Research suggests there may be gender, racial and socioeconomic disparities when it comes to robotic surgery.
The patient base for robot-assisted laparoscopic surgery skews white, male and wealthy, and the physicians performing those surgeries tend to be male, young and graduates of U.S. medical schools, especially in the state of New York, according to a recent study from New York City-based Mount Sinai Health System. The author of the study believes this may be the result of consolidation of healthcare facilities and the “regionalization” of major procedures.
The study was conducted using data on 63,725 robot cases from an all payer database from the state of New York and the American Medical Association, which includes current and historical data on doctors, residents and medical students. The study's results were adjusted to account for surgeries that are only performed on men or women and looked at data between 2009 and 2014, because ICD-9 modifier codes for robotic surgery were established towards the end of 2008.
New York state is a good sample of what the country as a whole may look like because it has one of the largest provider populations in the country and has a highly diverse patient base, said author Dr. Michael Palese, who is chairman of urology at Mount Sinai Beth Israel Hospital in New York City.
Industry consolidation has shifted complex cases and expensive equipment to regional hubs, and that may be affecting access to robotic surgery for lower-income patients and minorities, Palese said.
Minorities and low-income individuals are served in high numbers at safety net facilities, smaller community hospitals and rural hospitals, which may be less likely to have an expensive surgical robot. The equipment can cost a hospital as much as $2 million. People who can afford it are likely seeking facilities that provide more sophisticated, high-cost care, Palese said.
Some small hospitals have purchased the devices to attract new patients and retain and recruit surgeons. But many have acknowledged that it's hurting their bottom line.
Palese said he did the study because no other researcher had looked into the demographics of robotic surgery patients and surgeons. His study also compares the frequency of robotic surgery procedures in different specialties.
“I think what this study does is it opens our eyes to how care is really being delivered at the forefront of healthcare,” Palese said. “Common healthcare is the norm, the standard of care that everyone should get it. But in the beginning stages of new technology and surgical procedures, who is really benefiting from these things?”
Palese is witnessing centralization firsthand at his own hospital, as Mount Sinai Health System recently announced plans to convert Beth Israel to a largely outpatient center. Though there may be some access gaps now, Palese hypothesized that even the less fortunate will end up in larger regional facilities as more providers establish centers of excellence that excel in certain procedures, like robotics.
“I think that a lot of this will change over time,” Palese said. “Once these patterns of care are stabilized, everything is going to go there anyway, no matter who you are, that's where you'll end up getting your care.”
Palsese said it is less clear why men might be more likely to get robotic surgery, and male physicians are more likely to have performed it, but said that might just be unscientifically attributed to men liking gadgets more than women. Younger surgeons are more likely to have performed the procedure because they're more likely to try something new, while the surgeon population skews toward U.S. graduates because foreign graduates would need additional training, he said.
Dr. Jim Hu, a urologist and director of the Lefrak Center for Robotic Surgery at Weill Cornell Medicine and New York-Presbyterian Hospital, said direct-to-consumer marketing may be partly to blame for disparities revealed in Palese's study. He said many patients who receive robotic surgery had self-referred themselves for the procedure, and men may also be more likely to self-direct their care.
Hu also noted that, because it hasn't been universally proven that robot-assisted surgery is better than conventional or laparoscopic surgery, there shouldn't be a rush to offer the services at hospitals that serve disadvantaged populations.
“It is critical to ensure there are proficient surgeons at safety net or community hospitals before the argument can be made that these hospitals need robots,” because a surgical robot is still dependent on a knowledgeable, experienced surgeon, Hu said.
