“Missing productivity gains in the medicare physician fee schedule: Where are they?”
Cromwell, J., N. McCall, et al. (2010).
Medical Care Research and Review67(6): 676-693.
The Medicare Fee Schedule with payments for thousands of visits and procedures is updated periodically for the work component of changes in physician relative work. Three 5-year reviews of physician work by Medicare have been biased against finding productivity gains and reductions in physician work relative values. The authors present four studies showing shorter physician times with patients in their offices and in the operating room, increases in surgeons’ self-reported total work in spite of declining operating room times, and growing numbers of costly handoffs to nonsurgeons, while surgeons receive full payment for postoperative follow-up with patients. Substantial savings exist in the fee schedule if productivity gains from greater delegation to ancillary staff and specialists, reengineering of services, and rapid learning by experience with new technologies were integrated into the periodic reviews. © 2010 The Author(s).
“Laparoscopic surgery for endometrial cancer: A phenomenological study.”
Hughes, C., W. Knibb, et al. (2010).
Journal of Advanced Nursing66(11): 2500-2509.
Aim: This paper is a report of a study of women’s perspectives on the experience of laparoscopic surgery for endometrial cancer. Background: Laparoscopic surgery is increasingly used to treat early endometrial cancer. It is associated with low levels of morbidity and is considered safe as cancer surgery, but research on quality of life and women’s experiences is limited.Method. Heideggerian hermeneutic phenomenology was used to explore the experiences of 14 women who had undergone the procedure in two English cancer centres between February 2008 and July 2009. In-depth interviews were taped, transcribed and analysed using Colaizzi’s framework.Findings. A phenomenological description was produced from five identified themes: having cancer, transfer of responsibility to the surgeon, information and support, independence, and normality. The experience of laparoscopic surgery was overshadowed by the presence of cancer. Fear and lack of knowledge played an important role in entrusting the surgeon with the responsibility for decision-making. Individual, unmet information needs focused on the practicalities of treatment and being in an unfamiliar situation and environment. Loss of control and vulnerability were associated with illness and surgery, but early postoperative mobility and reduced pain, facilitated rapid return to independence and maintained a sense of normality. Conclusion: Healthcare professionals should deliver care in early endometrial cancer in a way that recognizes the significance of the cancer diagnosis, the role of the surgeon in decision-making and the need for practical information. Women with endometrial cancer should have access to treatments that reduce dependency and maintain normality. © 2010 The Authors.Journal of Advanced Nursing © 2010 Blackwell Publishing Ltd.
“New technology-based innovation changes surgical practice and research direction in solid cancers.”
Katsios, C., G. Baltogiannis, et al. (2010).
Surgical Endoscopy and Other Interventional Techniques24(11): 2916-2917.
“Abdominal adhesions: Current and novel therapies.”
Ward, B. C. and A. Panitch (2011).
Journal of Surgical Research165(1): 91-111.
An adhesion occurs when two tissues that normally freely move past each other attach via a fibrous bridge. Abdominal adhesions place a tremendous clinical and financial burden on public health. Adhesions develop after nearly every abdominal surgery, commonly causing female infertility, chronic pelvic pain, and, most frequently, small bowel obstruction. A National Hospital Discharge Survey of hospitalizations between 1998 and 2002 reported that 18.1% of hospitalizations were related to abdominal adhesions annually accounting for 948,000 days of inpatient care at an estimated cost of $1.18 billion. This review discusses the current or proposed therapies for abdominal adhesions. While many therapies for abdominal adhesions have been attempted, the need for a definitive therapy to prevent or even reduce abdominal adhesions still exists. © 2011 Elsevier Inc. All rights reserved.
“Randomized clinical trials presented at the world congress of endourology: How is the quality of reporting?”
Autorino, R., C. Borges, et al. (2010).
Journal of Endourology24(12): 2067-2073.
