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Robotic Lobectomy and the Principles of Technology DiffusionRobotic Lobectomy and Technology Diffusion FREE TO VIEW

Daniel P. McCarthy, MD, MBA; Malcolm M. DeCamp, MD, FCCP
Author and Funding Information

From the Department of Surgery (Drs McCarthy and DeCamp), and the Robert H. Lurie Comprehensive Cancer Center (Dr DeCamp), Northwestern University Feinberg School of Medicine; and the Division of Thoracic Surgery (Dr DeCamp), Northwestern Memorial Hospital.

CORRESPONDENCE TO: Malcolm M. DeCamp, MD, FCCP, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 650, Chicago, IL 60611; e-mail: mdecamp@nmh.org


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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):1425-1426. doi:10.1378/chest.14-1442
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The roots of modern robotic surgery can be traced back to US Department of Defense-funded research focused on applications for battlefield telesurgery. Following a period of commercial development, legal battles, and industry consolidation, robotic surgery has matured and expanded across a variety of disciplines. Yet there is still uncertainty regarding the value generated by this proliferation. In this issue of CHEST (see page 1505), Paul and colleagues1 add to the growing literature on robotic technology in thoracic surgery. They identify several important findings. First, robotic lobectomy volume increased substantially over their study period. Second, when compared with an established minimally invasive platform, video-assisted thoracoscopic surgery (VATS), robotic lobectomy was associated with more intraoperative hemorrhage and iatrogenic injury and cost, yet offered no clinical benefit.

Early in its evolution, VATS also faced criticism regarding cost and outcomes.2,3 However, the adoption dynamics for robotic lobectomy are quite different. Traditional VATS now offers well-documented benefits over thoracotomy and is arguably the gold standard for treatment of early-stage lung cancer.4 How do we explain the rise of robotic lobectomy when an established minimally invasive approach already exists?

There is a robust body of literature investigating the process by which a new technology diffuses through a market. This work spans multiple decades and academic disciplines, including sociology, applied mathematics, and economics. Models of technology diffusion seek to explain a consistent empirical fact: The rate of adoption of a new technology varies over time and is described by an S-shaped curve with characteristic phases.5 The classic models of technology diffusion are focused on information transfer and decision-making.6

Technology adoption may be viewed as a function of information flow through a population. The epidemic model grew out of seminal work on the diffusion of hybrid corn and other technologic advances in the 1950s and 1960s and has transitioned out of academia into popular culture.7,8 This model examines the way knowledge about an innovation spreads through a community and “infects” potential adopters. Information is derived from any direct or indirect exposure to the technology. Individuals can be characterized based on their role in the transmission process: Some have early access to new innovations, and others possess extensive social connections and facilitate rapid information spread, whereas others have persuasive powers that enable them to “infect” even the most resilient nonadopters.

Other theories focus on the decision-making process itself. Probit models of diffusion use the standard tools of economic theory.9 These models assume that all potential adopters are infinitely rational and perfectly informed. Each individual invests in the new technology when the perceived benefits exceed costs. Yet individuals have different endogenous characteristics (eg, preferences, access to resources) that affect the optimal timing of the investment decision. The adoption curve thus depends on how these endogenous characteristics are distributed within a population and how the costs or benefits of a technology change over time.

These classic models are useful tools, but real-world technology adoption is undoubtedly more complex. Modern models combine elements of both approaches and incorporate additional variables related to uncertainty, competitive strategy, and network effects. Technology adoption in health care is particularly difficult to predict because of multiple decision-makers (patients, physicians, administrators, payors) and various information types (popular opinion, scientific data, firsthand experience). Nevertheless, the classic models of technology adoption can help us understand the growth of robotic thoracic surgery.

There is clearly endogenous heterogeneity in the costs and benefits of adopting robotic techniques. Robotic surgery is capital intensive and requires a skilled team. Institutional variation in affordability of the robot and access to trained nursing staff affect the opportunity cost for surgeons considering adoption. Nonfinancial benefits also accrue to physicians and institutions offering robotic surgery. Surgeons and hospitals may experience reputational effects by staying on the “cutting edge” of surgical technology or may use robotic surgery as a competitive marketing tool. The weight of these benefits will vary based on the surgeon’s personal preferences and the local competitive dynamics.

Arguably the most important type of information transfer in health-care technology diffusion revolves around clinical benefit. Theoretical benefits are particularly important in the early stages of diffusion, when definitive evidence is lacking. At least two potential clinical benefits of robotic lobectomy have been proposed. First, improved visualization and control may enable more complete nodal evaluation compared with VATS.10 However, a randomized trial of lobe-specific systematic mediastinal nodal sampling vs formal lymph node dissection after VATS or open lobectomy failed to show any advantage to a more radical lymphadenecetomy.11 The early retrospective data on robotic upstaging must be further evaluated with matched cohorts or a prospective controlled study and linked to clinical end points. Second, robotic lobectomy may have a reduced learning curve compared with VATS because of similarities between robotic and open approaches. Multiple obstacles have limited the penetration of VATS, particularly in the community setting.12,13 As it did with minimally invasive prostatectomy, robotic surgery could theoretically bring the benefits of minimally invasive lobectomy to a broader population.14 But it is unclear to what extent robotic surgery is growing in areas without access to VATS and how this trend will be influenced by the newer generation of thoracic surgeons trained on VATS.

