Socioeconomic Factors and Parity of Access to Robotic Surgery in a County Health System

Fernando Garcia, MD¹, Bradley Putty, MD¹, Leah Tatebe, MD², Mark Bayouth, MD¹, Daniel Zieglar, MD¹, Gary Alexander, MD¹, Gr Stephenson, MD¹, David McReynolds, MD¹. ¹John Peter Smith Hospital, ²Baylor University

INTRODUCTION – Equal access to novel surgical technologies remains a policy concern as hospitals adopt robotic surgery with increasing prevalence. Due to high upfront capital costs and periodic maintenance fees, robotic surgery would theoretically be regarded as a less practical option in a hospital system serving the economically disadvantaged. We examined the use of robotic surgery in a 547 bed county hospital and sought to determine whether socioeconomic factors influence access to robotic surgery.

METHODS – All laparoscopic and robotic fundoplasty and paraesophageal hernia repairs performed from July 2008- June 2014 at a county and neighboring private hospitals were identified. Demographic information including health insurance and median household income at subjects' respective zip codes were collected and analyzed, comparing treatment with robotic surgery versus laparoscopy as the primary outcome. Continuous and categorical variables were examined using student's t-test, Χ² analysis, and logistic regression analysis as indicated.

RESULTS – Overall, 481 subjects underwent surgery (71.5% female, mean age 54 years): 180 (43%) performed in the county hospital and 261 (62.4%) with robotic assistance, with 79.2% of subjects presenting with reflux and 70.1% with paraesophageal hernia. Subjects treated at the county facility were older (56.2 vs 51 yrs), were associated with a lower median household income, and were less likely to undergo an operation involving mesh insertion (44% vs 77%) or the robot (46% vs 74%), as compared to subjects at private hospitals (all p-values <.001). Within the county subject cohort (n=180), robotic surgery was associated with the presence of a paraesophageal hernia and use of mesh. However, there was no association between robotic surgery and median income (Low Quartile 42% vs. 54% those with higher income) or health insurance (Medicaid and uninsured 46.4% vs 43.9% insured).

Conclusion: Factors influencing the use of robotic surgery in gastroesophageal operations in a county health system included presence of paraesophageal hernia and insertion of mesh. No disparity in access to robotic surgery offered in the county hospital was observed in subjects insured by Medicaid or associated with a lower median household income.