Industry Insights

What’s the Minimum Annual Case Volume for a Robotic Surgeon? Part 2

Building on last week’s CAVA blog, the literature has identified a learning curve of 25-90 cases required to be safe AND proficient, with the average surgeon at about 50 cases.

Likewise, simulation has been studied to shorten this initial learning curve by approximately 50% so that 20-25 cases is achievable.  SAGES and urologic societies support the above findings with excellent studies showing docking time efficiency is achieved at 20-25 cases.  Specimen margins, lymph nodes, blood loss, etc. have all been used as proxies for the learning curve and validate the above findings. ACOG committee opinion 628 also addresses this.  Maintenance of skills have been less well documented, but it has been suggested at 12 to 50 cases and the AAGL has published 20 as the standard.
There are some excellent studies that show that at less than 20 cases per year, operative times (and therefore risk), EBL and complications all increase.  When case volume are greater than 40 cases per year, all of these numbers fall to rates that are comparable with laparoscopic or open surgery.  Simulator performance also deteriorates as the time between cases increases.

What’s the Minimum Annual Case Volume for a Robotic Surgeon? Part 1

The literature supports that a surgeon should use the robot at least every 2 weeks in order to minimize degradation of skills. It is the consensus in robotic programs that 24 cases is the very minimum annually.  The fact is, very few surgeons would feel comfortable revealing to their patients that they do less than 24 cases a year and still consider themselves an expert.
Low volume robotic surgeons WHO DO NOT COMMIT to robotics and simulation are well known to be less efficient with poorer clinical and financial outcomes.  Both national benchmarking data as well as CAVAlytics data demonstrate the same.  This fact is obvious: the more operations a surgeon performs, it would be expected that he or she would become faster and better.  As simulation then progresses and evolves into procedural simulation (where actual operations on simulated tissue rather than skill drills are available), low volume surgeons should be able to maintain their skillset at a very high level despite the restricted access to actual, live tissue.  The goals of higher surgeon quality with better financial and clinical outcomes are exactly what CAVA holds as our core objectives for our clients’ robotic programs.
Remember, however, that simulation is not a means to substitute for actual case experience but rather it is an alternative that is available that is unique to robotics.  Most programs that have the minimal governance and a functional, active robotic program require BOTH simulation and case volume.

MIT Technology Review Provides More Insights into Future of Robotics

This article provides some fascinating insights into the future of where one emerging robotic technology vendor in the surgical robotic space may be going, and the concepts here are very exciting.  To what degree these ideas will be realized commercially is not known yet. However, the undeniable fact is that over the next 5 years or so, there will be significant evolution to what we know as surgical robotics today.  Hospitals that either have a robotic program, or who are considering starting one, MUST be thinking down the road as they acquire technology, develop contracts, create program structure, and manage all aspects of their robotic program. CAVA is poised to assist any hospital is meeting these critical resource, training, and operational challenges.  Preparing for the future in surgical robotics today is one of the many things CAVA provides to all our clients.
Take a look into the future…

Robotics in Smaller Hospitals? MUCH Better Guidance is Needed!

Here’s an interesting piece on the challenges small hospitals face in assessing whether to invest in a robotic program.  CAVA encounters stories like this one regularly. What you read here is fairly typical of the approach many small hospitals take.  Be warned, however, there is MUCH MORE any small hospital should be aware of in making a go/ no-go decision to get into into robotics than the info presented here. While this article provides insight into some of the questions, the understanding here is VASTLY incomplete. Determining cost-effectiveness is a complex 21-element algorithm. CAVA can help any smaller hospital considering a robotic program to approach this optimally.  The difference can be measured in months vs years to program success (if at all), as well as hundreds of thousands, if not millions of dollars, in bottom line impact.

http://www.modernhealthcare.com/article/20140419/MAGAZINE/304199985

A Sneak Peek…Get Ready!

A sneak peek into some of the exciting advances in the computer-assisted surgical environment over the next decade. CAVA approaches the design and optimization of all our client’s robotic programs with a vision to the future, meaning that hospitals must establish robotic program design, governance, and infrastructure that is agnostic to the technology vendor. There is much evolution and new competition coming to computer-assisted surgery!  Get ready.

 

http://www.fiercebiotech.com/medical-devices/verb-s-huennekens-unveils-vision-next-gen-robotic-surgery

Data Deficiencies Are Costing You Millions (Part 2):

Part 2: Unrecognized Costs in Computer Assisted Surgery – Equipment Malfunction and Repair.

