Work out robotics value equation before adoption
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Adoption of robotic systems by orthopedic surgeons has been slow and limited due to lack of improved efficiencies, the requirement of significant capital expenditure and no convincing evidence of changes in outcomes, according to an article in The Journal of Arthroplasty, by Brian S. Parsley, MD, in 2018. However, since these were first introduced in the specialty, robotics have continued to evolve, Parsley noted, which provide greater opportunities for advanced surgical planning, optimization of component placement and improved overall mechanical alignment.
In cases where surgeons once solely used X-rays and CT scans to document the surgical process, active, semi-active and passive robotic systems may provide more accurate intraoperative measurements, according to Anthony M. DiGioia, MD, medical director of Bone and Joint Center and Innovation Center at University of Pittsburgh Medical Center.
“The promise of robotics and navigation and computer-assisted surgery was to increase the accuracy of the surgery, as well as to tightly couple preoperative planning with the intraoperative execution of the plan and tightly couple outcomes with intraoperative performance,” DiGioia told Orthopedics Today. “Those are always a primary objective and with the idea that if you improve the accuracy of surgery, whether it be the cuts or the alignment of the implants, that you could then potentially improve outcomes,” he said.
Source: Nate Langer - UPMC
Financial aspects of robotics
Use of surgical robotic and navigation systems has expanded in the past 30 years to encompass several areas of orthopedics, including total joint replacement, spine surgery and trauma. This “will most likely increase over time” as technology utilization trends increase and more robotic systems are introduced to the market, according to research by Antonia F. Chen, MD, MBA, and colleagues. However, when it comes to implementing robotic surgery or navigation in a practice or hospital system, sources who spoke with Orthopedics Today noted it is important for surgeons and administrators to consider the financial and business aspects of that decision.
“The initial navigation equipment has run everywhere from $200,000 to $400,000, so it is not necessarily something someone would buy for their office,” Bernard Stulberg, MD, head of the robotic center at St. Vincent Charity Medical Center, told Orthopedics Today. “They are dependent on a hospital environment to buy it and ... insurance [companies] are all about the results for what happens for 90 days or 1 year. They are not about long-term success and so it gets hard to convince institutions to buy [robotics].”
Surgeons and hospital administration should also consider the additional, often smaller, costs associated with robotic systems.
“Understand what the cost is for buying the capital, what the disposables are going to cost, what the training and ongoing maintenance is going to cost,” Brenda Dudley, RN, CNOR, BSN, MBA, executive administrator of Perioperative Services at Keck Medical Center of USC and USC Norris Cancer Hospital, said. “Just do not forget any of the little details.”
Purchase considerations
It is critical for institutions to develop a business case that collects and addresses the reasons for purchasing a robotic system and includes the per case basis volume, revenue capture vs. cost, and takes public and market demands into account, Dudley said. In the annual budget for these systems, hospital administration should include the number of robotic cases that were performed and how much was spent on disposables.
“There is an ongoing cost for robotic surgery that you have to take into consideration and make sure that you have built that into your budget to support [adoption],” Dudley said. “That goes back to the cost of the case. All those things are what drive up the cost per case.”
One way orthopedic surgeons can provide cost-effectiveness while standardizing the use of robotic systems at their institution is by coordinating which supplies and equipment they use for their robotic cases, according to Dudley.
“If you have five different surgeons and they all do total knees, can they standardize what they are using?” she said. “That is definitely how we can get help from a cost-effectiveness perspective,” Dudley said.
Evaluate prior to purchasing
Thoroughly reviewing robotic and navigation technologies may also provide insight prior to widespread adoption. University of Pittsburgh Medical Center uses a system-wide approach to review how these technologies may fit within a given practice. The center also has a committee of surgeons, leaders within the hospital and individuals involved in purchasing and supply chain, that evaluates any new technologies, DiGioia noted. He said the evaluation includes a small pilot trial in which two or three surgeons report on their experience in terms of understanding and learning to use the technology and whether it is safe and effective for a particular procedure.
“We cannot look at long-term outcomes because we do not have those data from these shorter pilots, but you can look at the disposable costs and examine OR ergonomics associated with using these new technologies. Then, you have a process in place to evaluate whether these technologies should be used or widely scaled,” DiGioia said.
