Perioperative Outcomes and Trends in the Use of Robotic Colectomy for Medicare Beneficiaries From 2010 Through 2016

Abstract

Importance: The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice.

Objective: To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings.

Design, setting, and participants: This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019.

Exposures: Receipt of robotic colectomy.

Main outcomes and measures: Incidence of postoperative medical and surgical complications and length of stay.

Results: A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients]).

Conclusions and relevance: While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.

Figure 1.. Forest Plots Indicating the Relative Risk of Complications Associated With Robotic Colectomy Compared With Open or Laparoscopic Surgery

Results from the conventional risk-adjustment analysis are displayed first, followed by results from the instrumental variable analysis. The relative risk estimates from the instrumental variable analysis represent the local mean treatment effect of robotic surgery in patients who would be considered candidates for either surgical approach.

Figure 2.. Population-Based Trends in Surgical Approach for All Medicare Beneficiaries Undergoing Elective Colectomy (2010-2016)

A, Sample size reflects all US hospitals; starting values were 58.1% (37 952 of 65 332 patients) for open surgery, 41.1% (26 847 of 65 332 patients) for laparoscopic surgery, and 0.7% (457 of 65 332 patients) for robotic surgery, and ending values were 51.5% (39 093 of 75 909 patients) for open surgery, 37.1% (28 162 of 75 909 patients) for laparoscopic surgery, and 10.9% (8274 of 75 909 patients) for robotic surgery. B, Starting values were 59.3% (33 371 of 56 276 patients) for open surgery and 40.7% (22 904 of 56 276 patients) for laparoscopic surgery; ending values were 55.1% (14 381 of 26 099 patients) for open surgery and 45.9% (11 979 of 26 099 patients) for laparoscopic surgery. C and D, Temporal trends for hospitals with the lowest and highest rates of adoption of robotic surgery. Robotic adoption rates were derived for each hospital from the slope with respect to time and hospitals’ proportional use of robotic colectomy. C, Starting values were 55.4% (7360 of 13 286 patients) for open surgery, 43.2% (5739 of 13 286 patients) for laparoscopic surgery, and 1.4% (186 of 13 286 patients) for robotic surgery, and ending values were 52.2% (8430 of 16 149 patients) for open surgery, 42.3% (6831 of 16 149 patients) for laparoscopic surgery, and 5.5% (888 of 16 149 patients) for robotic surgery. D, Starting values were 55.4% (6937 of 12 522 patients) for open surgery, 43.8% (5485 of 12 522 patients) for laparoscopic surgery, and 0.8% (100 of 12 522 patients) for robotic surgery, and ending values were 41.9% (6918 of 16 511 patients) for open surgery, 25.2% (4161 of 16 511 patients) for laparoscopic surgery, and 32.8% (5416 of 16 511 patients) for robotic surgery.