Research Original Investigation
Robotically Assisted Mitral Valve Surgery
56. Department of Health Science Research. Rochester, MN: Mayo Clinic; 1995. 28. Morgan JA, Thornton BA, Peacock JC, et al. Does robotic technology make minimally invasive cardiac surgery too expensive? a hospital cost analysis of robotic and conventional techniques. J Card Surg. 2005;20(3):246-251. 29. Kam JK, Cooray SD, Kam JK, Smith JA, Almeida AA. A cost-analysis study of robotic versus conventional mitral valve repair. Heart Lung Circ. 2010;19(7):413-418. 30. Murphy KM, Topel RH. Measuring the Gains From Medical Research: An Economic Approach. Chicago, IL: University of Chicago Press; 2003. 31. Stoker ME, Vose J, O'Mara P, Maini BS. Laparoscopic cholecystectomy: a clinical and financial analysis of 280 operations. Arch Surg. 1992;127(5):589-595.
32. Fisher KS, Reddick EJ, Olsen DO. Laparoscopic cholecystectomy: cost analysis. Surg Laparosc Endosc. 1991;1(2):77-81. 33. Fajardo R, Valenzuela JI, Olaya SC, et al. Cost-effectiveness of laparoscopic versus open cholecystectomy [in Spanish]. Biomedica. 2011;31 (4):514-524. 34. Zacks SL, Sandler RS, Rutledge R, Brown RS Jr. A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy. Am J Gastroenterol. 2002;97(2): 334-340. 35. McIntyre RC Jr, Zoeter MA, Weil KC, Cohen MM. A comparison of outcome and cost of open vs laparoscopic cholecystectomy. J Laparoendosc Surg. 1992;2(3):143-149.
general thoracic surgery. Ann Thorac Surg. 1993;56 (3):804-806. 37. Bhatnagar NK. The impact of video assisted thoracoscopic surgery (VATS). Respir Med. 1994;88 (6):403-406. 38. Molin LJ, Steinberg JB, Lanza LA. VATS increases costs in patients undergoing lung biopsy for interstitial lung disease. Ann Thorac Surg. 1994; 58(6):1595-1598. 39. Swanson SJ, Meyers BF, Gunnarsson CL, et al. Video-assisted thoracoscopic lobectomy is less costly and morbid than open lobectomy: a retrospective multiinstitutional database analysis. Ann Thorac Surg. 2012;93(4):1027-1032.
36. Miller JI Jr. The present role and future considerations of video-assisted thoracoscopy in
Invited Commentary
Assessing the Value of Surgical Robotics Not Your Grandfather’s Widget David D. Yuh, MD
Mihaljevic and colleagues1 have courageously entered the fray in assigning and assessing relative “value” in health care. Unlike applying conventional profit-loss analyses in producing and marketing widgets in business school, health care Related article page 679 administrators and physicians must grapple with the conundrum of justifying the quantifiable costs of new technologies with vaguely defined measures of patient benefit, even more ambiguous assessments of benefit to society, and the perpetually moving target of marketing advantage. The need for a cogent method to optimize value in health care is accentuated by the nation’s focus on rising health care costs and unfavorable value comparisons to other nations’ health care systems. The authors rightly acknowledge the imperfections of their method. Translating faster recovery into monetary equivalents and comparing these with direct hospital costs begs scrutiny and criticism but represents a reasonable attempt to draw on precedent to conceptualize patient and societal benefits. Furthermore, the psychological overlay that might encourARTICLE INFORMATION
REFERENCES
Author Affiliation: Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut.
1. Mihaljevic T, Koprivanac M, Kelava M, et al. Value of robotically assisted surgery for mitral valve disease [published online May 21, 2014]. JAMA Surg. doi:10.1001/jamasurg.2013.5680.
Corresponding Author: David D. Yuh, MD, Section of Cardiac Surgery, Yale University School of Medicine, 333 Cedar St, Boardman 204, PO Box 208039, New Haven, CT 06520 (david.yuh@yale .edu). Published Online: May 21, 2014. doi:10.1001/jamasurg.2013.5710. Conflict of Interest Disclosures: None reported.
