Experts Discuss Best Practices of Robotic Surgery in SpecialtyCare Webinar

Experts Discuss Best Practices of Robotic Surgery in SpecialtyCare Webinar

To provide transparency around the advantages and disadvantages of hospital robotic surgery programs, SpecialtyCare hosted a webinar with three experts from CAVA Robotics: Josh Feldstein, President and CEO of Cava Robotics, an applied health economist with a specialization in robotic surgery; Dr. Herb Coussons, a practicing gynecologist who started robotic surgery for benign gynecology around 2005, who has been with Cava Robotics for 14 years; and Pete Schommer, MBA, who joined CAVA Robotics in January 2024 as a strategic advisor, who has been familiar with CAVA for almost 10 years. 

Feldstein, Dr. Coussons, and Schommer discussed what it looks like to achieve best practice in a robotics program and how hospitals can redeem the capital they spend on robotics, especially in relation to efficiency, cost savings, and patient safety. The following is a summary of their special webinar presentation, the first in a series of three.

What’s Considered Best Practice in Robotic Surgery?

The challenges surrounding robotics often include the perception that it costs too much compared to laparoscopy and that case times are too long.

Robotic costs must be equal to or less than laparoscopy, and robotic quality needs to be equal to or better than laparoscopy for a program to truly be best practice. When considering the appropriate use of robotics, the focus should be on advancing all minimally invasive surgical services, with robotic surgery being the leading edge.

When you’re thinking about quantifying whether your program is a best practice robotic program, here are some questions to consider:

  1. Do you know the cost per case of your robotic procedures across different service lines like gynecology, general surgery, thoracic, bariatric, urology, and colorectal?
  2. Do you know your contribution margin for robotic cases versus laparoscopic cases?

If you’re going to offer robotic surgery as an option comparable to laparoscopy in minimally invasive surgery, and it’s difficult to differentiate the clinical value, you need to show a cost advantage to drive the value equation for your patients.

Considering the value of robotics over the long term, there isn’t an abundance of literature comparing long-term outcomes of robotic versus laparoscopic surgery. However, in the near-term postoperatively, robotics has been shown to lower pain medication use, enable a faster return to work, and reduce complication rates, which all contribute to overall cost-effectiveness.

Another critical question for hospital administrations is the size of their robotic fleet. Do you know how many cases per year are performed on your robots? Understanding the number of surgical procedures annually per robot is a significant indicator of efficiency and profitability.

Additionally, how does your robotic program track clinical quality? Do you have data on performance metrics such as instrument use, supply use, costs, or time metrics for all your robotic surgeons? These metrics provide valuable insights into designing, developing, and managing a successful robotic program.

How Does Your Robotics Program Measure Performance?

Since the implementation of EMRs, hospitals collect a lot of data, but extracting and analyzing this data to turn it into actionable information is challenging. Clinicians often don’t have access to the data driving costs in the operating room. Some hospitals also lack cost accounting systems, making it difficult to marry clinical and cost data.

To manage this data effectively, a proactive steering committee is essential. This committee must have a clear plan to address various categories of performance.

Here are 21 specific categories or dimensions that define a great robotic program. These insights are based on over 10 years of experience inside hundreds of hospitals:

For each of these categories, a proactive plan is necessary. This table organizes the 21 dimensions into categories of ad hoc, reactive or weak, and proactive. Ad hoc means there is no plan or strategy; reactive addresses problems as they arise. It’s important to get programs to the proactive stage, where there’s a clear, forward-thinking strategy for each dimension.

Robotic vs. Laparoscopic: Cost Per Case Comparison

It’s worth comparing cost per case between laparoscopic and robotic procedures. For example, most people in the C-suite level might find it difficult to accept that robotic cholecystectomies can be equal to or less expensive than laparoscopic cholecystectomies. But it’s actually possible.

It’s common knowledge that complex cases, like converting an open prostatectomy to a minimally invasive prostatectomy — and getting the patient out of the hospital quicker with less complications — is the value of the robot. But when it comes to a growing general surgery case selection, such as appendectomy or cystectomy or even inguinal hernia, there’s a lot of controversy. Should these cases be done on the robot? The concern is that it takes too long and costs too much. 

