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Ramamoorthy Robotic Surgery Capturing da Vinci Metrics to Improve Quality, Efficiency and Education in Robotics Sonia L. Ramamoorthy, MD, FACS, FASCRS Professor of Surgery, Vice Chair of Quality Chief, Division of Colon and Rectal Surgery Sarah Stringfield, MD PGY-3 1 Perspective Critical investments within the surgical service line should be monitored over time for return on investment, observed vs expected outcomes, and utilization Prior to development of robotic surgery, few enterprises felt compelled to obtain metrics on surgical tools The robot presented a new challenges (paradigm?) not only in surgery but in administration, nursing, and supply chain 2 Initiative • Safety First • Create a body of peers to govern safe use of the da vinci robot • Provide the hospital with a methodology for credentialing robotic surgeons • Identify structured support teams • Structured Access • More surgeons meant more robotic time request • Overburdened OR • Physician utilization • OR time • Procedures • Financial metrics • Payer mix • Cost per case 3 Robotic Subcommittee (Perioperative Exec. ) • Chair and VC • All surgeon stakeholders • Administration • Nursing • Purchasing • Supply side • Industry support 4 Methods to obtain data at UCSD • All robotic operations performed at UCSD Medical Center were reviewed • August 2005-July 2016 • Data sources: • Electronic surgical scheduling system • ORSOS (2005-2013) • Epic (Oct 2013-present) • Da Vinci system • Hospital administrative databases • Robotic Surgery Subcommittee 5 Results: Robotic system 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Hillcrest S Si Thornton S System- Loaned/Purchased Si System Donated JMC Si Xi 6 FIRST DASHBOARDS UCSD 2008-2012 7 8 9 10 Results: Case volume • Total cases: 3393 • August 2005-July 2016 Total cases 600 500 400 300 200 100 0 2005 2006 2006 2008 2009 2010 2011 2012 2013 2014 2015 2016 11 Results: Volume by specialty Cases per Specialty 2% 24% 51% 23% 0% Other:Cardiothoracic General NeurosurgeryGynecology Other Otolaryngology 12 Urology Results: Volume by specialty Cases by specialty 200 180 160 140 120 100 Cases 80 60 40 20 0 2004 2006 2008 2010 2012 2014 2016 Year Cardiothoracic General Gynecology Urology Other 13 Results: Unique faculty • Total of 43 unique attendings Attendings by Specialty 10 9 8 7 6 Cardiothoracic 5 General Gynecology 4 Attendings Urology 3 Other 2 1 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year 14 Results: Types of Cases General: Colorectal 281 General: Oncology 88 General: MIS 311 LAR 103 Esophagectomy 54 Donor Kidney, living 99 Segmental Colectomy 74 Bowel Resection NOS 8 Myotomy 84 APR, Proctectomy 49 Esophagogastrectomy 7 Paraesophageal hernia 49 Rectopexy 36 Hepatectomy 6 Cholecystectomy 47 Proctocolectomy 14 Adrenalectomy 6 Fundoplication 14 Ileostomy 2 Gastrectomy 6 Sleeve gastrectomy 8 Gastric band Stoma reversal 2 4 placement/removal Stricturoplasty 1 Esophageal 3 diverticulum repair Other Hernia 1 15 Results: Types of Cases Combined specialty, Urology 1463 Gynecology 652 19 other Prostatectomy 1075 Hysterectomy 391 Lymph node dissection 8 Nephrectomy 221 Sacrocolpopexy 133 Pelvic Exenteration 3 Cystectomy 69 Salpingooophorectomy 110 Pelvic Mass Removal 3 Cystoprostatectomy 43 Myomectomy 7 Enterocele repair 2 Pyeloplasty 32 Ovarian cystectomy 7 Transoral surgery 1 Ureteral reimplantation, Vesicovaginal fistula 2 resection, or 13 Nerve transection 1 Cervical ureterolysis 2 Resection Peritoneal biopsy/resection 1 Lymphocele 3 cyst Cystoscopy 2 Cardiothoracic 52 Mullerian Duct excision 1 CABG 24 Nephropexy 1 Aortic/Mitral Valve 14 Mediastinal Mass 4 Orchiectomy 1 excision Seminal Vesicle 1 Repair of septal defect 4 Excision Pyelolithotomy 1 VATS 4 16 Ablation 2 Results: Types of Cases Total number of cases: 65 • Top 5 cases: Prostatectomy 1075 Hysterectomy 391 Nephrectomy 320 Proctectomy 165 Sacrocolpopexy 133 • Account for 