Robotic surgery combines sophisticated technology with plausible, albeit unproven, clinical benefits. This combination is often sufficient to precipitate technologic diffusion; early adoption is driven by information on salient features and decisions are made based on short-term benefits and expected long-term outcomes. Yet technology diffusion must be accompanied by a rigorous process of evaluation and reflection focused on both patient safety and procedural efficacy. Paul and colleagues1 remind us that true innovation in health care requires ongoing attention to the core determinants of value: quality and cost.

References

Paul S, Jalbert J, Isaacs AJ, Altorki NK, Isom OW, Sedrakyan A. Comparative effectiveness of robotic-assisted vs thoracoscopic lobectomy. Chest. 2014;146(6):1505-1512.
 
Miller JI Jr. The present role and future considerations of video-assisted thoracoscopy in general thoracic surgery. Ann Thorac Surg. 1993;56(3):804-806. [CrossRef] [PubMed]
 
Molin LJ, Steinberg JB, Lanza LA. VATS increases costs in patients undergoing lung biopsy for interstitial lung disease. Ann Thorac Surg. 1994;58(6):1595-1598. [CrossRef] [PubMed]
 
Hartwig MG, D’Amico TA. Thoracoscopic lobectomy: the gold standard for early-stage lung cancer? Ann Thorac Surg. 2010;89(6):S2098-S2101. [CrossRef] [PubMed]
 
Wilson CB. Adoption of new surgical technology. BMJ. 2006;332(7533):112-114. [CrossRef] [PubMed]
 
Geroski PA. Models of technology diffusion. Res Policy. 2000;29(4-5):603-625. [CrossRef]
 
Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. 1st Back Bay pbk. Boston, MA: Back Bay Books; 2002.
 
Rogers EM. A prospective and retrospective look at the diffusion model. J Health Commun. 2004;9(suppl 1):13-19. [CrossRef] [PubMed]
 
David PA. A Contribution to the Theory of Diffusion. Stanford, CA: Research Center in Economic Growth, Stanford University; 1969.
 
Wilson JL, Louie BE, Cerfolio RJ, et al. The prevalence of nodal upstaging during robotic lung resection in early stage non-small cell lung cancer. Ann Thorac Surg. 2014;97(6):1901-1907. [CrossRef] [PubMed]
 
Darling GE, Allen MS, Decker PA, et al. Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: results of the American College of Surgery Oncology Group Z0030 Trial. J Thorac Cardiovasc Surg. 2011;141(3):662-670. [CrossRef] [PubMed]
 
Adams RD, Bolton WD, Stephenson JE, Henry G, Robbins ET, Sommers E. Initial multicenter community robotic lobectomy experience: comparisons to a national database. Ann Thorac Surg. 2014;97(6):1893-1900. [CrossRef] [PubMed]
 
Cao C, Tian DH, Wolak K, et al. Cross-sectional survey on lobectomy approach (X-SOLA). Chest. 2014;146(2):292-298. [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]
 

Figures

Tables

References

Paul S, Jalbert J, Isaacs AJ, Altorki NK, Isom OW, Sedrakyan A. Comparative effectiveness of robotic-assisted vs thoracoscopic lobectomy. Chest. 2014;146(6):1505-1512.
 
Miller JI Jr. The present role and future considerations of video-assisted thoracoscopy in general thoracic surgery. Ann Thorac Surg. 1993;56(3):804-806. [CrossRef] [PubMed]
 
Molin LJ, Steinberg JB, Lanza LA. VATS increases costs in patients undergoing lung biopsy for interstitial lung disease. Ann Thorac Surg. 1994;58(6):1595-1598. [CrossRef] [PubMed]
 
Hartwig MG, D’Amico TA. Thoracoscopic lobectomy: the gold standard for early-stage lung cancer? Ann Thorac Surg. 2010;89(6):S2098-S2101. [CrossRef] [PubMed]
 
Wilson CB. Adoption of new surgical technology. BMJ. 2006;332(7533):112-114. [CrossRef] [PubMed]
 
Geroski PA. Models of technology diffusion. Res Policy. 2000;29(4-5):603-625. [CrossRef]
 
Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. 1st Back Bay pbk. Boston, MA: Back Bay Books; 2002.
 
Rogers EM. A prospective and retrospective look at the diffusion model. J Health Commun. 2004;9(suppl 1):13-19. [CrossRef] [PubMed]
 
David PA. A Contribution to the Theory of Diffusion. Stanford, CA: Research Center in Economic Growth, Stanford University; 1969.
 
Wilson JL, Louie BE, Cerfolio RJ, et al. The prevalence of nodal upstaging during robotic lung resection in early stage non-small cell lung cancer. Ann Thorac Surg. 2014;97(6):1901-1907. [CrossRef] [PubMed]
 
Darling GE, Allen MS, Decker PA, et al. Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: results of the American College of Surgery Oncology Group Z0030 Trial. J Thorac Cardiovasc Surg. 2011;141(3):662-670. [CrossRef] [PubMed]
 
Adams RD, Bolton WD, Stephenson JE, Henry G, Robbins ET, Sommers E. Initial multicenter community robotic lobectomy experience: comparisons to a national database. Ann Thorac Surg. 2014;97(6):1893-1900. [CrossRef] [PubMed]
 
Cao C, Tian DH, Wolak K, et al. Cross-sectional survey on lobectomy approach (X-SOLA). Chest. 2014;146(2):292-298. [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]
 
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