In the Journals

Medicare patients less likely to have minimally invasive surgery despite benefits

Elderly Medicare recipients were less likely to undergo minimally invasive laparoscopic surgery compared with the general population, even though those who did had better outcomes and lower costs than patients who had open surgery, according to new research published in Surgical Endoscopy.

Martin A. Makary, MD, MPH, professor of surgery at Johns Hopkins University School of Medicine, and colleagues wrote that despite the evidence demonstrating both clinical and economic benefits of minimally invasive surgery (MIS), the rate at which it is utilized in Medicare recipients is still quite low compared with the general population. This “underuse of MIS for eligible candidates in the Medicare population is an example of low-value care,” he said in a press release.

Given that Medicare insures about a quarter of all Americans, costing nearly $600 billion in 2016 alone, Makary and colleagues sought to evaluate the potential efficiencies and cost savings to be gained by using MIS in this patient population. To do so, they analyzed records from 233,984 patients using the 2014 Medicare Provider Analysis and Review Inpatients Limited Data Set and identified patients who underwent bariatric, cholecystectomy, colectomy, hysterectomy, inguinal hernia, thoracic and ventral hernia procedures. They compared the odds of complications and all-cause 30-day readmission for MIS (n = 131,255) vs. open surgery (n = 102,729), and estimated differences in length of hospital stay, and Medicare claim cost and reimbursement.

They observed lower complication rates for five of the seven MIS procedures (OR = 0.36–0.69), lower readmission rates for six of the MIS procedures (OR = 0.43–0.87), and shorter hospital stays for six of the MIS procedures (point estimate range, 0.35–2.47 days shorter).

Further, they found that Medicare claim costs were lower for four of the MIS procedures ($3,010.23 to $4,832.74 less per procedure), and Medicare reimbursements were lower for three of the MIS procedures ($841.10 to $939.69 less per procedure).

“Interestingly, the incidence of complications and claim costs were higher for inguinal hernias performed using an MIS approach,” they noted.

Despite these benefits, they found that MIS was more common in the general population compared with Medicare recipients, regardless of the procedure. For example, 96% of bariatric surgeries in the general population were MIS compared with 86% in the Medicare population, as well as 92% vs. 87% of cholecystectomies and 42% vs. 27% of colectomies.

However, the researchers acknowledged that determining candidacy for MIS on a population level is difficult, which is an important study limitation.

“This study shows there is an opportunity for Medicare and other payers to spend health care dollars more wisely so that they reward high-value care,” Makary said in the press release. – by Alex Young

Disclosures: Makary reports no relevant financial disclosures. See the full study for a list of all other authors’ relevant financial disclosures.

Elderly Medicare recipients were less likely to undergo minimally invasive laparoscopic surgery compared with the general population, even though those who did had better outcomes and lower costs than patients who had open surgery, according to new research published in Surgical Endoscopy.

Martin A. Makary, MD, MPH, professor of surgery at Johns Hopkins University School of Medicine, and colleagues wrote that despite the evidence demonstrating both clinical and economic benefits of minimally invasive surgery (MIS), the rate at which it is utilized in Medicare recipients is still quite low compared with the general population. This “underuse of MIS for eligible candidates in the Medicare population is an example of low-value care,” he said in a press release.

Given that Medicare insures about a quarter of all Americans, costing nearly $600 billion in 2016 alone, Makary and colleagues sought to evaluate the potential efficiencies and cost savings to be gained by using MIS in this patient population. To do so, they analyzed records from 233,984 patients using the 2014 Medicare Provider Analysis and Review Inpatients Limited Data Set and identified patients who underwent bariatric, cholecystectomy, colectomy, hysterectomy, inguinal hernia, thoracic and ventral hernia procedures. They compared the odds of complications and all-cause 30-day readmission for MIS (n = 131,255) vs. open surgery (n = 102,729), and estimated differences in length of hospital stay, and Medicare claim cost and reimbursement.

They observed lower complication rates for five of the seven MIS procedures (OR = 0.36–0.69), lower readmission rates for six of the MIS procedures (OR = 0.43–0.87), and shorter hospital stays for six of the MIS procedures (point estimate range, 0.35–2.47 days shorter).

Further, they found that Medicare claim costs were lower for four of the MIS procedures ($3,010.23 to $4,832.74 less per procedure), and Medicare reimbursements were lower for three of the MIS procedures ($841.10 to $939.69 less per procedure).

“Interestingly, the incidence of complications and claim costs were higher for inguinal hernias performed using an MIS approach,” they noted.

Despite these benefits, they found that MIS was more common in the general population compared with Medicare recipients, regardless of the procedure. For example, 96% of bariatric surgeries in the general population were MIS compared with 86% in the Medicare population, as well as 92% vs. 87% of cholecystectomies and 42% vs. 27% of colectomies.

However, the researchers acknowledged that determining candidacy for MIS on a population level is difficult, which is an important study limitation.

“This study shows there is an opportunity for Medicare and other payers to spend health care dollars more wisely so that they reward high-value care,” Makary said in the press release. – by Alex Young

Disclosures: Makary reports no relevant financial disclosures. See the full study for a list of all other authors’ relevant financial disclosures.