2084 of 2882 cases (72%) • Prostatectomy alone accounts for 37% of cases 17 Results: Case time Case Time 500.00 450.00 400.00 350.00 300.00 250.00 200.00 150.00 Average Minutes 100.00 50.00 0.00 2004 2006 2008 2010 2012 2014 2016 Year • 2005-2006 decreased by 31% • 2006-2007 decreased by 22% • 2007-2015 average time 236 minutes (range 226-247) 18 Results: Case time • After 2007, case times 78-80% of OR time • Console time 54-59% of OR time Case times 600 500 86% 400 83% 300 80% 79% 79% 80% 80% 81% 78% 78% 79% Minutes 200 58% 57% 59% 59% 54% 58% 100 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year Console time Case time Room time 19 Results: Case time Urology 700 600 500 400 300 Minutes 200 100 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year • After 2005: • Case time 250 minutes (81% OR time) • Console time 193 minutes (62% OR time) 20 Results: Case time Gynecology 400 350 300 250 200 Minutes 150 100 50 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year • After 2005: • Case time 253 minutes (80% OR time) • Console time 174 minutes (55% OR time) 21 Results: Case time General Surgery 350 300 250 200 150 Minutes 100 50 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year • Case time 212 minutes (77% OR time) • Console time 127 minutes (46% OR time) 22 Results: Case time Cardiothoracic 600 500 400 300 Minutes 200 100 0 2010 2011 2012 2013 2014 2015 Year Console time Case time OR time • After 2005: • Case time 294 minutes (67% OR time) • Console time 228 minutes (52% OR time) 23 Results: Case time Case times by specialty 500 450 400 350 67% 300 81% 80% 52% 250 77% 62% 55% 200 46% 150 100 50 0 Urology Gynecology General Cardiothoracic 24 Results: Operating Room costs • Since 2013, costs for OR supplies range from $1800- $6000 per case (excluding cardiac cases) • Costs for robotic supplies range from $925-$2100 per case • On average, robotic disposables account for 42.8% of supply costs in robotic cases • Living donor kidney 21% • Ureteral operations 70% 25 Results: Admissions costs • 2014-2015 admissions data for all robotic surgeries and their equivalent open operations • 22 types of operations across all specialties, selected by ICD9 code • ALOS for robotic cases 4.1 days compared to 5.9 days for their equivalent open operations • Range: -6.2 to +3.9 days • >5 day difference between robotic vs open • Total colectomy • Cardiac valve • CABG 26 Results: Admissions costs • Average cost/day for admission after robotic surgery 1.9x higher than open surgery • When factoring in shorter length of stay, robotic costs only 1.08x higher than open cases • Most cost-effective operations: • Total colectomy • Cardiac valve • CABG • Nephrectomy • Cholecystectomy • In 2015, prostatectomy, esophagectomy, and sacrocolpopexy were exclusively performed robotically 27 Education • Area of development for UCSD • Urology and Gyn following national guidelines • General Surgery still evolving • Residents interested • Faculty time challenge • Facilities state of the art • Integrating into residency • Progression from bedside to console surgeon • Progression from simple tasks to more complex • Demonstrated interest and skill • Challenge is integration into resident curriculum 28 Conclusions • Tracking our data has allowed us to fully “own” our program and make strategic decisions that benefits patients and the health system • A multidiscliplinary robotic subcommittee has been the key to • Monitoring safety, cost, and efficiency • Large increase in number and types of cases, across many specialties • Robotic trained faculty • Robotic trained residents 29 Future directions • Learning curve: surgeon specific vs OR staff • Residency Training • Conversion rates • Outcomes: transfusion, readmits, oncologic • Value undefined metrics- surgeon preference, ergonomics, single platform integration • Modelling for anticipated changes in future payment 30.
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