Purpose: To assess the quality of reporting of randomized conrolled trials (RCTs) presented in abstract form at the annual World Congress of Endourology (WCE) and evaluate their course of subsequent publication. Materials and Methods: All RCTs presented in abstract form at the 2004, 2005, and 2006 WCE annual meetings were identified for review. Quality of reporting was assessed by applying a standardized 14-item evaluation tool based on the Consolidated Standards for the Reporting of Trials (CONSORT) statement. The subsequent publication rate for the corresponding studies by scanning Medline was also evaluated. Appropriate statistical analysis was performed. Results: A total of 94 RCTs (3.5% of 2669) were identified for review: 21 in 2004, 36 in 2005, and 37 in 2006. Overall, 45 (47.3% of the total) were subsequently published as a full length indexed manuscript with a mean time to publication of 16.4±13.2 months. Approximately 61 (60%) identified the study design as RCT in the abstract title. None reported the method of randomization. In studies that reported blinding (seven, 11% of 62), five were double blinded and two single blinded. Adverse events were reported in 38% of cases. Only 10% of the abstracts complied fully with more than 10 items according to our CONSORT-based checklist, whereas the majority of them failed to comply with most of the CONSORT requirements. Conclusions: Although representing a small portion of the overall number of abstracts, there has been a steady increase of presentation of RCTs at the WCE over the assessed 3-year period. Most of the time they are recognized as RCTs in the abstract title. When applying the CONSORT criteria, necessary information to assess their methodologic quality is incomplete in some cases. Copyright © 2010, Mary Ann Liebert, Inc.
“Robot-assisted surgery and health care costs .”
Awad, M. M. and J. W. Fleshman (2010).
New England Journal of Medicine363(22): 2174-2175.
“The authors reply.”
Barbash, G. I. and S. A. Glied (2010).
New England Journal of Medicine363(22): 2176.
“Live surgical demonstrations in urology: Valuable educational tool or putting patients at risk?” Challacombe, B., R. Weston, et al. (2010).
BJU International106(11): 1571-1574.
“Advances in medical robotic systems with specific applications in surgery–a review.”
Najarian, S., M. Fallahnezhad, et al. (2011).
Journal of Medical Engineering and Technology35(1): 19-33.
Although robotics was started as a form of entertainment, it gradually became used in different branches of science. Medicine, particularly in the operating room, has been influenced significantly by this field. Robotic technologies have offered valuable enhancements to medical or surgical processes through improved precision, stability and dexterity. In this paper we review different robotics and computer-assisted systems developed with medical and surgical applications. We cover early and recently developed systems in different branches of surgery. In addition to the united operational systems, we provide a review of miniature robotic, diagnostic and sensory systems developed to assist or collaborate with a main operator system. At the end of the paper, a discussion is given with the aim of summarizing the proposed points and predicting the future of robotics in medicine.
“Robot-assisted surgery and health care costs .”
Shukla, P. J., D. S. Scherr, et al. (2010).
New England Journal of Medicine363(22): 2174.
“Cost-effectiveness of robotic-assisted laparoscopic procedures in urologic surgery in the USA.”
Sleeper, J. and Y. Lotan (2011).
Expert Review of Medical Devices8(1): 97-103.
New technologies such as robotic-assisted surgery are constantly introduced clinically without a complete understanding of benefits and costs. This article will discuss general concepts of health economics and apply them to the application of robotic-assisted surgery to urologic procedures. Utilization of robotic surgery has increased dramatically in recent years. This has been most dramatic in the treatment of prostate cancer. The robot adds significant costs from acquisition, maintenance and recurrent instrument costs. These added costs, thus far, have not been associated with significant improvement in outcomes over ‘pure’ laparoscopy or open procedures. In order for the robot to be cost effective, there needs to be an improvement in efficacy over alternative approaches, and a decrease in costs of the robot or instrumentation. Robotic surgery has not been found to be cost effective in urology. Future studies may yet reveal indirect benefits that are not yet obvious.
“Establishing a Robotic Surgery Program.”
Stanton, C. (2010).
“Robotic suturing on the FLS model possesses construct validity, is less physically demanding, and is favored by more surgeons compared with laparoscopy.”
Stefanidis, D., W. W. Hope, et al. (2010).
