Regional Variation in the Performance of Minimally Invasive Surgical Procedures

Lindsay Kuo, MD1, Kristina Simmons, PhD1, Kenric Murayama, MD2, Rachel R Kelz, MD, MSCE1. 1Hospital of the University of Pennsylvania, 2Abington Memorial Hospital

Background: Regional variation in the performance of surgical procedures exists, and indicates an inefficient health care system. Variation in the performance of minimally invasive surgical procedures has not been studied. The goal of this study was to examine regional variation in the performance of common minimally invasive surgical procedures.

Methods: Five surgical procedure groups that can be readily performed via open or minimally invasive techniques were selected: cholecystectomy, appendectomy, colectomy, antireflux procedures, and bariatric procedures. Using a three-state database from 2007-2012, all patients over age 18 years who received one of these procedures were included in the study. The three states were divided into hospital service areas (HSAs). For each type of surgery, the HSA-specific per-capita number of procedures, open and laparoscopic, was calculated per HSA. Procedure rates were adjusted by gender, race and age for each HSA. The percentage of procedures performed laparoscopically was calculated. HSAs with less than 50% or greater than 150% of the average for each procedure were identified and considered to be outlier regions. The number of low, high and total outlier regions was calculated for each procedure. The ratio of the highest to lowest rate of performance between regions was also calculated for each procedure.

Results: Cholecystectomy was most frequently performed via minimally invasive technique, with 89.5% of all cholecystectomies done by MIS. 88.4% of bariatric procedures, 80.7% of antireflux procedures and 74.9% of appendectomies were laparoscopic. In contrast, only 28.5% of colectomies were done by the minimally invasive approach. There was little variation in the percentage of cholecystectomies done by MIS: the ratio between the highest-performing and lowest-performing regions was only 1.8:1, and there were no outlier regions. Bariatric procedures, antireflux procedures, and appendectomies exhibited intermediate variation in the percentage performed by MIS. Colectomies exhibited 13 outlier regions and had a ratio of 23.4:1 between the highest-performing and lowest-performing procedures, demonstrating high variation.

Conclusion: The benefits of laparoscopy are widely known, however our results demonstrate that laparoscopy is not widely performed. Variation in utilization of the MIS approach differs by procedure type. The degree of variation in the performance of laparoscopic procedures depends on the acceptance of laparoscopy as the gold standard, it this not the only factor in the adoption of laparoscopic procedures: laparoscopic cholecystectomy, appendectomy, bariatric and antireflux procedures were rapidly adopted before substantial scientific evidence supported these transitions. The learning curve for technically complex laparoscopic procedures may also contribute to the variation in performance. A deeper investigation of the causes of regional variation for each procedure is warranted before interventions can be made.


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