During the same time period, women experienced a Knee arthroplasty was the most common OR procedure for hospital stays paid by Medicare and by private insurance. Among hospitalizations that involved an OR procedure, knee arthroplasty was the OR procedure performed most frequently during hospital stays paid by Medicare Knee arthroplasty was not among the top five most frequently performed OR procedures for stays paid by Medicaid or for uninsured stays. Cholecystectomy was the most common OR procedure for hospital stays paid by Medicaid and for uninsured stays.
Cholecystectomy was the most frequently performed OR procedure during hospital stays paid by Medicaid 7. Cholecystectomy was not among the top five most frequently performed OR procedures for stays paid by Medicare or private insurance. Percutaneous coronary angioplasty PTCA was among the most common procedures for hospital stays across all payers. PTCA was among the five procedures that were performed most frequently during hospital stays that involved an OR procedure for all types of payers: Medicare 7.
Brachytherapy was the OR procedure with the greatest change in occurrence among hospital stays paid by Medicare and private insurance. The number of hospital stays involving brachytherapy decreased by an average of approximately 25 percent annually among stays paid by Medicare and private insurance. OR procedures related to the musculoskeletal system were among those with the greatest change in occurrence for stays paid by Medicaid and for uninsured stays.
The five OR procedures with the greatest change in occurrence for stays paid by Medicaid involved the musculoskeletal system, including knee arthroplasty 7.
Among uninsured hospital stays, the two OR procedures with the greatest change in occurrence also involved the musculoskeletal system: amputation of lower extremity 9. The statistics were generated from HCUPnet, a free, online query system that provides users with immediate access to the largest set of publicly available, all-payer national, regional, and State-level hospital care databases from HCUP.
CCS categories identified as Other typically are not reported; these categories include miscellaneous, otherwise unclassifiable procedures that may be difficult to interpret as a group. For this report, maternal and neonatal discharges were excluded from the analysis. Maternal hospital stays were identified using MDC 14 pregnancy, childbirth, and the puerperium , and neonatal hospital stays were identified using MDC 15 newborns and other neonates with conditions originating during the perinatal period.
DRGs comprise a patient classification system that categorizes patients into groups that are clinically coherent and homogeneous with respect to resource use. DRGs group patients according to diagnosis, type of treatment procedure , age, and other relevant criteria. Each hospital stay has one assigned DRG. For this report, major operating room OR procedures were defined using procedure classes that categorize each ICDCM procedure code as major therapeutic, major diagnostic, minor therapeutic, or minor diagnostic.
This classification scheme relies on physician panels that classify ICDCM procedure codes according to whether the procedure would be performed in a hospital OR in most hospitals. Major OR procedures were identified using all procedure fields first-listed and secondary that were available on the discharge record. Types of hospitals included in the HCUP National Nationwide Inpatient Sample The National Nationwide Inpatient Sample is based on data from community hospitals, which are defined as short-term, non-Federal, general, and other hospitals, excluding hospital units of other institutions e.
The NIS includes obstetrics and gynecology, otolaryngology, orthopedic, cancer, pediatric, public, and academic medical hospitals. Excluded are long-term care facilities such as rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. Beginning in , long-term acute care hospitals are also excluded. However, if a patient received long-term care, rehabilitation, or treatment for psychiatric or chemical dependency conditions in a community hospital, the discharge record for that stay will be included in the NIS.
For each hospital, a hospital-wide cost-to-charge ratio is used. Hospital charges reflect the amount the hospital billed for the entire hospital stay and do not include professional physician fees. The outpatient portion of hospitals' activities has been growing steadily and may exceed half of all hospital revenue in recent years.
On the basis of the American Hospital Association Annual Survey, outpatient gross revenues or charges were about 44 percent of total hospital gross revenues. These include Federal hospitals Department of Defense, Veterans Administration, Indian Health Services, and Department of Justice [prison] hospitals as well as psychiatric, substance abuse, and long-term care hospitals.
A third source of difference lies in the HCUP reliance on billed charges from hospitals to payers, adjusted to provide estimates of costs using hospital-wide cost-to-charge ratios, in contrast to the NHEA measurement of spending or revenue. HCUP costs estimate the amount of money required to produce hospital services, including expenses for wages, salaries, and benefits paid to staff as well as utilities, maintenance, and other similar expenses required to run a hospital.
NHEA spending or revenue measures the amount of income received by the hospital for treatment and other services provided, including payments by insurers, patients, or government programs. The difference between revenues and costs include profit for for-profit hospitals or surpluses for nonprofit hospitals.
