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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

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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

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Results:Volume by specialty

Other:Neurosurgery Otolaryngology

2%

24%

23%

0%

51%

CasesperSpecialty

Cardiothoracic General

Gynecology Other

Urology

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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%

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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)

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50

100

150

200

250

300

350

400

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Min

utes

Year

Gynecology

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Results:Case time

• Case time 212 minutes (77% OR time)• Console time 127 minutes (46% OR time)

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50

100

150

200

250

300

350

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Min

utes

Year

General Surgery

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Results:Case time

• After 2005:• Case time 294 minutes (67% OR time)• Console time 228 minutes (52% OR time)

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100

200

300

400

500

600

2010 2011 2012 2013 2014 2015

Min

utes

Year

Cardiothoracic

Console time Case time OR time

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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%

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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%

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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

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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