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Original Research: Cardiothoracic Surgery |

Comparative Effectiveness of Robotic-Assisted vs Thoracoscopic LobectomyAnalysis of Robotic-Assisted Lobectomy FREE TO VIEW

Subroto Paul, MD, FCCP; Jessica Jalbert, PhD, MD; Abby J. Isaacs, MS; Nasser K. Altorki, MD, FCCP; O. Wayne Isom, MD; Art Sedrakyan, MD, PhD
Author and Funding Information

From the Department of Cardiothoracic Surgery (Drs Paul, Altorki, and Isom) and the Department of Public Health (Drs Jalbert and Sedrakyan and Ms Isaacs), New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY.

CORRESPONDENCE TO: Subroto Paul, MD, FCCP, Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, 525 E 68th St, M-404, New York, NY 10065; e-mail: pas2022@med.cornell.edu


FOR EDITORIAL COMMENT SEE PAGE 1425

FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(6):1505-1512. doi:10.1378/chest.13-3032
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Published online

BACKGROUND:  Robotic-assisted lobectomy is being offered increasingly to patients. However, little is known about its safety, complication profile, or effectiveness.

METHODS:  Patients undergoing lobectomy in in the United States from 2008 to 2011 were identified in the Nationwide Inpatient Sample. In-hospital mortality, complications, length of stay, and cost for patients undergoing robotic-assisted lobectomy were compared with those for patients undergoing thoracoscopic lobectomy.

RESULTS:  We identified 2,498 robotic-assisted and 37,595 thoracoscopic lobectomies performed from 2008 to 2011. The unadjusted rate for any complication was higher for those undergoing robotic-assisted lobectomy than for those undergoing thoracoscopic lobectomy (50.1% vs 45.2%, P < .05). Specific complications that were higher included cardiovascular complications (23.3% vs 20.0%, P < .05) and iatrogenic bleeding complications (5.0% vs 2.0%, P < .05). The higher risk of iatrogenic bleeding complications persisted in multivariable analyses (adjusted OR, 2.64; 95% CI, 1.58-4.43). Robotic-assisted lobectomy costs significantly more than thoracoscopic lobectomy ($22,582 vs $17,874, P < .05).

CONCLUSIONS:  In this early experience with robotic surgery, robotic-assisted lobectomy was associated with a higher rate of intraoperative injury and bleeding than was thoracoscopic lobectomy, at a significantly higher cost.

Robotic-assisted surgical technologies have been adopted rapidly since US Food and Drug Administration (FDA) approval in 2000. More than 459,000 robotic surgeries were performed worldwide in 2012, with prostatectomy and hysterectomy accounting for the vast majority of procedures.1,2 The perceived benefits of robotic-assisted surgery are less postoperative pain, fewer complications, and quicker recovery times. Additionally, surgeons can be trained more easily to perform minimally invasive robotic-assisted surgery, which mimics open surgery, in contrast to the current minimally invasive methods, which require significant training. Studies examining the safety and effectiveness of robotic surgery are limited. FDA approval of the technology through the 510(k) premarket approval process did not require clinical evidence of patient benefit. Studies comparing robotic hysterectomy to laparoscopic hysterectomy have found no clinical benefit, but increased costs.36

The rapid adoption of a new surgical technology without proper safeguards in training brings new risks and could potentially lead to patient harm. Studies comparing the safety and effectiveness of robotic-assisted surgical technologies in cardiothoracic surgery are lacking. No large randomized trial has been performed, and any such trial may not be performed because of cost and the significant sample size requirement to detect small differences in outcomes. Observational data are likely to provide the best evidence related to perioperative benefits and harms, including iatrogenic harms.

Robotic-assisted technologies are currently being advocated in general thoracic surgery for lobectomy.3,712 To evaluate the safety and efficacy of robotic-assisted surgery for lobectomies, we performed a population-based analysis using the Nationwide Inpatient Sample (NIS).