686
age patients undergoing robotically assisted surgery to return to work earlier should not be underestimated, although it could be argued that this is just as valid a benefit of less invasive approaches as smaller incisions. Ultimately, the import of this study does not lie in validating robotic surgery. As with catheter-based interventions and other less invasive technologies, robotic surgical platforms will continue to evolve and perhaps even become cost-neutral.2 Certainly, the notion that less invasive surgical approaches lead to many clinical benefits has been validated excessively3-6and will continue to drive further development. The significance of this and similar studies lies in developing frameworks for determining relative short- and long-term values of highpriced technologies in this era of “value-based purchasing.” The oft-used justification that the high costs of a given new innovative device will ultimately decline and pay for itself (eg, laparoscopy) should not be assumed in this era of entrepreneurial technological innovation. Ironically, surgical robotics may demonstrate that expensive new technologies may be replaced with expensive newer technologies.
2. Suri RM, Thompson JE, Burkhart HM, et al. Improving affordability through innovation in the surgical treatment of mitral valve disease. Mayo Clin Proc. 2013;88(10):1075-1084. 3. Cheng DC, Martin J, Lal A, et al. Minimally invasive versus conventional open mitral valve surgery: a meta-analysis and systematic review. Innovations (Phila). 2011;6(2):84-103.
4. Galloway AC, Schwartz CF, Ribakove GH, et al. A decade of minimally invasive mitral repair: long-term outcomes. Ann Thorac Surg. 2009;88 (4):1180-1184. 5. Mihaljevic T, Jarrett CM, Gillinov AM, et al. Robotic repair of posterior mitral valve prolapse versus conventional approaches: potential realized. J Thorac Cardiovasc Surg. 2011;141(1):72-80.e4. 6. Murphy DA, Miller JS, Langford DA, Snyder AB. Endoscopic robotic mitral valve surgery. J Thorac Cardiovasc Surg. 2006;132(4):776-781.
JAMA Surgery July 2014 Volume 149, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/26/2015
jamasurgery.com
Robotically Assisted Mitral Valve Surgery
56. Department of Health Science Research. Rochester, MN: Mayo Clinic; 1995. 28. Morgan JA, Thornton BA, Peacock JC, et al. Does robotic technology make minimally invasive cardiac surgery too expensive? a hospital cost analysis of robotic and conventional techniques. J Card Surg. 2005;20(3):246-251. 29. Kam JK, Cooray SD, Kam JK, Smith JA, Almeida AA. A cost-analysis study of robotic versus conventional mitral valve repair. Heart Lung Circ. 2010;19(7):413-418. 30. Murphy KM, Topel RH. Measuring the Gains From Medical Research: An Economic Approach. Chicago, IL: University of Chicago Press; 2003. 31. Stoker ME, Vose J, O'Mara P, Maini BS. Laparoscopic cholecystectomy: a clinical and financial analysis of 280 operations. Arch Surg. 1992;127(5):589-595.
32. Fisher KS, Reddick EJ, Olsen DO. Laparoscopic cholecystectomy: cost analysis. Surg Laparosc Endosc. 1991;1(2):77-81. 33. Fajardo R, Valenzuela JI, Olaya SC, et al. Cost-effectiveness of laparoscopic versus open cholecystectomy [in Spanish]. Biomedica. 2011;31 (4):514-524. 34. Zacks SL, Sandler RS, Rutledge R, Brown RS Jr. A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy. Am J Gastroenterol. 2002;97(2): 334-340. 35. McIntyre RC Jr, Zoeter MA, Weil KC, Cohen MM. A comparison of outcome and cost of open vs laparoscopic cholecystectomy. J Laparoendosc Surg. 1992;2(3):143-149.
general thoracic surgery. Ann Thorac Surg. 1993;56 (3):804-806. 37. Bhatnagar NK. The impact of video assisted thoracoscopic surgery (VATS). Respir Med. 1994;88 (6):403-406. 38. Molin LJ, Steinberg JB, Lanza LA. VATS increases costs in patients undergoing lung biopsy for interstitial lung disease. Ann Thorac Surg. 1994; 58(6):1595-1598. 39. Swanson SJ, Meyers BF, Gunnarsson CL, et al. Video-assisted thoracoscopic lobectomy is less costly and morbid than open lobectomy: a retrospective multiinstitutional database analysis. Ann Thorac Surg. 2012;93(4):1027-1032.
