Cost-Benefit Analysis: Robotic (da Vinci) versus Laparoscopic Procedures
Robotic surgery involves performing laparoscopic or minimally invasive surgery (MIS). The da Vinci robot, presented by Intuitive Surgical Corporation in 2000, combines the advantages of both the laparoscopic procedures and open surgery. Its application in medicine is associated with a major breakthrough in the area of complex surgical operations, such as those of the esophagus, liver, etc. (Ramirez & Lotan, 2015). Until recently, these procedures were performed using an open technique of conventional operation, in which the surgeon had to cut a broad platform to gain access to the internal organs to overcome the insurmountable technical difficulties. Currently, however, the use of da Vinci surgical system, in many cases, has made it possible to avoid open surgery by replacing it with minimally invasive robotic medical technology. The latter is also used as a supplement to a conventional laparoscopy, e.g., in the treatment of prostate cancer. Robotic medical technology is a more gentle method of surgery that allows one to recover faster after the operation and keep all the functions of the operated organ. In the US, at present, most cases of surgical treatment of prostate cancer, as well as nearly 70% of urological and gynecological interventions are carried out using the robot-assisted technique (Diana & Marescaux, 2015). The paper discusses available approaches to identifying costs and benefits of the application of robotic (da Vinci) procedures versus laparoscopic surgery and their implications.
In the most recent systematic review, Tandogdu, Vale, Fraser and Ramsay (2015) assembled evidence to perform a robot-assisted laparoscopic (RAL) surgery cost-effective analysis. The authors assessed 47 studies reporting cost-benefit data. 72% of them were US-based, and most were conducted from a hospital perspective. Only six of them provided a full economic evaluation. Nearly half of the studies considered urological indications. The rest of them were related to the application of RAL across the following clinical areas descendingly: urology and gynecology, obstetrics and gynecology, general surgery, and cardiothoracic surgery. Given the limitations of the studies and the poor evidence of clinical effectiveness, total costs for RAL in prostatectomy, cystectomy, partial nephrectomy, hysterectomy, sacrocolpoplexy, antireflux surgery, colectomy, coronary artery bypass, and pulmonary lobectomy were reported to be higher than laparoscopy, open surgery, and other types of surgical procedures, if applied, in all studies. According to the data, the use of RAL gastric bypass surgery has led to lower rate of anastomotic leakages compared to laparoscopy and open surgery. Myotomy and cholecystectomy RAL costs were higher than laparoscopic surgery but slightly lower than open surgery.
Tandogdu et al. found that 85% of the reviewed studies focused on hospital costs only. 11% of them employed a publicly funded healthcare system. A time-horizon approach reporting long-term outcomes was identified in one study. The authors suggested that robotic surgical technology appeared safe and feasible having similar clinical outcomes compared to laparoscopic and open surgery. However, long-term clinical costs efficiency of robotic surgery is yet to be assessed. Decision makers are advised to consider both the paucity of the data underlying cost-benefits estimates, as well as its relevance to their particular systems. Given the similar pathway, the available economic models for radical prostatectomy and hysterectomy were recommended to be adapted.
In addition, according to Yang, Monn, Bahler, and Sundaram (2014), the decision to use RAL technology must be made by a surgeon based on one’s particular experience with pure laparoscopy and a specific patient, as well as the tumor factors. Whereas, during laparoscopic procedures, a doctor can influence costs via reusable instruments and hook electrode, robots’ related costs are not easily modifiable. However, with the robotic-assistance becoming prevalent and due to a longer learning curve associated with laparoscopic procedures, the pure laparoscopy skills of surgeons are likely to become inadequate in the future. As a result, RAL procedures will ultimately demonstrate better outcomes.
Diana and Marescaux (2015) argued that the benefits of the current healthcare procedures must be assessed in terms of increasingly scrutinized postoperative results, quality of life, and accelerated recovery. Robotic and computer sciences provided valuable innovations including da Vinci robot, “an amazing concentrate of technology” (p. e17), to augment the skills of surgeons. They enabled complex surgical procedures to be more accurate and highly precise. The authors reviewed the application of RAL to esophagectomy, gastric bypass, pancreatic and liver resections, and rectal resection for cancer procedures. They asserted that they may benefit from the assistance of robotic platforms. Although the latter are associated with higher costs, they are likely to decrease in the light of the developing surgical robotic platforms.