Data Source

The NIS is maintained by the Agency for Healthcare Research and Quality, as part of the Healthcare Cost and Utilization Project (HCUP). The NIS is the largest all-payer inpatient-care database in the United States and constitutes approximately a 20% stratified sample of all hospital discharges from nongovernment institutions. An extensive description of the NIS (http://www.hcup-us.ahrq.gov/nisoverview.jsp) and the collection and maintenance of data within the database is described elsewhere.13,14 This study was approved by the institutional review board of Weill Cornell Medical College (Protocol No. EXE-2011-057) and conforms to the data-use agreement for the NIS from the HCUP.

Study Cohort

The study cohort consisted of all patients who visited an HCUP NIS-participating hospital to undergo robotic-assisted lobectomy or thoracoscopic lobectomy. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients undergoing the previously-mentioned procedures (e-Table 1). To make more meaningful comparisons, we chose to compare robotic-assisted lobectomy with its established minimally invasive counterpart, thoracoscopic lobectomy.14,15 We included only procedures performed between 2008 and 2011 because the codes for robotic-assisted surgery were introduced in 2007. All patient admissions were elective, and patients were at least 18 years of age at the time of the procedure.

Outcomes

The study outcomes were in-hospital mortality, in-hospital complications, and a composite outcome consisting of in-hospital mortality and/or stroke or myocardial infarction. We identified complications listed as postoperative, known complications of these procedures, and, given that diagnosis and procedure dates were not available in the data, we selected conditions that would make the patient ineligible for such procedures had they presented with them at the time of hospital admission. We identified patients with the following complications (e-Table 1 for International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic algorithms): cardiovascular (supraventricular arrhythmia, myocardial infarction, postoperative stroke, or DVT), pulmonary (pneumonia, postoperative acute respiratory insufficiency, postoperative acute pneumothorax, postoperative pulmonary edema, pulmonary collapse, empyema, mechanical ventilation, or concurrent tracheostomy), and infectious (sepsis/shock, urinary tract infection, or postoperative wound infection), as well as iatrogenic complications occurring intraoperatively (accidental puncture or laceration, bleeding).

Variables

We categorized patients according to age (18-55 years, 56-64 years, ≥ 65 years), sex (man/woman), race (white/nonwhite), year of procedure (2008, 2009, 2010, or 2011), and insurance status (Medicare, Medicaid, commercial, or other). We identified patients with diagnoses of coronary artery disease, heart failure, hypertension, diabetes, chronic pulmonary disease, peripheral vascular disease, and chronic renal insufficiency during the index hospitalization using validated algorithms (e-Table 1).16 To summarize a patient’s comorbidity burden, we used information gathered during the hospitalization to calculate the Elixhauser comorbidity score.16,17 We also used the hospital-level information available in the NIS data to categorize hospitals according to location with respect to the census regions (North, West, Midwest, and South), size (small, medium, or large), teaching hospital status, and location (urban/rural).

Given that the NIS data contain all procedures done in a given hospital, but do not necessarily include the same hospitals in any given year’s sample, we used the hospital’s unique identifier to calculate an average annual procedure volume per facility. Charge data were provided at the discharge level in the NIS database. Cost was estimated using hospital-specific cost to charge ratios, in a preestablished method.18 When that variable is unavailable, the group-level cost to charge ratio was used, as recommended by the HCUP.19,20 A Diagnosis Related Group-based scaling factor released by the HCUP in 2009 was then applied to the data.19,20

Statistical Analysis

Baseline characteristics for the study population are reported and compared using percentages and χ2 tests for categorical variables, and medians, interquartile ranges, and Wilcoxon tests for continuous variables. To assess the relationship between exposure to robotic surgery and outcome, we reported crude and adjusted ORs created using univariate and multivariate logistic regression models, respectively. Covariates for the adjusted models were selected based on clinical significance and included age group, sex, year, coronary artery disease, chronic pulmonary disease, hospital lobectomy volume, teaching status, and region. We accounted for the stratified design and the clustering of patients within hospitals using proc surveylogistic; all analyses were performed using SAS, version 9.3 (SAS Institute Inc).

