title: Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review.
abstract: OBJECTIVE
  To determine casemix adjusted hospital level utilization of minimally invasive surgery for four common surgical procedures (appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy) in the United States.
  
  
  METHODS
  Retrospective review.
  
  
  METHODS
  United States.
  
  
  METHODS
  Nationwide inpatient sample database, United States 2010.
  
  
  METHODS
  For each procedure, a propensity score model was used to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, hospitals were categorized into thirds (low, medium, and high) based on their actual to predicted proportion of utilization of minimally invasive surgery.
  
  
  METHODS
  The primary outcome measures were the actual and predicted proportion of procedures performed with minimally invasive surgery. Secondary outcome measures included surgical complications and hospital characteristics.
  
  
  RESULTS
  Mean hospital utilization of minimally invasive surgery was 71.0% (423/596) for appendectomy (range 40.9-93.1% (244-555)), 28.4% (154/541) for colectomy (6.7-49.8% (36/541-269/541)), 13.0% (65/499) for hysterectomy (0.0-33.6% (0/499-168/499)), and 32.0% (67/208) for lung lobectomy (3.6-65.7% (7.5/208-137/208)). Utilization of minimally invasive surgery was highly variable for each procedure type. There was noticeable discordance between actual and predicted utilization of the surgery (range of actual to predicted ratio for appendectomy 0-1.49; colectomy 0-3.88; hysterectomy 0-6.68; lung lobectomy 0-2.51). Surgical complications were less common with minimally invasive surgery compared with open surgery, respectively: overall rate for appendectomy 3.94% (1439/36,513) v 7.90% (958/12,123), P<0.001; for colectomy: 13.8% (1689/12,242) v 35.8% (8837/24,687), P<0.001; for hysterectomy: 4.69% (270/5757) v 6.64% (1988/29,940), P<0.001; and for lung lobectomy: 17.1% (367/2145) v 25.4% (971/3824), P<0.05. High utilization of minimally invasive surgery was associated with urban location (appendectomy: odds ratio 4.66, 95% confidence interval 1.17 to 18.5; colectomy: 4.59, 1.04 to 20.3; hysterectomy: 15.0, 2.98 to 75.0), large hospital size (hysterectomy: 8.70, 1.62 to 46.8), teaching hospital (hysterectomy: 5.41, 1.27 to 23.1), Midwest region (appendectomy: 7.85, 1.26 to 49.1), south region (appendectomy: 21.0, 3.79 to 117; colectomy: 10.0, 1.83 to 54.7), and west region (appendectomy: 9.33, 1.48 to 58.8).
  
  
  CONCLUSIONS
  Hospital utilization of minimally invasive surgery for appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy varies widely in the United States, representing a disparity in the surgical care delivered nationwide.
authors.affiliation: Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Michol A
authors.initials: MA
authors.lastname: Cooper
authors.affiliation: Departments of Health Policy, Management and Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
authors.forename: Susan
authors.initials: S
authors.lastname: Hutfless
authors.affiliation: Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Dorry L
authors.initials: DL
authors.lastname: Segev
authors.affiliation: Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Ibrahim
authors.affiliation: Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Heather
authors.initials: H
authors.lastname: Lyu
authors.affiliation: Department of Surgery and the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA Departments of Health Policy, Management and Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA mmakary1@jhmi.edu.
authors.forename: Martin A
authors.initials: MA
authors.lastname: Makary
mesh_terms: D001062:Appendectomy / Q000379:methods*; D003082:Colectomy / Q000379:methods*; D016208:Databases, Factual; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D019060:Minimally Invasive Surgical Procedures / Q000706:statistics & numerical data*; D011013:Pneumonectomy / Q000379:methods*; D012189:Retrospective Studies; D014481:United States