85, 1.26 to 49.1), south region (appendectomy: 21.0, 3.79 to 117; colectomy: 10.0, 1.83 to 54.7), and west region (appendectomy: 9.33, 1.48 to 58.8).
Conclusion Hospital utilization of minimally invasive surgery for appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy varies widely in the United States, representing a disparity in the surgical care delivered nationwide.
Footnotes
Contributors: All the authors designed and conceived the study; collected, managed, analysed, and interpreted the data; and prepared, reviewed, or approved the manuscript. MC had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. She is guarantor.
Funding: None received.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: MM who receives royalties from Bloomsbury Press for a published book; no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: Not required.
Data sharing: The technical appendix, statistical code, and dataset are available from Susan Hutfless at shutfle1{at}jhmi.edu.
Transparency: MC affirms that the manuscript is an honest, accurate and transparent account of the study being reported, that no important aspects of the study have been omitted, and that any discrepancies from the study as planned have been explained.
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