BACKGROUND: The value of robotic assistance for intracorporeal suturing is not well defined. We compared robotic suturing with laparoscopic suturing on the FLS model with a large cohort of surgeons. METHODS: Attendees (n = 117) at the SAGES 2006 Learning Center robotic station placed intracorporeal sutures on the FLS box-trainer model using conventional laparoscopic instruments and the da Vinci((R)) robot. Participant performance was recorded using a validated objective scoring system, and a questionnaire regarding demographics, task workload, and suturing modality preference was completed. Construct validity for both tasks was assessed by comparing the performance scores of subjects with various levels of experience. A validated questionnaire was used for workload measurement. RESULTS: Of the participants, 84% had prior laparoscopic and 10% prior robotic suturing experience. Within the allotted time, 83% of participants completed the suturing task laparoscopically and 72% with the robot. Construct validity was demonstrated for both simulated tasks according to the participants’ advanced laparoscopic experience, laparoscopic suturing experience, and self-reported laparoscopic suturing ability (p < 0.001 for all) and according to prior robotic experience, robotic suturing experience, and self-reported robotic suturing ability (p < 0.001 for all), respectively. While participants achieved higher suturing scores with standard laparoscopy compared with the robot (84 +/- 75 vs. 56 +/- 63, respectively; p < 0.001), they found the laparoscopic task more physically demanding (NASA score 13 +/- 5 vs. 10 +/- 5, respectively; p < 0.001) and favored the robot as their method of choice for intracorporeal suturing (62 vs. 38%, respectively; p < 0.01). CONCLUSIONS: Construct validity was demonstrated for robotic suturing on the FLS model. Suturing scores were higher using standard laparoscopy likely as a result of the participants’ greater experience with laparoscopic suturing versus robotic suturing. Robotic assistance decreases the physical demand of intracorporeal suturing compared with conventional laparoscopy and, in this study, was the preferred suturing method by most surgeons. Curricula for robotic suturing training need to be developed.
“Robotic assisted microsurgery in hypothenar hammer syndrome: A case report.”
Facca, S. and P. Liverneaux (2010).
Computer Aided Surgery15(4-6): 110-114.
We report the case of a patient with bilateral hypothenar hammer syndrome. The therapeutic decision was to resect a thrombosed segment of the distal ulnar artery then reconstruct it using a forearm venous graft. The original aspect of this case concerns the microsurgical technique employed: All vascular sutures were made by separate nylon 10/0 stitches using a da Vinci S® surgical robot. No particular problems were observed postoperatively and, except for some cold-related pain, the patient no longer experienced any symptoms at 6 months post-surgery. This clinical case shows that robots may be employed for some specific tele-microsurgical procedures. © 2010 Informa UK Ltd All rights reserved.
“Robotic-assisted minimally invasive surgery; a useful tool in resident training–the Peoria experience, 2002-2009.”
Huettner, F., D. Dynda, et al. (2010).
Int J Med Robot6(4): 386-393.
BACKGROUND: The purpose of this study was to review the use of robotic-assisted general surgery at our institution. We evaluated the 8 year experience of one minimally invasive surgery (MIS) fellowship-trained surgeon in Peoria, IL, performing 240 cases of foregut, colon, solid organ and biliary surgery using the da Vinci system, with resident assistance. Foregut and colon procedures are the fifth and sixth most commonly performed procedures of the senior author annually. METHODS: An IRB-approved retrospective review of prospectively collected data representing 124 foregut and 102 colon operations was performed. Data analysed were procedure performed and indications for surgery, gender, age, body mass index (BMI), estimated blood loss (EBL), port set-up time (PST), robot operating time (ROT), total case time (TCT), length of stay (LOS), complications, conversions and resident involvement were recorded. Fourteen cases were excluded from the data review. Statistical analysis using the ANOVA test was applied. A specific review of resident participation was performed. RESULTS: Times for 226 foregut and colon cases were: PST 31.2 +/- 9.4 (range 10-64) min, ROT 119.3 +/- 41.5 (range 12-306) min, and TCT 194.8 +/- 50.3 (range 50-380) min. The EBL was 48.6 +/- 55.0 (range 5-500) ml, BMI 28.5 +/- 4.7 (range 15.4-46.8) kg/m(2) , and median LOS 2.0 (range 0-27) days. The overall complication rate was 13.3%. No deaths occurred. Over the 8 year study period the number of cases participated in by residents was 0, 16, 22, 15, 29, 26, 28 and 10 (as of June 2009), respectively. CONCLUSION: This series demonstrates the technical feasibility and safety of robotic surgery for the foregut and colon in a clinical setting where the surgeon does far more of other types of MIS. This series compares favorably with the literature. Incorporation of robotic training in the curriculum has allowed residents to learn robotic techniques in an effective manner.