This is the first in a series highlighting how gaps in data collection, data analysis or cost accounting leads to unrecognized financial losses in laparoscopy and computer assisted surgery.  This series draws upon CAVA Robotics extensive experience in assisting hospitals with their operating room clinical and financial data analysis and the lessions learned.  Today’s discussion focuses upon unrecognized costs in computer assisted surgery that are either difficult to assess, impossible to ascertain or frequently neglected.  For these reasons, they often are not considered in the “cost” of running a robotic program.

Several years ago, CAVA encountered a request from a hospital to evaluate costs that were not being fully represented in the financial analysis of each robotic surgical case.  As a beginning robotic surgical program, scope repairs were frequent and reposable instrument dysfunction was high.  The full breadth of the costs associated with the issue and the underlying factors influencing these events were unrecognized.

Together, we discovered that scope repair costs were underappreciated.  Due to a multitude of factors including staff training, sterile processing and scope handling, the incidence of scope repair was much higher than anticipated.  The total cost though of such repairs were very high.  Scope repair provided by the vendor despite a maintenance contract approached $9k/incident and over $60,000/year!

Unfortunately, reposable malfunction was much more difficult to quantify.  When an instrument malfunctioned, it was sent back to the vendor for evaluation.  The vendor determined the reason for the malfunction and whether the unused “lives” of the reposable instrument remaining were able to be credited back to the hospital.  In the cost accounting software and methodology of the hospital, keeping track of these incidents was challenging.  Our own analysis of the reasons for instrument failure however revealed several things.  Surgeon error and potential internal collisions were frequently a cause of instrument malfunction as indicated by things such as fracture of the “shaft” of the instrument.  Perhaps more worrisome was that most of these events often went unrecognized during the operation.  Another cause can be attributed to excessive or improper handling and processing of the reposable instruments.  This brought to light important changes in turnover and sterile processing protocol that are important to maximizing the life of these reposables.  The last cause is unknown in which a specific cause for instrument malfunction could not be found.  This includes things like a cable being displaced, the instrument not responding well and the scissors not cutting well.

CAVA’s advice:  avoid untracked costs of computer assisted surgery by keeping track of such “under the radar” costs and repairs.  More importantly, have the processes in place such as handling of reposables and scopes in all departments such as the operating room and sterile processing because the consequences can be significant.

Data Deficiencies Are Costing You Millions

Part 1: Unrecognized Costs in Computer Assisted Surgery – The Learning Curve.

This is the first in a series highlighting how gaps in data collection, data analysis or cost accounting leads to unrecognized financial losses in laparoscopy and computer assisted surgery.  This series draws upon CAVA Robotics extensive experience in assisting hospitals with their operating room clinical and financial data analysis and the lessons learned.  Today’s discussion focuses upon unrecognized costs in computer assisted surgery that are either difficult to assess, impossible to ascertain or frequently neglected.  For these reasons, they often are not considered in the “cost” of running a robotic program.

The first and most costly is the cost of a robotic learning curve.  Almost all surgeons are extremely efficient in their laparoscopic or open surgery already.  In making the transition to robotics, a unique “learning curve” is associated with every specialty and with every operation and is well defined.  During this learning curve, excessive time in the operating room, consumption of supplies, medical malpractice exposure and risk to the patient usually exist.  It is imperative that a robotic program establish expectations regarding the progression of a “novice” robotic surgeon through this learning curve as well and empower the surgeon with the resources necessary to conquer this learning curve in the expected time/case frame.

To give a more concrete example that we frequently see in the healthcare environment, let’s take an example of inguinal hernia repair.  Hospital X does laparoscopic bilateral inguinal hernia repair with a net margin of +$700/case and completes the operation in about 45 minutes.   When it started doing the case robotically, that same margin was expectantly negative.  After 100 cases however, that margin is still -$1200/case!  Factors which contribute to the negative margin include excessive robotic reposable use ($200/case), excessive operative time (60 min/case longer) and excessive supply usage ($600/case).  This example shows how the “urban legend” of robotics that it “costs too much” is perpetuated but is an all to common phenomenon in many robotic programs.

CAVA’s advice:  avoid this happening in your computer assisted surgical operating room by making sure that you define your learning curve, empower your surgeons with the knowledge and resources needed to progress through the learning curve then monitor your computer assisted surgical performance to make sure that excellent clinical and financial outcomes are maintained.

Next:  Part 2: Unrecognized costs in computer assisted surgery – equipment malfunction and repair.

Beware: The Dabblers!

Experience Counts!  Be sure to ask the right questions before undergoing a procedure.

https://youtu.be/8yEI9nHZJfg

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