Winter Marc L, Leu Szu-Yun, Lagrew David C, Bustillo Gerardo
Saddleback Memorial Medical Center, 24411 Health Center Drive, Suite 200, Laguna Hills, CA, 92653, USA.
Department of Pediatrics, School of Medicine, University of California, Irvine, USA.
J Robot Surg. 2015 Dec;9(4):269-75. doi: 10.1007/s11701-015-0526-z. Epub 2015 Jul 30.
The aim of the study was to assess if the cost of robotic-assisted total laparoscopic hysterectomy is similar to the cost of standard laparoscopic hysterectomy when performed by surgeons past their initial learning curve. A retrospective chart review of all hysterectomies was performed for benign indications without concomitant major procedures at Orange Coast Memorial Medical Center (OCMMC) and Saddleback Memorial Medical Center between January 1, 2013 and September 30, 2013. Robotic-assisted total laparoscopic hysterectomies (RTLH) and standard laparoscopic hysterectomies (LAVH and TLH) were compared. Data analyzed included only those hysterectomies performed by surgeons past their initial learning curve (minimum of 30 previous robotic cases). The primary outcome was the direct total cost of patient's hospitalization related to hysterectomy. The secondary outcomes were estimated blood loss, surgery time, and days in hospital post-surgery. A multiple linear regression model was applied to evaluate the difference between RTLH and LAVH/TLH in hospital cost, blood loss, and surgery time, while adjusting for hospital, patient's age, body mass index (BMI), whether or not the patient had previous abdominal/pelvic surgery, and uterine weight. The χ (2) test was applied to examine the association between hospital stay and surgery type. There were 93 hysterectomies (5 LAVH, 88 RTLH) performed at OCMMC and 90 hysterectomies (6 LAVH, 17 TLH, 67 RTLH) performed at Saddleback Memorial Medical Center. The hospitalization total cost result showed that, after adjusting for hospital, age, BMI, previous abdominal/pelvic surgery, and uterine weight, RTLH was not significantly more expensive than LAVH/TLH (mean diff. = $283.1, 95 % CI = [-569.6, 1135.9]; p = 0.51) at the 2 study hospitals. However, the cost at OCMMC was significantly higher than Saddleback Memorial Medical Center (mean diff. = $2008.7, 95 % CI = [1380.6, 2636.7]; p < 0.0001); and the cost increased significantly with uterine weight (β = 3.8, 95 % CI = [2.3, 5.3]; p < 0.0001). Further analysis showed significantly less blood loss (mean diff. = -78.5 ml, 95 % CI = [-116.8, -40.3]; p < 0.0001) and shorter surgery time (mean diff. = -21.9 min., 95 % CI = [-39.6, -4.2]; p = 0.016) for RTLH versus LAVH/TLH. There was no significant association between hospital stay and surgery type (p = 0.43). After adjusting for patient-level covariates, there was no statistically significant cost difference of performing robotically assisted laparoscopic hysterectomy versus standard laparoscopic hysterectomy when performed by surgeons past their initial learning curve at two community hospitals.
本研究的目的是评估，当由已度过初始学习曲线的外科医生进行手术时，机器人辅助全腹腔镜子宫切除术的成本是否与标准腹腔镜子宫切除术的成本相似。对2013年1月1日至2013年9月30日期间在奥兰治海岸纪念医疗中心（OCMMC）和鞍背纪念医疗中心因良性指征进行的所有子宫切除术（无伴随的重大手术）进行回顾性图表审查。比较机器人辅助全腹腔镜子宫切除术（RTLH）和标准腹腔镜子宫切除术（LAVH和TLH）。分析的数据仅包括由已度过初始学习曲线的外科医生（至少有30例先前的机器人手术病例）进行的那些子宫切除术。主要结局是与子宫切除术相关的患者住院直接总成本。次要结局是估计失血量、手术时间和术后住院天数。应用多元线性回归模型评估RTLH与LAVH/TLH在住院成本、失血量和手术时间方面的差异，同时对医院、患者年龄、体重指数（BMI）、患者是否曾接受过腹部/盆腔手术以及子宫重量进行调整。应用χ(2)检验来检查住院时间与手术类型之间的关联。在OCMMC进行了93例子宫切除术（5例LAVH，88例RTLH），在鞍背纪念医疗中心进行了90例子宫切除术（6例LAVH，17例TLH，67例RTLH）。住院总成本结果显示，在对医院、年龄、BMI、先前腹部/盆腔手术和子宫重量进行调整后，在两家研究医院中，RTLH的费用并不显著高于LAVH/TLH（平均差异 = 283.1美元，95%置信区间 = [-569.6, 1135.9]；p = 0.51）。然而，OCMMC的成本显著高于鞍背纪念医疗中心（平均差异 = 2008.7美元，95%置信区间 = [1380.6, 2636.7]；p < 0.0001）；并且成本随着子宫重量显著增加（β = 3.8，95%置信区间 = [2.3, 5.3]；p < 0.0001）。进一步分析显示，与LAVH/TLH相比，RTLH的失血量显著减少（平均差异 = -78.5毫升，95%置信区间 = [-116.8, -40.3]；p < 0.0001），手术时间更短（平均差异 = -21.9分钟，95%置信区间 = [-39.6, -4.2]；p = 0.016）。住院时间与手术类型之间无显著关联（p = 0.43）。在对患者层面的协变量进行调整后，在两家社区医院中，由已度过初始学习曲线的外科医生进行机器人辅助腹腔镜子宫切除术与标准腹腔镜子宫切除术的成本在统计学上无显著差异。
