Inequalities in access to minimally invasive general surgery: a comprehensive nationwide analysis across 20 years

Abstract

Background Minimally invasive surgery (MIS) has profoundly changed standards of care and lowered perioperative morbidity, but its temporal implementation and factors favoring MIS access remain elusive. We aimed to comprehensibly investigate MIS adoption across different surgical procedures over 20 years, identify predictors for MIS amenability and compare propensity score-matched outcomes among MIS and open surgery. Methods Nationwide retrospective analysis of all hospitalizations in Switzerland between 1998 and 2017. Appendectomies (n = 186,929), cholecystectomies (n = 57,788), oncological right (n = 9138) and left hemicolectomies (n = 21,580), rectal resections (n = 13,989) and gastrectomies for carcinoma (n = 6606) were included. Endpoints were assessment of temporal MIS implementation, identification of predictors for MIS access and comparison of propensity score-matched outcomes among MIS and open surgery. Results The rates of MIS increased for all procedures during the study period (p ≤ 0.001). While half of all appendectomies were performed laparoscopically by 2005, minimally invasive oncological colorectal resections reached 50% only by 2016. Multivariate analyses identified older age (p ≤ 0.02, except gastrectomy), higher comorbidities (p ≤ 0.001, except rectal resections), lack of private insurance (p ≤ 0.01) as well as rural residence (p ≤ 0.01) with impaired access to MIS. Rural residence correlated with low income regions (p ≤ 0.001), which themselves were associated with decreased MIS access. Geographical mapping confirmed strong disparities for rural and low-income areas in MIS access. Matched outcome analyses revealed benefits of MIS for length of stay, decreased surgical site infection rates for MIS appendectomies and cholecystectomies and higher mortality for open cholecystectomies. No consistent morbidity or mortality benefit for MIS compared to open colorectal resections was observed. Conclusion Unequal access to MIS exists in disfavor of older and more comorbid patients and those lacking private insurance, living in rural areas, and having lower income. Efforts should be made to ensure equal MIS access regardless of socioeconomic or geographical factors.

Systematic Review: Impact of Social Determinants of Health on the Management and Prognosis of Gallstone Disease

“…A Swiss study concluded that there was an increased risk of open surgery in patients without private insurance. 44 Similarly, it has been shown that socially frail patients are more likely to undergo cholecystectomy in an emergency setting than electively, regardless of the clinical situation and the cause of the intervention. In two studies, using collective indices of social deprivation, in particular the “Social Vulnerability Index,” Carmichael et al 45 , 46 showed that having a high index of deprivation increases the risk of emergency operation (OR=2.05, p <0.04).…”

“… 34 Finally, the Swiss study, previously cited, demonstrated that patients living in a rural area were more likely to have open surgery for cholecystectomy. 44 …”

The Hernia Coding Conundrum: A Potential Benefit of the International Hernia Collaboration Online Social Media Platform

“…1 For the inguinal hernia posts, there were 7 on inguinodynia, 7 on MIS inguinal hernia, and 4 on open inguinal hernia. For the ventral/incisional hernia, the most common posts were related to myofascial release techniques (29) followed by mesh, 6 botox, 5 hernia prevention, 3 other, 3 robotic surgery, 2 open surgery, 2 rectus diastasis, 2 and laparoscopic surgery. 2…”

“…Community and rural surgeons are now trained with laparoscopy and robotics and more frequently have access to these advanced tools and techniques. 2 As these new techniques gain popularity and the field of hernia surgery grows, questions regarding coding and billing have quickly risen. In 2017, twenty-seven separate CPT codes existed for open hernia repairs, 8 codes for laparoscopic codes, and 5 additional codes/modifiers that are frequently used for hernia operations.…”

“…Community and rural surgeons are now trained with laparoscopy and robotics and more frequently have access to these advanced tools and techniques. 2…”