New analytic approach pinpoints laparoscopic colectomy savings

Reuters Health Information: New analytic approach pinpoints laparoscopic colectomy savings

New analytic approach pinpoints laparoscopic colectomy savings

Last Updated: 2017-06-21

By Marilynn Larkin

NEW YORK (Reuters Health) - Laparoscopic colectomy is more cost-effective than open surgery, with most of the savings derived from reduced use of health services after discharge and fewer readmissions, according to researchers who used a novel analytic approach known as instrumental variable analysis.

“Many studies have demonstrated clinical benefits of laparoscopic colectomy - earlier recovery, shorter hospital stay, fewer wound infections,” Dr. Scott Regenbogen of the University of Michigan in Ann Arbor told Reuters Health.

“But there are important shortcomings of common research approaches,” he said by email. “Results of randomized trials might not apply well to the whole population, because they often only involve specialist surgeons and highly selected patients.”

“In most observational studies, there are often important differences between the patients who have laparoscopic versus open surgery,” he noted. “The open surgery cases are typically more complex and the patients have more severe illness, meaning we are comparing apples and oranges.”

“The analysis in this study deals with these problems by including all types of patients and surgeons, but we use the natural observed differences between geographic areas to make a fairer comparison,” he explained.

Coauthor Dr. Kyle Sheetz, also of the University of Michigan, added by email that despite the advantages, including reducing selection bias, instrumental variable analysis studies are difficult to design and therefore “cannot be widely applied without careful thought.”

As reported in JAMA Surgery, online June 14, the team evaluated Medicare payments for 428,799 patients (57% women; mean age, 74) who underwent laparoscopic or open colectomy from 2010 to 2012. Frequency and amount of physician, readmission and postacute care payments were included to identify factors responsible for potential cost savings.

Using standard methods, patients who underwent laparoscopic colectomy had lower total Medicare expenditures ($5,547 lower, on average; P<0.01).

Using instrumental variable methods, which account for potentially unmeasured patient characteristics, those who underwent laparoscopic colectomy still had lower Medicare expenditures, but the magnitude of the association was reduced ($3,676 lower, on average; P<0.01).

The key drivers of the cost differences were a reduction in costs for the laparoscopic patients from readmissions (mean reduction, $1,102) and postacute care (mean reduction, $1,446; P<0.01).

“This population-based study demonstrates the influence of selection bias on cost estimates in comparative effectiveness research,” the authors conclude. “While the use of laparoscopy reduced total episode payments, the source of savings is in the postacute care period, not the index hospitalization.”

Dr. Regenbogen said the results should motivate payers to “encourage increased dissemination and uptake of laparoscopic colectomy.”

However, he cautioned, “laparoscopic colectomy only accrues these clinical and economic benefits in experienced hands - we have found that high-volume, specialty surgeons get improved outcomes with laparoscopy that low-volume surgeons do not.”

Editorialist Dr. Stefan Holubar of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire said it’s difficult for surgeons “to take time out of their schedule and attend expensive laparoscopy courses to try to improve the quality of their surgery.”

Postoperative surgical team “debriefs,” during which surgeons “review what went well and what we could have been done better for that particular case,” can help, he suggested.

“Using video-recording of the laparoscopic operation can augment that process - not quite an instant replay, but as a video recap (of) the most important parts of the operation,” he told Reuters Health by email.

“As intra-operative computer and A/V equipment in the operating room continue to improve, I suspect this will happen naturally,” Dr. Holubar added.

He concluded, “Sometimes we need to pause to reflect on our performance so that we (don’t) just talk the continuous quality improvement talk, but walk the walk by trying to learn as much as we can from each and every individual patient’s surgery, so that we have a chance to ‘always do better the next time.’”


JAMA Surg 2017.

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