We identified 2,498 and 37,595 patient admissions between 2008 and 2011 for robotic-assisted and thoracoscopic lobectomy, respectively. The absolute number of robotic-assisted lobectomies, the number of centers performing robotic-assisted lobectomy, and the percentage of robotic-assisted lobectomies performed per center as a fraction of all lobectomy increased dramatically during that time frame (Table 1, e-Table 2). The rate of growth for thoracoscopic lobectomy in the same interval was small (Table 1, e-Table 2). For perspective, the number of lobectomies performed by thoracotomy during this period declined from 74.6% of all lobectomies in 2008 to 59.4% of all lobectomies in 2011 (n [% of total lobectomies]: for 2008, 23,988 [74.6%]; for 2009, 21,367 [69.6%]; for 2010, 21,534 [68.8%]; and for 2011, 18,762 [59.4%]). The patients undergoing robotic-assisted and thoracoscopic lobectomy were similar to each other in terms of characteristics (Table 1). These two groups had similar age, comorbidities, and types of insurance. A larger proportion of men underwent robotic-assisted lobectomy compared with the thoracoscopic approach. Robotic-assisted lobectomies were more likely to be performed in the South and West regions. A greater proportion of robotic-assisted cases were performed in smaller to medium-sized hospitals, nonteaching hospitals, and hospitals with moderate lobectomy volumes (Table 1).

Table Graphic Jump Location
TABLE 1 ]  Patient Demographics and Hospital Characteristics

Data are presented as mean (%) unless indicated otherwise. IQR = interquartile range.

a 

< 1% missing data.

b 

20% missing data.

c 

Nationwide Inpatient Sample data provided comorbidity information.

Outcomes were then compared between those patients undergoing nonrobotic and robotic-assisted procedures (Table 2). No differences in the unadjusted rate of mortality were noted between the two lobectomy groups (0.7% vs 1.3%, P = .15). The unadjusted rate for any complication was higher for those undergoing robotic-assisted lobectomy (50.1% vs 45.2%, P = .02). Specific complications that were higher included cardiovascular complications (23.3% vs 20.0%, P = .03) and iatrogenic bleeding complications (5.0% vs 2.0%, P < .001). After risk adjustment, only the rate of iatrogenic bleeding complications was found to be higher in those who underwent robotic-assisted lobectomy (adjusted OR, 2.64; 95% CI, 1.58-4.43) (Table 3). The increased rate of iatrogenic bleeding complications in robotic-assisted lobectomy persisted even when examining outcomes in centers that performed > 25 lobectomies annually (e-Table 3). Patients who underwent robotic-assisted lobectomy also had fewer routine discharges (60.8% vs 70.3%, P < .001) and, hence, were more likely to be discharged to a facility prior to going home. Moreover, robotic-assisted lobectomies cost significantly more than thoracoscopic procedures ($22,582 vs $17,874, P < .001) (Table 2).

Table Graphic Jump Location
TABLE 2 ]  In-Hospital Outcomes and Costs

Data are presented as mean (%) unless indicated otherwise. See Table 1 legend for expansion of abbreviation.

a 

< 1% missing data.

b 

Nonroutine discharge can be to a short-term hospital, skilled nursing facility, intermediate-care facility, or another type of facility, or against medical advice.

c 

Cost is estimated using Nationwide Inpatient Sample charge data, cost to charge ratio files, and a scaling factor by Diagnosis Related Group published by the Healthcare Cost and Utilization Project in 2009; < 10% missing cost/charge data.

Table Graphic Jump Location
TABLE 3 ]  Adjusted Odds of the Mortality and Complications

Our population-based analysis of a national database demonstrates that robotic-assisted lobectomy does not offer any substantial benefit over thoracoscopic lobectomy and may increase operative risk. Perioperative morbidity and mortality outcomes between the robotic and nonrobotic groups were similar. However, patients undergoing robotic-assisted lobectomy were at greater risk of iatrogenic intraoperative injury and bleeding. We also show that robotic lobectomies are performed at smaller hospitals and less frequently at teaching institutions. Robotic-assisted lobectomy procedures were performed less frequently in the hospitals located in the northeastern United States.

