Robotic partial nephrectomy: Benefits outweigh costs

The benefits of robot-assisted partial nephrectomy outweigh the health care and surgical costs, a new study found.

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In terms of quality-adjusted life-years gained, the benefits outweighed the costs to patients and payers by a ratio of five to one, reported the study’s authors, from Precision Health Economics in Los Angeles, Harvard Medical School in Boston, and the University of Southern California, Los Angeles.

The study appears in Health Affairs (2015; 34:220-8).

The researchers set out to determine if the investment in a surgical robot could be linked to improvements in long-term patient outcomes. They found that partial nephrectomy was associated with significantly lower rates of renal failure when compared with radical nephrectomy. The study also concluded that the costs incurred in adopting robot-assisted surgery were offset by higher survival and lower renal impairment rates.

"This study demonstrates the benefits-and pitfalls-of comparative research," said Dana P. Goldman, PhD, of Precision Health Economics and the University of Southern California. "While multiple surgical techniques may be equally beneficial, it turns out only robotic surgery can ensure that more patients get the best treatment."

The study found that adoption of robot-assisted minimally invasive surgery led to a 52% increase in the rate of kidney-sparing partial nephrectomy versus radical nephrectomy, according to a news release from Intuitive Surgical. The 5-year net benefit per procedure (in terms of the difference between quality-adjusted survival gains and health care costs incurred) was $406,217 for radical and $512,561 for partial nephrectomy patients, for an incremental value of $106,344 for each patient who received partial versus radical nephrectomy.

The study found that if all hospital referral regions (HRRs) had adopted the da Vinci Surgical System, there would have been an additional 23,166 partial nephrectomies performed over the study period. Valuing each partial nephrectomy procedure at $106,344 would have generated an additional $2.5 billion in value had the robot been adopted across all HRRs, the release stated.

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Researchers said they found no evidence that the availability of robot-assisted surgery increased the likelihood that inappropriate patients received partial nephrectomy. The study did find that use of robotic surgery might increase access to partial nephrectomy, which is associated with improvements in 1-year survival rates after surgery and large reductions in renal failure rates. HRRs most likely to offer partial nephrectomy attained significantly lower rates of renal failure in all three time periods studied.

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Partial nephrectomy improved 1-year mortality by 5.7 percentage points, the authors reported. In comparison, Tan et al found a 5.6 percentage-point improvement in two year mortality (JAMA 2012; 307:1629–35).

The study used national cancer registry data linked with Medicare claims for 1995–2010, the period in which robotic surgery was adopted into clinical practice. Patient cost and outcome data were derived from the Surveillance, Epidemiology and End Results (SEER) Program, linked to Medicare claims. The study sample included 26,789 Medicare beneficiaries who were diagnosed with kidney cancer between 1996 and 2010 and had a nephrectomy.

The study has some limitations, including the fact that it focused on kidney cancer, and the results may not be generalizable to other cancers.

Precision Health Economics conceptualized, designed, conducted the data analysis, and managed the study. Intuitive Surgical said it funded the study and supported article review but had no direct involvement in study execution or data analysis.

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