FG_AUTHORS: MedPage Today
Switching to the minimally invasive forms of some common surgeries could have saved an estimated $14 billion in healthcare spending in 2009, researchers said.
The estimated savings are a combination of lower medical costs and reduced workplace absenteeism, according to Andrew Epstein, PhD, and colleagues at the University of Pennsylvania in Philadelphia.
The finding is based on analysis of the effect of six minimally invasive procedures on costs and absenteeism among workers with employer-sponsored health plans, Epstein and colleagues reported online in JAMA Surgery.
While minimally invasive procedures are seen as a better surgical option for many patients, their impact on medical costs and worker productivity has not been widely studied.
"We saw a gap in discussions of what value really means in medical care," Epstein said in a statement.
"Clinical outcomes are obviously important, but they shouldn't be the sole measure of potential benefit," he said. "Recovery times also matter."
To help fill the gap, Epstein and colleagues turned to national health insurance claims data and matched workplace absenteeism data from Jan. 1, 2000, to Dec. 31, 2009.
They studied a sample of 321,956 adults with employer-sponsored health insurance who had either standard or minimally invasive surgery for six reasons: coronary revascularization, uterine fibroid resection, prostatectomy, peripheral revascularization, carotid revascularization, or aortic aneurysm repair.
For a subset of 23,814 patients, data was available from employees on absenteeism.
All told, 196,700 patients (61.1%) underwent the minimally invasive procedure and the remaining 125,256 (38.9%) had standard surgery. Among the subset with absenteeism data, 14,861 patients (62.4%) received minimally invasive surgery and 8,953 (37.6%) had the standard procedure.
In a multivariable analysis, costs were lower for minimally invasive surgery for coronary revascularization, uterine fibroid resection, and peripheral revascularization, with average per-procedure savings of $30,850, $1,509, and $12,031, respectively, compared with standard surgery.
On the other hand, average costs were higher for the minimally invasive versions of prostatectomy and carotid revascularization – an extra $1,350 and $4,900, respectively.
There was no significant difference for aortic aneurysm repair, they found.
For four procedures, the minimally invasive version was associated with missing significantly fewer days of work, Epstein and colleagues reported. Specifically, compared with standard surgery:
- Patients who underwent minimally invasive coronary revascularization missed 37.7 fewer days on average.
- Minimally invasive uterine fibroid resection cost 11.7 fewer days.
- Minimally invasive prostatectomy cost 9 fewer days.
- And minimally invasive peripheral revascularization meant 16.6 fewer days off work.
There was no significant difference in absenteeism for the other two procedures.
Based on those findings, the researchers used 2009 population and cost figures to calculate that the national effect on all employer-sponsored health would have to reduce spending by $8.9 billion and to cut worker absenteeism by some 53,134 person-years.
At the 2009 national average wage of $40 712, the reduction in absenteeism was worth $2.2 billion, they calculated.
They also estimated that if minimally invasive surgery had been used for all patients undergoing the six procedures in 2009 – regardless of the source of their health insurance -- the sum of the savings would have been more than $14 billion.
On the other hand, they noted that they did not assess differences in clinical outcomes, so the "findings should be interpreted with caution." Additionally, there are some patients for whom minimally invasive procedures "clearly remain inappropriate."
It is also possible that patients who received the different kinds of surgery differed from each other in systematic ways that were not measured, they wrote.
Indeed, the lack of randomization in the study raises some questions about the accuracy of the results, although it is not a "fatal flaw," commented Justin Dimick, MD, of the University of Michigan Ann Arbor and Andrew Ryan, PhD, of Weill Cornell Medical College in New York City.
Because the researchers used administrative data, they noted in an accompanying critique, there is little clinical detail, which raises the possibility that patient selection played a role.
"Selection bias likely results in an overestimation of the benefits of less invasive procedures," Dimick and Ryan noted, since they are less likely to be offered to patients who have advanced disease.
But "differences in patient selection account for some, but not likely all, of the benefits found with less invasive procedures," they concluded.
The study had support from the Institute for Health Technology Studies.
Epstein reported no conflicts of interest.
One co-author reported financial links with GlaxoSmith Kline.
The journal said the critique authors reported no conflicts of interest.