Our results extend and advance the results reported for robotic-assisted hysterectomy, which is currently the most commonly performed robotic procedure. Robotic-assisted hysterectomy for both benign and malignant conditions was found to be no better than its laparoscopic counterpart.5,6 From a technology perspective, lobectomy is similar to hysterectomy in that a minimally invasive approach is available and is used frequently. This is in contrast to prostatectomy, for which laparoscopic approaches are seldom used and a less invasive robotic approach seems to provide superior outcomes.2124

Our findings related to the potential for iatrogenic patient injury and harm in robotic-assisted lobectomy are new and are hard to ignore.25,26 The introduction of new surgical procedures and technologies into practice is complex. Surgeons and their staff experience a learning curve that varies with surgeon experience and ability.3,27 Robotic-assisted lobectomy is clearly at an early stage of adoption, accounting for slightly less than 5% of the total volume of each procedure performed in the United States. At this stage of adoption, the learning curve is often unclear (steep or protracted), and the potential for harm is great. The robotic platform, with its wristed instruments providing articulated movements, is designed to mimic open surgery and facilitates the adoption of minimally invasive techniques. However, the robotic platform does not provide tactile feedback and its high-definition three-dimensional operative camera comes at the cost of a lack of surgical perspective. Both these factors can also lead to an increased chance of injury by robotic arms by inadvertent excess use of force or when their movement is out of the field of view. This off-screen damage is neither seen nor felt, with the greatest risk from surgeons who are not completely familiar with the technology.

Interestingly, the pattern of adoption of robotic technology is not uniform. Robotic-assisted lobectomies are performed more commonly in the south and in smaller nonteaching hospitals. Given the expense of the robotic platform and its unproven benefits in thoracic surgery, it is surprising that smaller nonteaching institutions would invest in this technology for lobectomies. Marketing pressures, combined with a perceived benefit to both surgeon and patient, may lead to the early adoption by smaller hospitals vying for patients. Smaller nonteaching hospitals may, by necessity, have to be more nimble in adapting to new developments. The potential pressure to market the robotic platform has been reported extensively.5,28 However, it is still not clear to what extent it affects general thoracic surgery.

Societal fascination with new technologies is pervasive. New and expensive is associated with better. This fascination does not go unnoticed by aggressive advertising agencies. The faith in new technology often results in inadequate concern for potential harm. The costs of therapy often get misplaced, along with the potential harm and benefit. Assessing the effectiveness of robotic-assisted technologies is fundamental to the goal of providing health care without compromising quality and to the development of innovative medical technologies. Cost is important as well. We find, much like others, that robotic-assisted lobectomy costs more than its minimally invasive counterpart.4,5,29 Our cost estimate is based on the charges to the patient, a cost to charge ratio, and a Diagnosis Related Group-based scaling factor provided by the HCUP. The exact elements leading to higher costs cannot be determined from the NIS. We speculate that they are related to higher indirect costs from the use of robotic disposable equipment and possibly higher operative times, with operating room costs being some of the highest in any hospital. Our cost analysis does not take into account other nonbillable charges, especially the capital costs related to the robotic surgery platform itself and maintenance. These costs are substantial and they factor into the value-based equation facing institutions when considering robotic analysis. We were unable to evaluate these costs because they are not captured in the NIS.

Our analysis clearly represents the early experience with robotic surgery. As seen in our analysis, there was a dramatic rate of growth of robotic-assisted lobectomy in this time period, whereas the growth of thoracoscopic lobectomy was small. This suggests that robotic-assisted lobectomy was in a period of rapid adoption with the greatest learning curve. This can account for the increased rate of iatrogenic complications seen with robotic-assisted lobectomy. As surgeon and institutional experience with this technology platform grows, the rates of iatrogenic complications are likely to decrease. More stringent training and credentialing requirements should also decrease these rates. Cost is also likely to decrease as the technology improves and potential competitor technologies are introduced. The recent introductions of robotic energy and stapling devices and dual consoles for two surgeons are examples of the continuous improvement in technology that should not only decrease the potential for patient harm but also costs. Future studies of trends of morbidity and cost over time should investigate whether these expectations are realized.

