Evaluating the cost-effectiveness of robotic mitral valve repair and recovery improvement efforts
The rapidly changing health care economic environment necessitates the pursuit of innovation in order to improve patient outcomes in a cost-effective manner. Technical advances must add value to clinical and financial outcomes.
The approach to treating mitral valve regurgitation is but one example of changing practice guided by technological innovation. Many valves can be repaired rather than replaced, negating the need for long-term anticoagulation, and less-invasive robotic procedures can frequently be employed earlier in the clinical course, resulting in fewer atrial arrhythmias and preserved left ventricular function.
In a study published in 2013 in Mayo Clinic Proceedings, Mayo Clinic cardiovascular surgeons demonstrate the affordability of robotic mitral valve repair compared with traditional sternotomy.
Mayo researchers reviewed records from 747 consecutive patients who underwent mitral valve repair either via traditional sternotomy or minimally invasive robotic repair at Mayo Clinic in Minnesota between July 1, 2007, and Jan. 31, 2011. Patients were excluded from review if they:
- Required concomitant cardiac surgery, such as coronary artery bypass grafting or repair of congenital cardiac defects
- Had prior thoracotomy or sternotomy
- Had rheumatic valvular disease, active endocarditis or peripheral vascular disease
Of the 482 remaining patients, 282 had open mitral repair, while 200 underwent robotic repair. One hundred eighty-five propensity-matched pairs were identified with comparable baseline characteristics.
Direct costs were calculated by using standardized values for services and procedures obtained from the Olmsted County Healthcare Expenditure and Utilization Database, which has been used for cost studies since 1995. Provider and institutional costs were determined by applying appropriate Medicare fees. Costs were standardized over the time period studied. The results were then aggregated into categories to enable comparison between the two approaches.
Additionally, Mayo Clinic in Minnesota implemented a surgical process improvement project in July 2009 specifically designed to reduce the cost of cardiac surgical care without negatively impacting quality of care. Components of that redesign process included:
- Coordinated case sequencing across operating rooms
- Staggered start times
- On-time operating room start times
- Integrated staffing model
- Standardized postoperative care algorithms
Robotic and open operative groups were evaluated before and after implementation of the process improvement project.
Early complications were infrequent in both the open and robotic repair groups, with the exception of the need for blood transfusion and early atrial fibrillation; both were statistically less frequent in the robotic repair group. Hospital length of stay was initially shorter in the robotic group (3.5 vs. 5.3 days; P < 0.001).
Costs for both patient groups fell after implementation of the surgical process improvement project, but costs declined more dramatically in the robotic group. Overall costs for those patients undergoing robotic mitral repair were slightly less than, but statistically indistinguishable from, costs for patients who underwent open repair who were also exposed to the improvement project.
Important findings in this study
- Systems innovation can lead to cost savings, even in a large diverse cardiac valve surgery program.
- Technical innovation can be introduced and optimized to be cost neutral.
- Patients treated under this combined model benefit from accelerated recovery and shorter hospital stays.
The current health care environment mandates that new medical treatments demonstrate added value either by reducing cost or improving outcomes. This study demonstrates that improvements in both are facilitated by concurrent deployment of both technical and systems innovations in a large and diverse academic heart valve practice.
Robotic heart valve repair is also associated with a shorter recovery time after hospital dismissal, due to lack of sternotomy. Patients have less pain, shorter recovery times, and are usually able to return to work and other activities sooner than individuals who have open repair. While these factors were not addressed in the published review, they are important considerations for patients, their families and the American economy. Mayo researchers are currently studying these very important outcomes and will hopefully have more to share on this topic in the very near future.
For more information
Suri R., et al. Improving Affordability Through Innovation in the Surgical Treatment of Mitral Valve Disease. Mayo Clinic Proceedings. 2013;88:1075.