Minimally invasive surgical procedures can halve the risk for postoperative complications compared with open procedures, but they are still being used infrequently in many US hospitals, results of a retrospective study suggest.
The use of minimally invasive procedures varies widely among US hospitals, with urban hospitals being more than 4 times as likely as rural hospitals to perform laparoscopic appendectomies and colectomies and 15 times more likely to perform minimally invasive hysterectomies, report Michol A. Cooper, MD, a surgical resident at John Hopkins University School of Medicine in Baltimore, Maryland, and colleagues.
Use of minimally invasive procedures also varied by hospital size, teaching hospital status, and geographic region.
“We found that rural hospitals were less likely to perform minimally invasive surgery for three of the four procedures studied (appendectomy, colectomy, and hysterectomy, the fourth being lobe lobectomy). This disparity may be due to the broad range of surgical services some surgeons in rural areas are required to provide and a scarcity of surgical specialists in such areas with advanced skills in minimally invasive surgery,” the investigators write in a study published July 8 in BMJ.
The researchers analyzed records of a nationwide inpatient sample database from the US Agency for Healthcare and Research Quality to determine use rates and patterns of the 4 common surgical procedures. The data set included information on a representative sample of patients discharged from 1051 hospitals in 45 states in 2010.
They chose to look at records for 3 procedures supported by a strong evidence base (laparoscopic appendectomy, partial colectomy, and total abdominal hysterectomy) and 1 for which the benefits of a minimally invasive procedure vs an open procedure are less certain (thorascopic lung lobectomy).
The authors created a propensity score model to calculate the expected number and proportion of events that can be compared with those observed. They found that there was “sharp discordance” between the predicted and actual use of procedures performed with a minimally invasive technique, the study’s primary endpoint.
For example, the predicted percentage of appendectomies performed at each hospital fell in the range of 60% to 80%, but a small number of hospitals actually performed no minimally invasive appendectomies, whereas a few performed nothing but laparoscopic appendectomies.
The percentages of hospitals that performed no minimally invasive procedures for each of the 4 surgeries were as follows: appendectomy, 1.6%; colectomy; 11.5%, hysterectomy, 35%; and lung lobectomy, 15.9%.
The percentages of hospitals performing more than 75% of all procedures with a minimally invasive approach were appendectomy, 56.4%; colectomy, 0.7%; hysterectomy, 1.6%; and lung lobectomy, 8.2%.
Less Invasive, Fewer Complications
As expected, overall complication rates, a secondary endpoint, were significantly lower among patients treated with minimally invasive procedures compared with open surgery, at 3.94% vs 7.90%, respectively, for appendectomy (P less than .001); 13.8% vs 35.8% for colectomy (P less than .001); 4.69% vs 6.64% for hysterectomy (P less than .001); and 17.1% vs 25.4% for lobectomy (P less than .05).
Hospital factors significantly associated with high use of at least 1 minimally invasive procedure included urban setting, large size, teaching hospital, and Midwestern, Western, and Southern locations.
Teaching hospitals were significantly less likely, however, to perform minimally invasive colectomies; Midwestern hospitals were less likely to perform thorascopic lung lobectomies; and both private not-for-profit and government hospitals were less likely to perform minimally invasive appendectomies.
The authors acknowledge that despite the lower complication rates and faster patient recovery times associated with minimally invasive procedures, some patients are not appropriate candidates for such procedures, and some surgeons prefer for various reasons to stick with the more invasive open techniques.
Nonetheless, “[b]ased on our findings, many hospitals have an opportunity to decrease surgical complications by increasing utilization of minimally invasive surgery,” they write.
“Important ways to deal with this disparity may be more standardized postgraduate training, training of surgeons currently in practice, transparency of hospital rates of utilization of minimally invasive surgery, and better information for patients,” they conclude.