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Improving Affordability Through Innovation in the Surgical Treatment of Mitral Valve Disease

      Abstract

      Objective

      To determine whether technically innovative cardiac surgical platforms (ie, robotics) deployed in conjunction with surgical process improvement (systems innovation) influence total hospital costs to address the concern that expanding adoption might increase health care expenses.

      Patients and Methods

      We studied 185 propensity-matched patient pairs (370 patients) undergoing isolated conventional open vs robotic mitral valve repair with identical repair techniques and care teams between July 1, 2007, and January 31, 2011. Two time periods were considered, before the implementation of system innovations (pre-July 2009) and after implementation. Generalized linear mixed models were used to estimate the effect of the type of surgery on cost while adjusting for a time effect.

      Results

      Baseline characteristics of the study patients were similar, and all patients underwent successful mitral valve repair with no early deaths. Median length of stay (LOS) for patients undergoing open repair was unchanged at 5.3 days (P=.636) before and after systems innovation implementation, and was lower for robotic patients at 3.5 and 3.4 days, respectively (P=.003), throughout the study. The overall median costs associated with open and robotic repair were $31,838 and $32,144, respectively (P=.32). During the preimplementation period, the total cost was higher for robotic ($34,920) than for open ($32,650) repair (P<.001), but during the postimplementation period, the median cost of robotic repair ($30,606) became similar to that of open repair ($31,310) (P=.876). The largest decrease in robotic cost was associated with more rapid ventilator weaning and shortened median intensive care unit LOS, from 22.7 hours before July 2009 to 9.3 hours after implementation of systems innovations (P<.001).

      Conclusion

      Following the introduction of systems innovation, the total hospital cost associated with robotic mitral valve repair has become similar to that for a conventional open approach, while facilitating quicker patient recovery and diminished utilization of in-hospital resources. These data suggest that innovations in techniques (robotics) along with care systems (process improvement) can be cost-neutral, thereby improving the affordability of new technologies capable of improving early patient outcomes.

      Abbreviations and Acronyms:

      ICU (intensive care unit), LOS (length of stay), MR (mitral regurgitation), PCU (progressive care unit)
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      References

        • Antman E.M.
        • Harrington R.A.
        Transforming clinical trials in cardiovascular disease: mission critical for health and economic well-being.
        JAMA. 2012; 308: 1743-1744
        • Milstein A.
        • Shortell S.
        Innovations in care delivery to slow growth of US health spending.
        JAMA. 2012; 308: 1439-1440
      1. Orszag PR. How health care can save or sink America: the case for reform and fiscal sustainability. Foreign Affairs website. http://www.foreignaffairs.com/articles/67918/peter-r-orszag/how-health-care-can-save-or-sink-america. Published July/August 2011. Accessed January 1, 2013.

        • Enriquez-Sarano M.
        • Avierinos J.F.
        • Messika-Zeitoun D.
        • et al.
        Quantitative determinants of the outcome of asymptomatic mitral regurgitation.
        N Engl J Med. 2005; 352: 875-883
        • Suri R.M.
        • Vanoverschelde J.L.
        • Grigioni F.
        • et al.
        Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets.
        JAMA. 2013; 310: 609-616
        • Nifong L.W.
        • Chu V.F.
        • Bailey B.M.
        • et al.
        Robotic mitral valve repair: experience with the da Vinci system.
        Ann Thorac Surg. 2003; 75: 438-442
        • Nifong L.W.
        • Chitwood W.R.
        • Pappas P.S.
        • et al.
        Robotic mitral valve surgery: a United States multicenter trial.
        J Thorac Cardiovasc Surg. 2005; 129: 1395-1404
        • Schmitto J.D.
        • Mokashi S.A.
        • Cohn L.H.
        Minimally-invasive valve surgery.
        J Am Coll Cardiol. 2010; 56: 455-462
        • Suri R.M.
        • Antiel R.M.
        • Burkhart H.M.
        • et al.
        Quality of life after early mitral valve repair using conventional and robotic approaches.
        Ann Thorac Surg. 2012; 93: 761-769
        • Cima R.R.
        • Brown M.J.
        • Hebl J.R.
        • et al.
        • Surgical Process Improvement Team, Mayo Clinic, Rochester
        Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center.
        J Am Coll Surg. 2011; 213: 83-92
        • Rosenbaum P.R.
        • Rubin D.B.
        The central role of the propensity score in observational studies for causal effects.
        Biometrika. 1983; 70: 41-55
        • Bonow R.O.
        • Carabello B.A.
        • Kanu C.
        • et al.
        • American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons
        ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.
        Circulation. 2006; 114 ([published corrections appear in Circulation. 2007;115(15):e409 and Circulation. 2010;121(23):e443]): e84-e231
        • Suri R.M.
        • Burkhart H.M.
        • Rehfeldt K.H.
        • et al.
        Robotic mitral valve repair for all categories of leaflet prolapse: improving patient appeal and advancing standard of care.
        Mayo Clin Proc. 2011; 86: 838-844
        • Suri R.M.
        • Burkhart H.M.
        • Daly R.C.
        • et al.
        Robotic mitral valve repair for all prolapse subsets using techniques identical to open valvuloplasty: establishing the benchmark against which percutaneous interventions should be judged.
        J Thorac Cardiovasc Surg. 2011; 142: 970-979
        • Dunlay S.M.
        • Shah N.D.
        • Shi Q.
        • et al.
        Lifetime costs of medical care after heart failure diagnosis.
        Circ Cardiovasc Qual Outcomes. 2011; 4: 68-75
        • Thompson J.M.
        • Luedtke C.A.
        • Oh T.H.
        • et al.
        Direct medical costs in patients with fibromyalgia: cost of illness and impact of a brief multidisciplinary treatment program.
        Am J Phys Med Rehabil. 2011; 90: 40-46
      2. Centers for Medicare and Medicaid Services. Berenson-Eggers Type of Service (BETOS). CMS.gov website. http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/BETOS.html. Accessed September 1, 2012.

        • Kaplan R.S.
        • Porter M.E.
        How to solve the cost crisis in health care.
        Harv Bus Rev. 2011; 89 (54, 56-61 passim): 46-52
        • Barbash G.I.
        • Glied S.A.
        New technology and health care costs—the case of robot-assisted surgery.
        N Engl J Med. 2010; 363: 701-704
        • Porter M.E.
        What is value in health care?.
        N Engl J Med. 2010; 363: 2477-2481
        • Anyanwu A.C.
        • Bridgewater B.
        • Adams D.H.
        The lottery of mitral valve repair surgery.
        Heart. 2010; 96: 1964-1967
        • Gammie J.S.
        • Sheng S.
        • Griffith B.P.
        • et al.
        Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database.
        Ann Thorac Surg. 2009; 87: 1431-1437
        • Cohn L.H.
        • Adams D.H.
        • Couper G.S.
        • et al.
        Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair.
        Ann Surg. 1997; 226: 421-426
        • Cosgrove III, D.M.
        • Sabik J.F.
        • Navia J.L.
        Minimally invasive valve operations.
        Ann Thorac Surg. 1998; 65: 1535-1538
        • Iribarne A.
        • Easterwood R.
        • Russo M.J.
        • et al.
        A minimally invasive approach is more cost-effective than a traditional sternotomy approach for mitral valve surgery.
        J Thorac Cardiovasc Surg. 2011; 142: 1507-1514