Unit of analysis The unit of analysis is the hospital discharge i. This means that a person who is admitted to the hospital multiple times in 1 year will be counted each time as a separate discharge from the hospital. Average annual percentage change Average annual percentage change is calculated using the following formula: Average annual percentage change equals open bracket, open parenthesis, end value divided by beginning value, close parenthesis, to the power of 1 divided by change in years, minus 1, close bracket, multiplied by Payer Payer is the expected primary payer for the hospital stay.
Because most State data do not identify patients in SCHIP specifically, it is not possible to present this information separately. When more than one payer is listed for a hospital discharge, the first-listed payer is used. HCUP databases bring together the data collection efforts of State data organizations, hospital associations, and private data organizations HCUP Partners and the Federal government to create a national information resource of encounter-level data.
HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to programs, and outcomes of treatments at the national, State, and local market levels.
The reports use HCUP administrative data. The NIS is nationally representative of all community hospitals i. The NIS is a sample of hospitals and includes all patients from each hospital, regardless of payer. It is drawn from a sampling frame that contains hospitals comprising more than 95 percent of all discharges in the United States. The vast size of the NIS allows the study of topics at the national and regional levels for specific subgroups of patients.
In addition, NIS data are standardized across years to facilitate ease of use. The NIS was redesigned to optimize national estimates. The redesign incorporates two critical changes: Revisions to the sample design—the NIS is now a sample of discharge records from all HCUP-participating hospitals , rather than a sample of hospitals from which all discharges were retained.
The new sampling strategy is expected to result in more precise estimates than those that resulted from the previous NIS design by reducing sampling error: for many estimates, confidence intervals under the new design are about half the length of confidence intervals under the previous design.
The change in sample design for necessitates recomputation of prior years' NIS data to enable analysis of trends that uses the same definitions of discharges and hospitals. HCUPnet has an easy step-by-step query system that creates tables and graphs of national and regional statistics as well as data trends for community hospitals in the United States.
Updated July We then centered all hospitals on this date and evaluated the trends in the proportional use of each approach in the years before and after the hospital performed its first robotic operation. We used linear splines to model absolute levels and trends in the periods before and after introduction of robotic surgery.
This analysis was designed to test the incremental association of adopting robotic surgery with trends in surgical practice but not to make assumptions about what would have happened had the hospital not begun performing robotic surgery.
Our primary analysis was not adjusted for specific procedures, but we generated estimates for each procedure group in a sensitivity analysis. We estimated cluster-robust standard errors to account for repeated observations within hospitals.
We performed all statistical analyses using Stata, version Characteristics for the patients and 73 hospitals are included in Table 1. The mean SD age for all patients was Of the 73 hospitals included in the study, 31 Sixty-two hospitals From January through June , the use of robotic surgery for all general surgery procedures increased from 1. During the same period, the use of both laparoscopic and open surgery declined. For example, the proportional use of open surgery was Trends in robotic surgery use were similar for specific procedures, although for some, the magnitude of the increase was greater.
For example, the use of robotic surgery for inguinal hernia repair increased from 0. The proportion of hospitals and surgeons performing robotic surgery increased from January through June For example, 8. During the study period, 23 hospitals In those hospitals, the use of robotic surgery increased from 3. The use of laparoscopic surgery decreased from Before hospitals performed robotic surgery, a trend toward greater use of laparoscopic surgery occurred slope, 1.
Results remained the same when stratified across specific procedures. This study used a unique, clinically oriented, and manually abstracted data source to characterize the use of robotic surgery across a wide range of common general surgical procedures.
These data identify the correct procedure approach with greater precision and accuracy than claims. We found that the use of robotic surgery increased dramatically from to Although the use of robotic surgery increased across all procedures, for certain operations, such as inguinal hernia repair, practice patterns shifted by an order of magnitude toward greater use of robotics.
We also found that the use of robotic surgery increased rapidly and diffused widely across numerous different procedures in the years after hospitals begin performing robotic surgery. This trend was associated with a decrease in the use of open and laparoscopic minimally invasive procedures, which for most surgeons was already considered a safe and effective approach when clinically feasible.
Recent work suggests that the United States now performs more robotic surgery than any other country in the world, although overall trends in other specialties eg, urology toward greater use of robotic surgery have been present for many years.
However, accurate data on how robotic surgery is being applied in contemporary practice is lacking. Prior studies are limited to single-center reports and claims-based analyses that may be inaccurate owing to unreliable coding. It also limits the ability of policy makers and regulators to scope oversight or, more broadly, the public health implications of rapid changes in surgical practice.