“ProMIS() Can Serve as a da Vinci((R)) Simulator-A Construct Validity Study.”
Jonsson, M. N., M. Mahmood, et al. (2010).
Journal of Endourology.
Abstract Purpose: The purpose of this study was to investigate if the ProMIS simulator could serve as a training platform for the da Vinci((R)) surgical system and if this constellation could prove construct validity. Materials and Methods: The da Vinci system was connected to the ProMIS simulator, which registered objective data concerning how the surgeon performed in the box environment related to time, path, and smoothness. Five experienced robotic surgeons passed four different surgical tasks with progressive difficulty. A novice group-constituted of 13 consultants and 6 residents, none of them with any previous experience in the da Vinci system-passed the same tasks and the data were compared with the results from the expert group. Results: A statistically significant difference between experts and novices was demonstrated in all tasks concerning time and smoothness. For the parameter path, significant difference was only noted in the more complex tasks. Conclusions: Our study showed that ProMis could differentiate between experienced robotic surgeons and novices, thereby proving construct validity. Smoothness appeared to be the most sensitive objective parameter in our study. Tasks with high complexity are recommended when designing the program for robotic training.
“Teaching first or teaching last: Does the timing matter in simulation-based surgical scenarios?”
Zendejas, B., D. A. Cook, et al. (2010).
Journal of Surgical Education67(6): 432-438.
Objective: The optimal timing of instruction in simulation-based scenarios remains unclear. We sought to determine how varying the timing of instruction, either before (teaching first) or after (teaching last) the simulation, affects knowledge outcomes of surgical trainees. Design: We conducted a pretest/posttest crossover study in which fourth-year medical students and general surgery residents (PGY 13) participated in 3 instructional modules, each repeated twice in consecutive weeks: endocrine surgery (sessions 1 and 2), trauma resuscitation (sessions 3 and 4), and team training (sessions 5 and 6). Each session comprised 3 cases, each involving a prescenario briefing, a simulated scenario, and a postscenario debriefing. The timing of instruction varied between sessions. For the teaching-first sequence (sessions 1, 4, and 6), participants received a lecture during each prescenario briefing. In the teaching-last sequence (sessions 2, 3, and 5), trainees received an identical lecture during the postscenario debriefings. We assessed attitudes and knowledge using a postsession survey and identical 10-question multiple-choice tests at the start (pretest) and end (posttest) of each session, respectively. The mean differences in knowledge scores between groups were analyzed with repeated-measures analysis of variance (ANOVA). Results: Forty-nine participants (11 medical students and 38 surgical residents) attended at least 1 session, providing 76 observations. Mean pretest scores were equivalent (p > 0.05). The change in scores from pretest to posttest varied between the 2 groups (p = 0.002). The mean posttest score was 8.24 (standard error [SE], 0.29) for the teaching-last group and 6.68 (SE, 0.27) for the teaching-first group (mean difference, 1.56; 95% confidence interval, 0.792.33). Both teaching-last and teaching-first group participants preferentially rated debriefings and scenarios, respectively, as the better learning experience. Conclusions: Participants who received instruction after simulated scenarios achieved higher mean knowledge scores than those who received instruction before simulated scenarios. Cognitive overload, stress, or activation of prior knowledge could all be involved as causal mechanisms. © 2010 Association of Program Directors in Surgery.