Not only can such a process help surgeons correctly use the technology, it may support to the proper adoption of the robotic system into clinical practice, he said.
“You can gather a lot of useful information so that, if you do decide to allow these systems to be more widely used, you have an adoption pathway to export its use to other surgeons and hospitals,” DiGioia said.
Despite the cost of the capital purchase of a robotic system and of the associated disposables that a practice incurs, spine surgeon Jeffrey L. Gum, MD, said the benefits of the adoption of such technology may lead to reduced costs in the long-term. He said the savings may stem from increased surgical accuracy, less variability due to the ability to better plan procedures preoperatively, as well as a reduced number of open trays in the OR.
“What we have found is we are making up money with length of stay because we are dissecting less muscle and the recovery of these patients is quicker. We are getting them out of the hospital quicker even though it may cost a little bit more in the OR,” Gum, adult and pediatric spine surgeon at Norton Leatherman Spine Center, told Orthopedics Today.
Allow for training costs
The cost of providing training for robotic and navigation systems must be considered in the business case and adoption plan, including allowing for sending surgeons away for training, having other surgeons and staff available to care for patients during the period of off-site training, and cross-training staff so they are familiar with the surgical process.
“All of that support needs to be known upfront, that there is an impact based on that and, when you bring new surgeons or new employees in, just making sure everybody’s competent to use the robot so we get the most efficient and timely use out of the resource,” Dudley said.
The training costs may be incurred more often when surgeons already in practice need to have continued training and education from the implant companies to learn the specifics of a robotic system or a related implant, according to DiGioia.
“There are programs where surgeons will buddy you up with another surgeon who has more experience in using these technologies in surgery,” he said, noting that hands-on training is invaluable.
However, Gum said using a robotic system in a cadaver lab may not translate into real-life situations as well as when the system is used in the OR. Therefore, he recommends surgeons who are interested in a particular robotic system should visit a colleague at a hospital who has successfully implemented the robotic system to see it in action in the OR.
“That is a component of robotic education that I feel strongly about — that before you incorporate it into your practice, I think it is worthwhile to visit somebody and observe them in the OR,” Gum said.
Educates fellows, residents
DiGioia noted training surgeons on new techniques and technologies, such as robotics, may be easier to provide to surgeons-in-training — fellows and residents — and in return, these systems are valuable training tools.
When use of robotic systems is incorporated into the training that traditionally occurs during a fellowship or residency program, Stulberg said it may be a helpful way to instruct physicians on the correct placement of surgical tools and those areas of the body that need to be protected during surgery.
“People in the training environment now are finding it a little easier to teach. I think the younger population is used to dealing with digital information, so they like to see a knee implant sitting on a femur and a tibia on a computer screen first,” he said. “That does not phase them, whereas the more senior folk, that is not necessarily how they are used to looking at them.”
According to Isador H. Lieberman, MD, MBA, FRCSC, president of Texas Back Institute, the amount of training an individual receives on a robotic system depends on where they are trained.
“There are some major training centers around the country that still have not embraced robotic technology in orthopedics or in spine surgery,” Lieberman told Orthopedics Today. “I think that is going to change soon because it is going to be a standard.”
As increases are seen in the use of robotic and navigation systems, Gum said fellows and residents should continue to learn to perform certain surgical tasks, such as placing a pedicle screw freehand, a technique which he noticed has started to decline.
“We need to be careful as we move forward not to lose the art of freehand pedicle screw [placement] and rely on this technology because, as we all know as we become more technology dependent, if that technology is not working, we could get into sticky situations,” Gum said. “That is something we need to pay attention to as we move forward, to make sure our trainees are getting a balanced education on utilizing this technology and not utilizing it. So, if they get in that situation, they are not solely dependent on it.”
Adoption: Pathway to change
Lieberman noted surgeons who want to implement the use of robotic and navigation systems into their practice should be patient with the system, learn from it and embrace it.
“It is not the only tool. What we have today is going to be different than what we have and what we are doing in 5 years and 10 years, so be adaptable, be willing to change,” he said.
However, surgeons should also be critical of robotic systems, adjusting as needed if they do not think the system is giving them the right information, according to DiGioia.