We recognize that there are limitations to our analysis. First and foremost, this is not a randomized controlled trial and there are inherent selection biases, which can be controlled for but never completely eliminated. We attempted to account for this in our multivariable analysis; however, we cannot account for differences that are not known between the two groups. In addition, our study is limited to short-term inpatient outcomes only. The NIS does not record long-term outcomes or pathologic data and, hence, the oncologic efficacy of either robotic or thoracoscopic lobectomy cannot be assessed. The NIS also does not capture the functional status of patients and, hence, quality-of-life measures are not known for each approach. Lastly, the specialty training and board certification of the operating surgeon is not known within the NIS dataset, which may be an important determinant of quality of care in addition to patient and hospital factors. However, a randomized controlled trial is unlikely to be performed to compare robotic-assisted cardiothoracic procedures with standard open or other less invasive technologies. Even if performed, the robotic technology used at the time of the trial is likely to be outdated. Ideally, a national registry would allow continuous evaluation of the outcomes of robotic-based procedures and devices.

In conclusion, our population-based analysis with its inherent limitations demonstrates that robotic-assisted lobectomy at its early stage of adoption is associated with both a higher rate of intraoperative injury and bleeding than is thoracoscopic lobectomy and a significantly higher cost.

Author contributions: S. P., A. J. I., and A. S. had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. S. P., N. K. A., O. W. I., and A. S. contributed to the study concept and design; S. P., J. J., and A. J. I. contributed to acquisition, analysis, and interpretation of the data; N. K. A., O. W. I., and A. S. contributed to the acquisition and interpretation of the data; S. P., J. J., and A. J. I. contributed to drafting of the manuscript; S. P., N. K. A., and A. S. contributed to critical revision of the manuscript for important intellectual content; S. P. and J. J. contributed to study supervision; and J. J. and A. J. I. contributed to statistical analysis.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Paul is a senior investigator within the Weill Cornell Medical College Patient Centered Comparative Effectiveness Program and the US FDA’s Medical Device Epidemiology Network’s (MDEpiNet) Science and Infrastructure Center. Dr Sedrakyan received funding from the US FDA for establishing the MDEpiNet Science and Infrastructure Center. Drs Jalbert, Altorki, and Isom and Ms Isaacs have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Additional information: The e-Tables can be found in the Supplemental Materials section of the online article.

FDA

US Food and Drug Administration

HCUP

Healthcare Cost and Utilization Project

NIS

Nationwide Inpatient Sample

Paul S, McCulloch P, Sedrakyan A. Robotic surgery: revisiting “no innovation without evaluation.” BMJ. 2013;346:f1573. [CrossRef] [PubMed]
 
Intuitive Surgical, Inc website. http://phx.corporate-ir.net/phoenix.zhtml?c=122359&p=irol-IRHome. Accessed September 2013.
 
Cerfolio RJ, Bryant AS, Minnich DJ. Starting a robotic program in general thoracic surgery: why, how, and lessons learned. Ann Thorac Surg. 2011;91(6):1729-1736. [CrossRef] [PubMed]
 
Park BJ, Flores RM. Cost comparison of robotic, video-assisted thoracic surgery and thoracotomy approaches to pulmonary lobectomy. Thorac Surg Clin. 2008;18(3):297-300. [CrossRef] [PubMed]
 
Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689-698. [CrossRef] [PubMed]
 
Wright JD, Burke WM, Wilde ET, et al. Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer. J Clin Oncol. 2012;30(8):783-791. [CrossRef] [PubMed]
 
Chitwood WR Jr, Rodriguez E, Chu MW, et al. Robotic mitral valve repairs in 300 patients: a single-center experience. J Thorac Cardiovasc Surg. 2008;136(2):436-441. [CrossRef] [PubMed]
 
Nifong LW, Chitwood WR, Pappas PS, et al. Robotic mitral valve surgery: a United States multicenter trial. J Thorac Cardiovasc Surg. 2005;129(6):1395-1404. [CrossRef] [PubMed]
 
Nifong LW, Rodriguez E, Chitwood WR Jr. 540 consecutive robotic mitral valve repairs including concomitant atrial fibrillation cryoablation. Ann Thorac Surg. 2012;94(1):38-42. [CrossRef] [PubMed]
 
Park BJ, Melfi F, Mussi A, et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg. 2012;143(2):383-389. [CrossRef] [PubMed]
 