Ramji et al. (2015) conducted a retrospective review of 79 rectal cancer interventions comprising 26 cases completed through the open approach, 27 via laparoscopic surgery, and 26 via robotic assistance. The studied groups had similar demographic characteristics. The results indicated that early experience in RAL had led to similar clinical and oncological outcomes compared with conventional methods. The advantages of da Vinci regarding improved conversion rates and decreased intraoperative blood loss came at a higher financial cost and implied no short-term clinical benefits. Not considering the initial investment for the device, the operational cost of the application of da Vinci robot increased the average cost of stay for a patient by 1.5 times. The important functional outcome of preserving nerve function by post-rectal cancer surgery afforded by robotic approach is yet to be assessed in long-term studies, as well as the quality of life improvements in RAL prostate surgery.
Responding to the limitations of the studies focused solely on the total costs assessments, Fuertes-Guiro, Girabent-Farre’s, and Viteri-Velasco (2014) aimed to evaluate the opportunity cost associated with the application of da Vinci robot compared to traditional laparoscopic procedures, regardless of the disease operated. They derived from the statement that any use of healthcare resources is a sacrifice that involves making a decision not to use them for alternative ends. To this end, the strategies of analyzing total healthcare costs are said to ignore the cost advantages in efficiency that the certain procedures may have over another. The RAL and laparoscopic surgeries should be compared in terms of additional time spent during interventions and outcomes of quantity and quality of life. According to the authors, despite the higher total operating cost of robots, the difference is not substantially relevant and the choice of technology should not be linked to the cost of the technique. The use of da Vinci has eliminated the major drawbacks of traditional laparoscopy in many pathologies. It has also made it an attractive surgical procedure.
The benefits of using da Vinci, including reduced blood loss, the length of surgery, and hospital stay, are offset by the costs of equipment and its maintenance. However, robotic technology is associated with unprecedented opportunities of executing complex surgeries with improved task quality and better patient outcomes that justify the high initial investments. It has become more prevalent and increased patient demand (Turchetti, Palla, Pierotti, & Cuschieri, 2012; Ramirez & Lotan, 2015). The fragmented decision-making has contributed to the commercial success of surgery robots. Hospitals cannot resist surgeons’ preferences, as the institutions compete to attract professionals and patients (Barbash & Glied, 2010). Moreover, the high cost can be explained in terms of the lack of market competition and expenses associated with new, early phase technology. The latter is yet to mature the low-cost systems that will deliver great value to the economy of healthcare (Gomes, 2010; Cundy, Harling, Marcus, Athanasiou, & Darzi, 2014).
Despite the undeniable effectiveness and safety of da Vinci surgical system, its application is not always acceptable. There are medical cases when the use of such technology is not appropriate (Yang et al., 2014). The concept of robotic program is diversified and includes the purchase of surgical system, service maintenance, monitoring, repair, and procurement of consumables. Training of medical personnel is also of great importance. The total costs currently offset the benefits of da Vinci’s application (Ramji et al., 2015; Ramirez & Lotan, 2015; Gomes, 2010; Cundy et al., 2014). However, in healthcare, the cost-effectiveness evaluation cannot be limited to the exclusive considering of total financial costs. The cost-value debate over the use of RAL and laparoscopy can be balanced by obtaining data on long-term outcomes and quality of life metrics (Tandogdu et al., 2015; Diana & Marescaux, 2015; Gomes, 2010; Cundy et al., 2014; Ramji et al., 2015). It must also take into account the opportunity cost (Fuertes-Guiro et al., 2014). The prevalence of robotic surgical technologies and extensive patients’ demand are the independent factors that will increase their effectiveness compared with laparoscopic procedures (Yang et al., 2014; Barbash & Glied, 2010). Finally, some of the existing data reflecting short-term clinical effectiveness could be affected by the very skills of surgeons operating da Vinci robots during the studies (Ramji et al., 2015).
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