“The system is there to help, but it does not necessarily, especially if there are technical glitches, mean it is the only answer for that specific patient,” he said. “The bottom line is the surgeon should feel free to step in and change the flow of the surgery or ignore the information the system is providing if they feel that something is amiss.”
Surgeons must be aware of the unique subtleties between available robotic systems, which may not be translatable, understand the learning curve, and have realistic expectations, Gum said.
“If [a surgeon] thinks [they are] going to, on the first case, just walk in and everything is going to go super smooth, I think surgeons are going to get really frustrated,” he said.
He noted that surgeons need to understand the limits of the system.
“If a surgeon or a group of surgeons plans to implement [robotics] into their practice and they do not understand how the system works and functions and the limits of the system, they are going to get themselves in trouble,” Gum said.
DiGioia noted many of the robotic and navigation systems are directly linked to specific implants. Therefore, he recommends surgeons interested in implementing a robotic system learn the robotic system associated with the implants they use regularly.
“I would be reluctant to have a surgeon not only adopt a robotic or navigation system, but to change their implants at the same time,” DiGioia said. “That is way too many parameters that are changing at once and it would be fraught with potential error.”
Surgeons should also ensure they have the resources, including a dedicated team of nurses, technicians, anesthesiologists and physician assistants, to support the time and training commitment that is needed for learning the fine points of a robotic system, according to Lieberman.
“You have to have people who understand the implications, [who] understand how to get into trouble and get out of trouble and [who] can work together on this,” he said.
Plan, implementation
Despite the opportunities that use of robotic and navigation systems present for helping surgeons and their patients, DiGioia noted longer surgical times and an impact on the staff and the overall flow within the OR is possible. In addition, he said the published literature contains mixed results with this technology and still lacks longer-term outcomes.
“That is why I think this general area needs to begin to focus on factors that may improve outcomes, like doing functional planning, design of implants that are more functional and not based on the anatomic criteria we have used in the past,” DiGioia said. “If you do show improved value through increased functionality and safety, then you could begin to start answering the value equation.”
As there is no well-defined pathway yet for implementation of robotic systems in orthopedics, DiGioia said the next steps may be to “go back to basics” in terms of new implant designs and better surgical techniques using robotic and navigation systems, which can, for the first time, measure and document intraoperative performance and then tightly couple what was done in the OR to outcomes and especially functional outcomes.
“There is no doubt [robotics are] here to stay,” DiGioia said. “The rate of adoption may fluctuate, but it is here to stay and it is our job ... to find out the right places to apply these kinds of technologies.” – by Casey Tingle
- Reference:
- Chen AF, et al. JBJS. 2018;doi:10.2106/JBJS.17.01397.
- Parsley BS. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.02.032.
- For more information:
- Anthony M. DiGioia, MD, can be reached at UPMC Magee-Womens Hospital, 300 Halket St., Suite 1601-A, Pittsburgh, PA 15213; email: tony@pfcusa.org.
- Brenda Dudley, RN, BSN, CNOR, MBA, can be reached at 2011 N. Soto St., Suite 2455, Los Angeles, CA 90032; email: meg.aldrich@med.usc.edu.
- Jeffrey L. Gum, MD, can be reached at 9880 Angies Way, Suite 300, Louisville, KY 40241; email: joe.hall@nortonhealthcare.org.
- Isador H. Lieberman, MD, MBA, FRCSC, can be reached at 6020 W. Parker Road, Suite 200, Plano, TX 75093; email: ilieberman@texasback.com.
- Bernard Stulberg, MD, can be reached at 33001 Solon Road, Suite 112, Solon, Ohio 44139; email: dtjankowski01@gmail.com.
Disclosures: Gum reports he is a consultant for Medtronic, is a paid speaker for Mazor and is the chair of the Medtronic robotics advisory board. Lieberman reports he is a consultant for Medtronic, Globus Medical, SI Bone Inc., Misonix and Safe Orthopaedics and he was a principal investigator and consultant at Mazor Robotics prior to Medtronic’s acquisition of Mazor Robotics. Stulberg reports he is a consultant for Think Surgical and designs implants for Exactech. DiGioia and Dudley report no relevant financial disclosures.
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