36. Miller JI Jr. The present role and future considerations of video-assisted thoracoscopy in
Invited Commentary
Assessing the Value of Surgical Robotics Not Your Grandfather’s Widget David D. Yuh, MD
Mihaljevic and colleagues1 have courageously entered the fray in assigning and assessing relative “value” in health care. Unlike applying conventional profit-loss analyses in producing and marketing widgets in business school, health care Related article page 679 administrators and physicians must grapple with the conundrum of justifying the quantifiable costs of new technologies with vaguely defined measures of patient benefit, even more ambiguous assessments of benefit to society, and the perpetually moving target of marketing advantage. The need for a cogent method to optimize value in health care is accentuated by the nation’s focus on rising health care costs and unfavorable value comparisons to other nations’ health care systems. The authors rightly acknowledge the imperfections of their method. Translating faster recovery into monetary equivalents and comparing these with direct hospital costs begs scrutiny and criticism but represents a reasonable attempt to draw on precedent to conceptualize patient and societal benefits. Furthermore, the psychological overlay that might encourARTICLE INFORMATION
REFERENCES
Author Affiliation: Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut.
1. Mihaljevic T, Koprivanac M, Kelava M, et al. Value of robotically assisted surgery for mitral valve disease [published online May 21, 2014]. JAMA Surg. doi:10.1001/jamasurg.2013.5680.
Corresponding Author: David D. Yuh, MD, Section of Cardiac Surgery, Yale University School of Medicine, 333 Cedar St, Boardman 204, PO Box 208039, New Haven, CT 06520 (david.yuh@yale .edu). Published Online: May 21, 2014. doi:10.1001/jamasurg.2013.5710. Conflict of Interest Disclosures: None reported.
686
age patients undergoing robotically assisted surgery to return to work earlier should not be underestimated, although it could be argued that this is just as valid a benefit of less invasive approaches as smaller incisions. Ultimately, the import of this study does not lie in validating robotic surgery. As with catheter-based interventions and other less invasive technologies, robotic surgical platforms will continue to evolve and perhaps even become cost-neutral.2 Certainly, the notion that less invasive surgical approaches lead to many clinical benefits has been validated excessively3-6and will continue to drive further development. The significance of this and similar studies lies in developing frameworks for determining relative short- and long-term values of highpriced technologies in this era of “value-based purchasing.” The oft-used justification that the high costs of a given new innovative device will ultimately decline and pay for itself (eg, laparoscopy) should not be assumed in this era of entrepreneurial technological innovation. Ironically, surgical robotics may demonstrate that expensive new technologies may be replaced with expensive newer technologies.
2. Suri RM, Thompson JE, Burkhart HM, et al. Improving affordability through innovation in the surgical treatment of mitral valve disease. Mayo Clin Proc. 2013;88(10):1075-1084. 3. Cheng DC, Martin J, Lal A, et al. Minimally invasive versus conventional open mitral valve surgery: a meta-analysis and systematic review. Innovations (Phila). 2011;6(2):84-103.
4. Galloway AC, Schwartz CF, Ribakove GH, et al. A decade of minimally invasive mitral repair: long-term outcomes. Ann Thorac Surg. 2009;88 (4):1180-1184. 5. Mihaljevic T, Jarrett CM, Gillinov AM, et al. Robotic repair of posterior mitral valve prolapse versus conventional approaches: potential realized. J Thorac Cardiovasc Surg. 2011;141(1):72-80.e4. 6. Murphy DA, Miller JS, Langford DA, Snyder AB. Endoscopic robotic mitral valve surgery. J Thorac Cardiovasc Surg. 2006;132(4):776-781.
JAMA Surgery July 2014 Volume 149, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/26/2015
jamasurgery.com
