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Minimally invasive surgery

Minimally invasive surgeries underused in older patients

MIS use was greater in the general population than in Medicare population for all procedures

A study of more than 200,000 Medicare patients who had common surgical procedures shows that, compared to the general population, they underwent far fewer minimally invasive operations, whose benefits include lower rates of complications and readmissions, along with shorter hospital stays. The paper, ‘Minimally invasive versus open surgery in the Medicare population: a comparison of post-operative and economic outcomes’, published in Surgical Endoscopy, suggests that the disparities short-circuit the potential for better care and cost savings.

“This study shows there is an opportunity for Medicare and other payers to spend health care dollars more wisely so that they reward high-value care over low-value care” said Dr Martin Makary, professor of surgery at the Johns Hopkins University School of Medicine and a widely published expert on health care disparities and quality improvement programmes.

In an effort to highlight potential efficiencies and cost savings, Makary and his team focused on the use of minimally invasive surgery (MIS) in elderly patients. Previous studies have shown that MIS is associated with lower postoperative complication rates, readmission rates, mortality and health care costs, as well as shorter lengths of stay. These improved outcomes stand to benefit elderly patients as much as nonelderly patients, yet MIS is still underused. For select operations, the use of MIS nearly eliminates the risk of a wound infection, and for others, it halves the overall complication rate.

Makary added that complication prevention is a key goal in older, sometimes frail patients because a single complication can lead to a cascade of harmful and costly events. This study provides a comprehensive review of data for seven surgical procedures: cholecystectomy, bariatric, colectomy, hysterectomy, inguinal hernia, thoracic and ventral hernia.

For the study, Makary and colleagues used the 2014 Medicare Provider Analysis and Review Inpatient Limited Data Set to identify patients who underwent the seven common procedures. The research team also evaluated odds of complications and readmissions for any cause within 30 days.

Data from 233,984 patients (102,729 who underwent standard operations and 131,255 who underwent MIS procedures) showed that MIS complication rates were lower for five of seven procedures examined. Readmission rates after MIS were lower for six procedures (with the exception of inguinal hernia) and MIS was associated with less time in the hospital for six procedures. In addition, Medicare claim costs for MIS were lower for four (range US$3,010.23–US$4,832.74 less per procedure) and Medicare reimbursements were lower for three (range US$841.10–US$939.69 less per procedure). Overall, MIS use was greater in the general population than in Medicare population for all procedures.

One limitation of the study was that candidacy for MIS can be difficult to determine on a population level. But, he said, he believes that the study supports the idea that “underuse of MIS for eligible candidates in the Medicare population is an example of low-value care.”

“MIS benefited Medicare patients undergoing a range of surgical procedures. MIS was associated with fewer complications and re-admissions as well as shorter LOS and lower Medicare costs and reimbursements versus open surgery,” the researchers conclude. “MIS may represent a better quality and cost proposition in the Medicare population.”

Funding for this study was provided by The Rodda Family Partnership.

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