Within this context, regulators from the FDA recently expressed safety concerns about the rapidly growing use of robotic approaches for certain cancer operations. For example, randomized clinical trials have failed to demonstrate the benefits of robotic surgery over other approaches in the treatment of rectal cancer 12 and have shown even potentially worse outcomes in procedures for cervical cancer. This study expands on prior work in several ways. We used manually abstracted data from a statewide surgical registry to ensure that our estimates reflect the true incidence of robotic surgery across a wide range of procedures, hospitals, and surgeons.
Making further use of these unique data, we estimated how the initiation of robotic surgery within hospitals had broad associations with surgical practice for numerous procedures that differed in complexity, anatomical location, and surgical indications eg, repair of a hernia vs removal of an organ. This investigation builds on existing literature, which has shown similar associations of an increase in robotic prostatectomy with hospital acquisitions of robotic systems.
For many common and low-risk procedures, such as cholecystectomy, conventional laparoscopic surgery is already the accepted standard of care.
Laparoscopic approaches are also less expensive and can be performed by most general surgeons without robotics. This study suggests that regulators and the surgical community can take additional steps to monitor the ongoing diffusion of robotic surgery and ensure that this trend does not lead to diminished patient safety.
Use of these provisions would facilitate greater understanding of how robotic procedures are being used in real-world practice. Akin to postmarket surveillance of pharmaceuticals, such provisions would also create a common data resource from which the comparative safety and effectiveness of robotic operations can be evaluated by numerous investigators. This action would also allow hospitals, which provide credentials to perform robotic surgery, to better understand where sufficient evidence suggests plausible benefit.
At present, surgeons are largely able to use robotic surgery for any procedure at their professional discretion. As has been shown in the FDA warning and through prior studies, this discretionary use may place patients at risk for poor outcomes. After all, for many of the procedures we report in this study, little to no evidence suggests that robotic surgery increases patient safety or treatment effectiveness compared with other approaches.
Our results should be interpreted within the context of several limitations. Our clinical registry only captures data from Michigan and therefore may not be generalizable to the country as a whole. However, the MSQC represents a heterogeneous group of hospitals, surgeons, and practice settings.
Furthermore, we report on the most common general surgery procedures performed in the United States. Changes in patient factors, such as obesity, may influence trends in procedure choice. Our estimates may therefore be limited by a lack of adjustment for patient characteristics. That said, adjusting for patient factors may introduce its own biases because no clinical consensus exists around how robotic procedures should be allocated.
Much of this decision-making is based on case-by-case surgeon assessments and clinical nuance not captured in any registry. Our results are consistent across multiple different procedures, which also suggests that these trends are independent of unique clinical domains or disease processes. Our study is unable to account for how other nonclinical factors, such as marketing, may influence the adoption of robotic surgery. However, others have found that the chances of receiving robotic surgery were 2- to 5-fold greater in highly competitive vs noncompetitive health care markets.
This study found that robotic surgery is rapidly diffusing across a broad range of common general surgical procedures. Trends toward greater use of the robotic platform appeared to occur rapidly after hospitals begin performing robotic surgery and were associated with a decrease in the use of established minimally invasive techniques, such as laparoscopic surgery.
This trend was consistent across numerous specific procedures, even those for which conventional laparoscopic surgery is already considered standard of care and for which robotic surgery offers little theoretical clinical benefit to the patient.
These findings highlight a need to continually monitor the diffusion of robotic surgery to ensure that enthusiasm for a new technology does not outpace the evidence needed to use it in the most effective clinical contexts. Published: January 10, Corresponding Author: Kyle H.
Author Contributions: Drs Sheetz and Dimick 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. Critical revision of the manuscript for important intellectual content: Sheetz, Dimick. While there still exists a plethora of opportunities in the emerging regions, such as Asia-Pacific, Middle East, and Latin America, due to a rising number of government-funded cancer screening programs.
The endoscopy devices segment can further be categorized into Endoscopes and Endoscopic Systems; Video and Visualization Systems; Instruments and Accessories; and Other Reprocessing and Sterilization ; among others. In , endoscope and endoscopic systems had the largest market value of 4. The high growth rate for the video and visualization systems segment is primarily due to the rising demand for improving diagnostic accuracy from the medical community requiring enhanced image resolution.
The endoscopy devices market segment can further be bifurcated into rigid and flexible endoscopes.
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