Minimally Invasive Surgery Cuts Costs, Lowers Days Absent from Work

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Minimally invasive surgery reduces health care costs and helps patients miss fewer workdays compared with conventional surgery, according to a decade-long study looking at several different types of interventions. The findings were published March 20, 2013, ahead of print in JAMA Surgery.

Andrew J. Epstein, PhD, of the University of Pennsylvania (Philadelphia, PA), and colleagues examined national health insurance claims data and matched workplace absenteeism records for a sample of patients treated from January 1, 2000, to December 31, 2009, who were enrolled in employer-sponsored health insurance. They considered 6 separate categories:

  • Coronary revascularization
  • Uterine fibroid resection
  • Peripheral revascularization
  • Prostatectomy
  • Carotid revascularization
  • Aortic aneurysm repair

In all, 321,956 patients underwent intervention during that period, including 196,700 treated with minimally invasive surgery (61.1%) and 125,256 who received standard surgery (38.9%). Patients in the minimally invasive group tended to be older, male, have more comorbidities, live in rural areas, and be covered by less restrictive health plans.

After adjustment for year of procedure, the patient’s propensity for receiving minimally invasive treatment, and other factors, health care spending over 1 year after treatment was lower with minimally invasive treatment in 3 of 6 categories. Two categories, meanwhile, had higher spending (table 1).

Table 1. Health Plan Spending: Minimally Invasive vs. Standard Surgery

 

Mean Difference

95% CI

Coronary Revascularization

-$30,850

-$31,629 to -$30,091

Uterine Fibroid Resection

$1,509

-$1,754 to -$1,280

Peripheral Revascularization

-$12,031

-$15,552 to -$8,717

Carotid Revascularization

$4,900

$1,772 to $8,370

Prostatectomy

$1,350

$611 to $2,212


Information regarding work absenteeism was available for 23,814 patients who were employees of self-insured firms. Within this cohort, minimally invasive treatment also was associated with fewer days absent from work in 4 of the 6 categories (table 2).

Table 2. Days Absent from Work: Minimally Invasive vs. Standard Surgery

 

Mean Difference

95% CI

Coronary Revascularization

-37.7 days

-41.1 to -34.3 days

Uterine Fibroid Resection

-11.7 days

-14.0 to -9.4 days

Peripheral Revascularization

-16.6 days

-28.0 to -5.2 days

Prostatectomy

-9.0 days

-14.2 to -3.7 days


The researchers calculated that in 2009 alone, use of minimally invasive over standard surgery saved $8.9 billion and 53,134 person-years of absenteeism. Had minimally invasive procedures been used exclusively, spending would have been lowered by another $2.3 billion dollars and absenteeism by another 19,635 person-years. Coronary revascularization, which accounted for 43.1% of 2009 cases, was responsible for most of the savings.

Altogether, the projected savings—both from reduced health spending and from the economic advantages of less absenteeism—in 2009 would reach $14 billion, the paper reports.

Procedures Not Interchangeable

Justin B. Dimick, MD, MPH, of the University of Michigan (Ann Arbor, MI), and Andrew M. Ryan, PhD, of Weill Cornell Medical College (New York, NY), point out in an editorial accompanying the paper that the study’s reliance on administrative data translates to a lack of “clinical detail on how patients were chosen for less invasive vs. standard surgery.”

Because of possible selection bias, the benefit of minimally invasive surgery is likely overestimated, they suggest. However, this drawback “is not a fatal flaw,” they conclude, because bias could only partially explain the findings. “This study is also valuable because it broadens our thinking to include the societal perspective, which is not always considered in the clinical literature,” they write.

Dr. Epstein told TCTMD in a telephone interview that, while the editorial made a valid point about methodology, the researchers were working with the only data available.

However, he stressed, “[f]rom a physician’s perspective, what we want to be careful about saying is that our study does not speak at all to clinical appropriateness—obviously.” Thus, the results say nothing about which treatment is best suited for a particular patient.

“The results are not shocking. Minimally invasive surgery leads to less missed work [and lower health plan spending]. But what we’re able to do is quantify that. [A]long with everything else that clinicians are thinking about, this is potentially 1 more thing to put into the mix,” Dr. Epstein noted.

More generally, he said, the study “raises questions about how we value new technology” and its impact, which often is not quantified.

Quality of Life Matters

In a telephone interview with TCTMD, Cindy L. Grines, MD, of Detroit Medical Center (Detroit, MI), said she was pleasantly surprised by the degree to which PCI enabled a quicker return to work and that PCI, even with the possibility of restenosis, was cheaper than CABG at 1 year.

The findings serve as a reminder that hard endpoints are not everything, she related. “Of course, death, MI, those things are important,” Dr. Grines said. “But most procedures we do in this country aren’t done for lifesaving reasons. . . . If you get a knee or hip replacement, it’s all quality of life.”

Raising awareness among clinicians is important, Dr. Grines stressed, because many do not fully understand why patients want minimally invasive treatments. It is not about avoiding scars in the name of vanity, she explained. “That’s the attitude that a lot of us [physicians] have, when in fact now there’s pretty substantial evidence that patients recover way more quickly and it’s less expensive for many of these procedures, particularly the cardiac ones,” Dr. Grines said.

While angioplasty is known to reduce mortality in MI patients—and death, MI, and readmission in those with unstable angina—“we’ve really been taking a beating on the stable angina patients. But we do know that quality of life is improved [in this population],” Dr. Grines commented. “So what’s the problem? Why can’t we do angioplasty to improve quality of life? It’s really just the cost. We’re not harming these patients, really. So now that we’ve shown that it’s actually cost-effective compared to 1 other alternative, I think that’s great.”

 


Sources:
1. Epstein AJ, Groeneveld PW, Harhay MO, et al. Impact of minimally invasive surgery on medical spending and employee absenteeism. JAMA Surg. 2013;Epub ahead of print.

2. Dimick JB, Ryan AM. Taking a broader perspective on the benefits of minimally invasive surgery. JAMA Surg. 2013;Epub ahead of print.

 

 

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Disclosures
  • The study received research grant support from the Institute for Health Technology Studies.
  • Drs. Epstein, Dimick, Ryan, and Grines report no relevant conflicts of interest.

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