However, with appropriate training and peer-to-peer learning, you can look at the disposables that are direct costs in the case, and very easily, these simple cases can be less expensive on the direct supply cost compared to their counterpart in laparoscopy. But it does take experienced surgeons explaining how to use two robotic instruments instead of three or more.

Factoring in Robotic Cases Per Year

Many hospitals start to struggle with access when they eclipse 300 cases per year. They get to 320 or 350, and that’s usually when they’re starting to struggle with surgeons complaining or access issues or scheduling problems, and that’s usually when the vendor says, “You need another robot to expand capacity.” From a logical perspective, there are about 250 operating days in a year. That means that 300-350 cases is 1.2 cases a day. 

However, if you could do two cases per day on the robot over 250 work days — that’s 500 plus cases — which makes you able to achieve the level of best practice. With efficiency, CAVA Robotics hopes to help their hospital clients get to that 500 plus per robot, making the best use of the capital that they’ve invested in their robot fleet.

We’re heading towards a point in the marketplace where it is increasingly difficult for hospitals to attract and retain surgeons, particularly surgeons coming out of residency and fellowships, unless they have regular access to the robot. So there’s this increasing pressure on hospitals to make sure there’s good access and availability to the robot for all of their surgeons. If the state of play gets stuck at around 300 or so procedures per robot per year versus being able to get to 500 or so, there’s roughly a doubling of the amount of capital investment that has to go in as a result of being inefficient. But it should be no problem on an eight-hour shift to get two cases per day done on these robots. 

How to Drive a Best Practice Robotics Program

When it comes to the real work that goes into care delivery when that surgeon goes into the operating room and closes the door, the surgeon runs the program. Decisions are often made without knowledge of data or costs. A committee structure that routinely reviews data is very eye-opening for surgeons. They don’t know what five other surgeons use in their rooms because they don’t operate together, and there’s a tremendous amount of peer-to-peer learning that happens in a committee structure or with outside experts who come in and provide insights. For example, they might show that a hysterectomy can be done with three ports and three instruments instead of four ports and five instruments. This is tremendously valuable for surgeons to learn how to accomplish that safely for their patients.

Administrators often get frustrated with the costs they see in the books, but clinicians don’t know these costs unless there is a governance committee structure to share that data, ensure it’s collected accurately, and act on it to drive meaningful change. Transparency of data, costs, and performance is critical to quantify best practice performance. Video case reviews are also very powerful. They are widely used in aviation, sports, and many other areas. Despite some surgeons’ concerns about liability, if video reviews are done in a peer review-protected way, they are invaluable. There is peer-reviewed literature showing that what’s documented in an op note and what actually happened during surgery can differ 30% of the time. Video tells a story that paper can’t, and it’s one of the best ways for peers to help each other improve.

Benefits of Working with CAVA Robotics to Enhance Your Robotics Program

Working with CAVA Robotics moves a hospital’s robotics program from a vendor-influenced model, which is typically less efficient and cost-effective, to the top quartile or 10th percentile of performance. Over the course of years, this difference can amount to hundreds of thousands or even millions of dollars in contribution margin. For example, in hysterectomy, best practice supply costs are about $950, while the 50th percentile costs are around $1,200. CAVA differs by employing over 50% physicians and OR crews, allowing for specific peer-to-peer conversations about instrument choices and efficient operations to drive down time and costs.

Regarding the role of a robotic coordinator in the OR, it significantly enhances overall efficiency. Every program should have one, with the position becoming full-time as case volume exceeds 400-600 cases. A robotic coordinator liaises between surgeons, crew, administration, and SPD, coordinating meetings, documentation, training, and communication, all of which are vital for efficiency. Having a consistent team minimizes the number of people learning the robot, allows for deeper proficiency, and fosters teamwork, which leads to efficient OR turnover times.

If you are interested in increasing your robot program’s cost-effectiveness and productivity, contact us today! Where others cut corners, we create standards. All in the name of giving your OR the consistency it needs to operate effectively.