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Capturing da Vinci Metrics to Improve Quality, Efficiency and Education in Robotics
Sonia L. Ramamoorthy, MD, FACS, FASCRSProfessor of Surgery, Vice Chair of QualityChief, Division of Colon and Rectal Surgery
Sarah Stringfield, MD PGY-3
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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
Perspective
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• 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
Initiative
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• Chair and VC• All surgeon stakeholders • Administration• Nursing
• Purchasing• Supply side• Industry support
Robotic Subcommittee (Perioperative Exec. )
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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
6
Results:Robotic system
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Hillcrest
Thornton
JMC
S
Si
S System- Loaned/Purchased
Si System Donated
Si
Xi
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FIRST DASHBOARDS UCSD 2008-2012
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9
10
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Results:Case volume
• Total cases: 3393
• August 2005-July 2016
0
100
200
300
400
500
600
2005 2006 2006 2008 2009 2010 2011 2012 2013 2014 2015 2016
Totalcases
12
Results:Volume by specialty
Other:Neurosurgery Otolaryngology
2%
24%
23%
0%
51%
CasesperSpecialty
Cardiothoracic General
Gynecology Other
Urology
13
Results:Volume by specialty
0
20
40
60
80
100
120
140
160
180
200
2004 2006 2008 2010 2012 2014 2016
Cas
es
Year
Cases by specialty
Cardiothoracic General Gynecology Urology Other
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Results:Unique faculty
• Total of 43 unique attendings
0
1
2
3
4
5
6
7
8
9
10
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Atte
ndin
gs
Year
Attendings by Specialty
Cardiothoracic
General
Gynecology
Urology
Other
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Results:Types of Cases
General: Colorectal 281
LAR 103
Segmental Colectomy 74
APR, Proctectomy 49
Rectopexy 36
Proctocolectomy 14
Ileostomy 2
Stoma reversal 2
Stricturoplasty 1
General: Oncology 88
Esophagectomy 54
Bowel Resection NOS 8
Esophagogastrectomy 7
Hepatectomy 6
Adrenalectomy 6
Gastrectomy 6
General: MIS 311
Donor Kidney, living 99
Myotomy 84
Paraesophageal hernia 49
Cholecystectomy 47
Fundoplication 14
Sleeve gastrectomy 8Gastric band placement/removal 4
Esophageal diverticulum repair 3
Other Hernia 1
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Results:Types of Cases
Cardiothoracic 52
CABG 24
Aortic/Mitral Valve 14Mediastinal Mass excision 4
Repair of septal defect 4
VATS 4
Ablation 2
Gynecology 652
Hysterectomy 391
Sacrocolpopexy 133
Salpingooophorectomy 110
Myomectomy 7
Ovarian cystectomy 7
Vesicovaginal fistula 2Cervical biopsy/resection 2
Urology 1463
Prostatectomy 1075
Nephrectomy 221
Cystectomy 69
Cystoprostatectomy 43
Pyeloplasty 32Ureteral reimplantation, resection, or ureterolysis
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Lymphocele 3
Cystoscopy 2
Mullerian Duct excision 1
Nephropexy 1
Orchiectomy 1Seminal Vesicle Excision 1
Pyelolithotomy 1
Combined specialty, other 19
Lymph node dissection 8
Pelvic Exenteration 3
Pelvic Mass Removal 3
Enterocele repair 2
Transoral surgery 1
Nerve transection 1Resection Peritoneal cyst 1
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Results:Types of Cases
Total number of cases: 65
• Top 5 cases:
• Account for 2084 of 2882 cases (72%)
• Prostatectomy alone accounts for 37% of cases
Prostatectomy 1075
Hysterectomy 391
Nephrectomy 320
Proctectomy 165
Sacrocolpopexy 133
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Results:Case time
• 2005-2006 decreased by 31%
• 2006-2007 decreased by 22%
• 2007-2015 average time 236 minutes (range 226-247)
0.00
50.00
100.00
150.00
200.00
250.00
300.00
350.00
400.00
450.00
500.00
2004 2006 2008 2010 2012 2014 2016
Aver
age
Min
utes
Year
Case Time
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• After 2007, case times 78-80% of OR time
• Console time 54-59% of OR time
0
100
200
300
400
500
600
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Min
utes
Year
Case times
Console time Case time Room time
Results:Case time
86%
83%
80% 80% 80% 81% 78% 78% 79% 79% 79%
59% 58%54% 57% 59% 58%
20
Results:Case time
0
100
200
300
400
500
600
700
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Min
utes
Year
Urology
• After 2005:• Case time 250 minutes (81% OR time)• Console time 193 minutes (62% OR time)
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Results:Case time
• After 2005:• Case time 253 minutes (80% OR time)• Console time 174 minutes (55% OR time)
0
50
100
150
200
250
300
350
400
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Min
utes
Year
Gynecology
22
Results:Case time
• Case time 212 minutes (77% OR time)• Console time 127 minutes (46% OR time)
0
50
100
150
200
250
300
350
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Min
utes
Year
General Surgery
23
Results:Case time
• After 2005:• Case time 294 minutes (67% OR time)• Console time 228 minutes (52% OR time)
0
100
200
300
400
500
600
2010 2011 2012 2013 2014 2015
Min
utes
Year
Cardiothoracic
Console time Case time OR time
24
Results:Case time
0
50
100
150
200
250
300
350
400
450
500
Urology Gynecology General Cardiothoracic
Case times by specialty
81%
62%55%
80%
46%
77% 52%
67%
25
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%
26
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
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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
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• 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
Education
29
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
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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