Woo YJ, Nacke EA. Robotic minimally invasive mitral valve reconstruction yields less blood product transfusion and shorter length of stay. Surgery. 2006;140(2):263-267. [CrossRef] [PubMed]
 
Folliguet T, Vanhuyse F, Constantino X, Realli M, Laborde F. Mitral valve repair robotic versus sternotomy. Eur J Cardiothorac Surg. 2006;29(3):362-366. [CrossRef] [PubMed]
 
Paul S, Nasar A, Port JL, et al. Comparative analysis of diaphragmatic hernia repair outcomes using the nationwide inpatient sample database. Arch Surg. 2012;147(7):607-612. [CrossRef] [PubMed]
 
Paul S, Sedrakyan A, Chiu YL, et al. Outcomes after lobectomy using thoracoscopy vs thoracotomy: a comparative effectiveness analysis utilizing the Nationwide Inpatient Sample database. Eur J Cardiothorac Surg. 2013;43(4):813-817. [CrossRef] [PubMed]
 
Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg. 2010;139(2):366-378. [CrossRef] [PubMed]
 
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27. [CrossRef] [PubMed]
 
van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47(6):626-633. [CrossRef] [PubMed]
 
Gadzinski AJ, Dimick JB, Ye Z, Miller DC. Utilization and outcomes of inpatient surgical care at critical access hospitals in the United States. JAMA Surg. 2013;148(7):589-596. [CrossRef] [PubMed]
 
Cost-to-charge ratio files: 2011 nationwide inpatient sample (NIS) user guide. Agency for Healthcare Research and Quality website. http://www.hcup-us.ahrq.gov/db/state/CCR2011NISUserGuide.pdf. Accessed September 2013.
 
Sun Y, Friedman B. Tools for more accurate inpatient cost estimates with HCUP databases, 2009 [errata added October 25, 2012]. Agency for Healthcare Research and Quality website. http://www.hcup-us.ahrq.gov/reports/methods/2011_04.pdf. Accessed September 2013.
 
Hu JC. Why I perform robotic-assisted laparoscopic radical prostatectomy, despite more incontinence and erectile dysfunction diagnoses compared to open surgery: it’s not about the robot. Eur Urol. 2010;57(3):544-545. [CrossRef] [PubMed]
 
Hu JC, Gu X, Lipsitz SR, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009;302(14):1557-1564. [CrossRef] [PubMed]
 
Hyams E, Pierorazio P, Mullins JK, et al. A comparative cost analysis of robot-assisted versus traditional laparoscopic partial nephrectomy. J Endourol. 2012;26(7):843-847. [CrossRef] [PubMed]
 
Trinh QD, Sammon J, Sun M, et al. Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample. Eur Urol. 2012;61(4):679-685. [CrossRef] [PubMed]
 
Rabin RC. New concerns on robotic surgeries. The New York Times. September 9, 2013.
 
Cooper MA, Ibrahim A, Lyu H, Makary MA. Underreporting of robotic surgery complications [published online ahead of print August 27, 2013]. J Healthc Qual. doi:10.1111/jhq.12036.
 
Augustin F, Bodner J, Maier H, et al. Robotic-assisted minimally invasive vs. thoracoscopic lung lobectomy: comparison of perioperative results in a learning curve setting. Langenbecks Arch Surg. 2013;398(6):895-901. [CrossRef] [PubMed]
 
Jin LX, Ibrahim AM, Newman NA, Makarov DV, Pronovost PJ, Makary MA. Robotic surgery claims on United States hospital websites. J Healthc Qual. 2011;33(6):48-52. [CrossRef] [PubMed]
 
Ahmed K, Ibrahim A, Wang TT, et al. Assessing the cost effectiveness of robotics in urological surgery - a systematic review. BJU Int. 2012;110(10):1544-1556. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
TABLE 1 ]  Patient Demographics and Hospital Characteristics

Data are presented as mean (%) unless indicated otherwise. IQR = interquartile range.

a 

< 1% missing data.

b 

20% missing data.

c 

Nationwide Inpatient Sample data provided comorbidity information.

