Impact of robotic operative efficiency on profitability

doi:10.1016/j.ajog.2013.03.030

American Journal of Obstetrics and Gynecology

Volume 209, Issue 1, July 2013, Pages 20.e1-20.e5

Presented in oral format at the 41st Annual Global Congress of the American Association of Gynecologic Laparoscopists, Las Vegas, NV, Nov. 5-9, 2012; in poster format at the 33rd Annual Scientific Meeting of the American Urogynecologic Society, Chicago, IL, Oct. 3-6, 2012; and in oral format at the 37th Annual Scientific Meeting of the International Urogynecological Association, Brisbane, Australia, Sept. 4-8, 2012.

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Objective

We sought to determine the impact of robotic operative efficiency on profitability and assess the impact of secondary variables.

Study Design

Financial data were collected for all robotic cases performed for fiscal years 2010 (FY10) and 2011 (FY11) at University of North Carolina at Chapel Hill, and included 9 surgical subspecialties. Profitability was defined as a positive operating income.

Results

From July 2009 through June 2011, 1295 robotic cases were performed. Robotic surgery was profitable in both fiscal years, with an operating income of $386,735 in FY10 and $822,996 in FY11. In FY10, urogynecology and pediatric surgery were the only nonprofitable subspecialties. In FY11, all subspecialties were profitable. Profitability was associated with case time, payor mix, and procedure type (all P < .05). Urogynecology case time decreased from 220-179 minutes (P = .012) and pediatric surgery from 418-258 minutes (P = .019).

Conclusion

Robotic operative efficiency has a large impact on overall profitability regardless of surgical specialty.

Section snippets

Materials and Methods

After institutional review board exemption was obtained, a deidentified financial database was used to collect data for fiscal years 2010 (FY10) and 2011 (FY11) at 1 academic medical center: the University of North Carolina at Chapel Hill (UNC). Robotic-assisted surgery was first introduced at UNC in 2005 and an organized robotics program, the Computer and Robotic Enhanced Surgery (CARES) Center, was launched in 2008. A dedicated robotics nursing team and coordinator were also established. The

Results

From July 2009 through June 2011 there were 1295 robotic surgical cases performed at UNC among 9 surgical specialties and 29 surgeons. Each case was defined as a single patient encounter, even if >1 procedure was performed. In both years, gynecologic oncology had the largest proportion of cases (43.6%), followed by urology (32.5%), urogynecology (10.0%), advanced laparoscopy (6.9%), gastrointestinal surgery (2.9%), otolaryngology (1.5%), pediatric surgery (0.8%), general gynecology (0.6%), and

Comment

In this comprehensive financial review of an established, high-volume robotics program, we found that profitability was achieved and growing over 2 recent fiscal years. The observed increase in profitability was affected by 2 principal factors: increased robotic volume and a significant improvement in operative efficiency for urogynecology and pediatric surgery–the 2 subspecialties with a demonstrated loss in FY10. There was no demonstrable difference in reimbursement rates over the study

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Establishing the Learning Curve of Robotic Sacral Colpopexy in a Start-up Robotics Program
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Citation Excerpt :
The surgical complexity of a sacral colpopexy and the improved dexterity and visualization of robotics have made this a natural marriage. Critics of robotic surgery primarily cite length of time and thus increased cost as the main arguments against this technology [9,10]. However, surgical time is made up of many facets.
To determine the learning curve of the following segments of a robotic sacral colpopexy: preoperative setup, operative time, postoperative transition, and room turnover.
A retrospective cohort study to determine the number of cases needed to reach points of efficiency in the various segments of a robotic sacral colpopexy (Canadian Task Force II-2).
A university-affiliated community hospital.
Women who underwent robotic sacral colpopexy at our institution from 2009 to 2013 comprise the study population.
Patient characteristics and operative reports were extracted from a patient database that has been maintained since the inception of the robotics program at Winthrop University Hospital and electronic medical records. Based on additional procedures performed, 4 groups of patients were created (A–D).
Learning curves for each of the segment times of interest were created using penalized basis spline (B-spline) regression. Operative time was further analyzed using an inverse curve and sequential grouping. A total of 176 patients were eligible. Nonparametric tests detected no difference in procedure times between the 4 groups (A–D) of patients. The preoperative and postoperative points of efficiency were 108 and 118 cases, respectively. The operative points of proficiency and efficiency were 25 and 36 cases, respectively. Operative time was further analyzed using an inverse curve that revealed that after 11 cases the surgeon had reached 90% of the learning plateau. Sequential grouping revealed no significant improvement in operative time after 60 cases. Turnover time could not be assessed because of incomplete data.
There is a difference in the operative time learning curve for robotic sacral colpopexy depending on the statistical analysis used. The learning curve of the operative segment showed an improvement in operative time between 25 and 36 cases when using B-spline regression. When the data for operative time was fit to an inverse curve, a learning rate of 11 cases was appreciated. Using sequential grouping to describe the data, no improvement in operative time was seen after 60 cases. Ultimately, we believe that efficiency in operative time is attained after 30 to 60 cases when performing robotic sacral colpopexy. The learning curve for preoperative setup and postoperative transition, which is reflective of anesthesia and nursing staff, was approximately 110 cases.
Impact of robotic operative efficiency on profitability
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: The authors have received honoraria from Intuitive Surgical and provide an observation site for robotic surgery. They report no conflict of interest.

: Cite this article as: Geller EJ, Matthews CA. Impact of robotic operative efficiency on profitability. Am J Obstet Gynecol 2013;209:20.e1-5.

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American Journal of Obstetrics and Gynecology

Objective

Study Design

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

References (23)

Oral implantation of saliva-treated Streptococcus mutans in man

Arch Oral Biol

Comparative hospital cost-analysis of open and robotic-assisted radical prostatectomy

Urology

Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques

Gynecol Oncol

Cost-minimization analysis of robotic-assisted, laparoscopic, and abdominal sacrocolpopexy

J Minim Invasive Gynecol

Analysis of robotic performance times to improve operative efficiency

J Minim Invasive Gynecol

Use of bidirectional barbed suture in laparoscopic myomectomy: evaluation of perioperative outcomes, safety, and efficacy

J Minim Invasive Gynecol

Comparing robot-assisted with conventional laparoscopic hysterectomy: impact on cost and clinical outcomes

J Minim Invasive Gynecol

Cost-minimization analysis of robotic-assisted, laparoscopic, and abdominal sacrocolpopexy

J Minim Invasive Gynecol

Robotic hysterectomy versus conventional laparoscopic hysterectomy: outcome and cost analyses of a matched case-control study

Eur J Obstet Gynecol Reprod Biol

An economic analysis of robotic versus laparoscopic surgery for endometrial cancer: costs, charges and reimbursements to hospitals and professionals

Gynecol Oncol

Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial

Obstet Gynecol

Cited by (27)

Robotic-assisted minimally invasive surgery: Foregut procedures in pediatric patients

Minimally Invasive Pancreas Surgery

Guild interests: an insidious threat to professionalism in obstetrics and gynecology

Analysis on pure e-commerce congestion effect, productivity effect and profitability in China

Establishing the Learning Curve of Robotic Sacral Colpopexy in a Start-up Robotics Program