Table Graphic Jump Location
TABLE 2 ]  In-Hospital Outcomes and Costs

Data are presented as mean (%) unless indicated otherwise. See Table 1 legend for expansion of abbreviation.

a 

< 1% missing data.

b 

Nonroutine discharge can be to a short-term hospital, skilled nursing facility, intermediate-care facility, or another type of facility, or against medical advice.

c 

Cost is estimated using Nationwide Inpatient Sample charge data, cost to charge ratio files, and a scaling factor by Diagnosis Related Group published by the Healthcare Cost and Utilization Project in 2009; < 10% missing cost/charge data.

Table Graphic Jump Location
TABLE 3 ]  Adjusted Odds of the Mortality and Complications

References

Paul S, McCulloch P, Sedrakyan A. Robotic surgery: revisiting “no innovation without evaluation.” BMJ. 2013;346:f1573. [CrossRef] [PubMed]
 
Intuitive Surgical, Inc website. http://phx.corporate-ir.net/phoenix.zhtml?c=122359&p=irol-IRHome. Accessed September 2013.
 
Cerfolio RJ, Bryant AS, Minnich DJ. Starting a robotic program in general thoracic surgery: why, how, and lessons learned. Ann Thorac Surg. 2011;91(6):1729-1736. [CrossRef] [PubMed]
 
Park BJ, Flores RM. Cost comparison of robotic, video-assisted thoracic surgery and thoracotomy approaches to pulmonary lobectomy. Thorac Surg Clin. 2008;18(3):297-300. [CrossRef] [PubMed]
 
Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689-698. [CrossRef] [PubMed]
 
Wright JD, Burke WM, Wilde ET, et al. Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer. J Clin Oncol. 2012;30(8):783-791. [CrossRef] [PubMed]
 
Chitwood WR Jr, Rodriguez E, Chu MW, et al. Robotic mitral valve repairs in 300 patients: a single-center experience. J Thorac Cardiovasc Surg. 2008;136(2):436-441. [CrossRef] [PubMed]
 
Nifong LW, Chitwood WR, Pappas PS, et al. Robotic mitral valve surgery: a United States multicenter trial. J Thorac Cardiovasc Surg. 2005;129(6):1395-1404. [CrossRef] [PubMed]
 
Nifong LW, Rodriguez E, Chitwood WR Jr. 540 consecutive robotic mitral valve repairs including concomitant atrial fibrillation cryoablation. Ann Thorac Surg. 2012;94(1):38-42. [CrossRef] [PubMed]
 
Park BJ, Melfi F, Mussi A, et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg. 2012;143(2):383-389. [CrossRef] [PubMed]
 
Woo YJ, Nacke EA. Robotic minimally invasive mitral valve reconstruction yields less blood product transfusion and shorter length of stay. Surgery. 2006;140(2):263-267. [CrossRef] [PubMed]
 
Folliguet T, Vanhuyse F, Constantino X, Realli M, Laborde F. Mitral valve repair robotic versus sternotomy. Eur J Cardiothorac Surg. 2006;29(3):362-366. [CrossRef] [PubMed]
 
Paul S, Nasar A, Port JL, et al. Comparative analysis of diaphragmatic hernia repair outcomes using the nationwide inpatient sample database. Arch Surg. 2012;147(7):607-612. [CrossRef] [PubMed]
 
Paul S, Sedrakyan A, Chiu YL, et al. Outcomes after lobectomy using thoracoscopy vs thoracotomy: a comparative effectiveness analysis utilizing the Nationwide Inpatient Sample database. Eur J Cardiothorac Surg. 2013;43(4):813-817. [CrossRef] [PubMed]
 
Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg. 2010;139(2):366-378. [CrossRef] [PubMed]
 
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27. [CrossRef] [PubMed]
 
van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47(6):626-633. [CrossRef] [PubMed]
 
Gadzinski AJ, Dimick JB, Ye Z, Miller DC. Utilization and outcomes of inpatient surgical care at critical access hospitals in the United States. JAMA Surg. 2013;148(7):589-596. [CrossRef] [PubMed]
 
Cost-to-charge ratio files: 2011 nationwide inpatient sample (NIS) user guide. Agency for Healthcare Research and Quality website. http://www.hcup-us.ahrq.gov/db/state/CCR2011NISUserGuide.pdf. Accessed September 2013.
 
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NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
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