Advancing Minimally Invasive Hepato-Pancreato-Biliary Surgery: Barriers to Adoption and Equitable Access

Abstract

Background:

Despite a growing body of literature supporting the safety of robotic hepatopancreatobiliary (HPB) procedures, the adoption of minimally invasive techniques in HPB surgery has been slow compared to other specialties. We aimed to identify barriers to implementing robotic assisted surgery (RAS) in HPB and present a framework that highlights opportunities to improve adoption.

Methods:

A modified nominal group technique guided by a 13-question framework was utilized. The meeting session was guided by senior authors, and field notes were also collected. Results were reviewed and free text responses were analyzed for major themes. A follow-up priority setting survey was distributed to all participants based on meeting results.

Results:

Twenty three surgeons with varying robotic HPB experience from different practice settings participated in the discussion. The majority of surgeons identified operating room efficiency, having a dedicated operating room team, and the overall hospital culture and openness to innovation as important facilitators of implementing a RAS program. In contrast, cost, capacity building, disparities/risk of regionalization, lack of evidence, and time/effort were identified as the most significant barriers. When asked to prioritize the most important issues to be addressed, participants noted access and availability of the robot as the most important issue, followed by institutional support, cost, quality of supporting evidence, and need for robotic training.

Conclusions:

This study reports surgeons’ perceptions of major barriers to equitable access and increased implementation of robotic HPB surgery. To overcome such barriers, defining key resources, adopting innovative solutions, and developing better methods of collecting long term data should be the top priorities.

Introduction

Minimally invasive surgery (MIS), encompassing both laparoscopic and robotic surgery, can achieve improved patient outcomes compared to the traditional open approach [1–3]. Compared to laparoscopic techniques, robotic-assisted surgery (RAS) provides additional technical advantages such as enhanced dexterity, better visualization, and improved ergonomics [4, 5]. Despite the high acquisition and start-up costs associated with the robotic platform, the number of general surgery cases performed robotically increased 2460% from 2010 to 2017, with an estimated 877,000 robotic operations performed in 2017 in the United States alone [5, 6].

Although uptake of RAS has been rapid, there are disparities in patients’ access. In an analysis of over 20,000 patients with prostate cancer, Hispanic, Medicaid, and Medicare patients were more likely to be treated at a hospital that does not perform RAS [7]. Similarly, in an analysis of patients with colorectal cancer, those who were older, Black, or living in urban areas were less likely to undergo robotic resection [8]. Furthermore, due to cost considerations, uptake of RAS is quite low in countries with publicly funded healthcare such as Canada and European countries [9, 10].

Adoption of new surgical technology, such as RAS, is highly complex and varies based on the health care system, institution, and practice environment in which the technology is being implemented [11]. For hepato-pancreato-biliary (HPB) surgery, early adoption of MIS has primarily occurred in high volume centers, with further uptake prompted by subsequent studies demonstrating feasibility, safety, and improved patient outcomes [12]. However, despite a growing body of literature supporting its safety and the release of evidence-based guidelines outlining steps for safe implementation of new programs, adoption of MIS techniques in HPB has been slow compared to other specialties [12–19]. Furthermore, there is a gap in knowledge regarding determinants of RAS adoption in HPB surgery. Thus, we aimed to identify barriers and facilitators to implementing RAS adoption in HPB surgery, and use that information to propose a framework that highlights strategies to increase access to the MIS approach to all patients with HPB disease.

Materials and Methods

This study was developed as the second of a two-part series overlooking the use of MIS in HPB surgery, in which the first study examines safety in robotic HPB surgery. Both were directed by the leadership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) HPB committee in collaboration with the Oncology workgroup and the Robotics Committee.

Questionnaire development

Existing consensus guidelines for MIS HPB surgery were first identified and reviewed [12–24]. Given the lack of HPB-specific literature on barriers to implementation and access to RAS, a focused literature search was then performed for relevant literature in other surgical subspecialties, including colorectal surgery, urology, and gynecology [7, 8, 25–30]. Questions were developed based on identified gaps. After iterative review by three field experts, a total of 13 questions were generated (Supplemental Figure 1).

Participant selection

Purposive sampling with snowball technique was used to identify participants [31, 32]. Purposive sampling was first used to recruit surgeons from diverse practice environments and of varying experience levels. These surgeons were then invited to recommend others whom they felt would provide additional insight during the discussion.

Modified nominal group and data analysis

A modified nominal group technique was used to reach consensus and develop priorities. The nominal group method has four components: silent generation (individual generation of ideas), round robin (each participant shares their best idea with the group), clarification (discussion amongst the group about generated ideas), and voting (ranking the ideas) [33]. This method was chosen to help ensure that input from all group members was considered equally [34]. A hybrid meeting approach was used to allow participants to join virtually via an online meeting platform. The senior author facilitated the session, and review of the questionnaire and the subsequent discussion took place over a single two-hour meeting.

Participants were first allotted time to answer a given question independently via an online survey ahead of the live meeting. The senior author then facilitated an open discussion of the question, ensuring that all participants had an opportunity to share their views. Participants were then allowed to change their initial answer in the survey before the group collectively moved to the next question. The session was recorded for later review, and contextualized field notes were taken during the meeting by two on-site facilitators trained in nominal group and qualitative methodologies. Results were reviewed and free text responses were analyzed for major themes by two independent reviewers. Any discrepancies were resolved by a third reviewer. Based on the identified themes, a follow-up priority setting survey was distributed to all participants. Finally, all results were compiled and sent to participants to ensure congruency with views expressed during the meeting.

Results

Participant Characteristics

The working group was attended by 23 surgeons. The demographics and characteristics of the participants are summarized in Table 1. The majority of surgeons (78%) practiced at an academic institution, with 47% in practice for more than ten years. Importantly, given global differences in access to RAS, a total of four surgeons from Canada and Europe were included.

Table 1.

Characterization of participants (n = 23)

Characteristics	N (%)
Geographic Region
Northeast	3 (13)
Southwest	3 (13)
West	2 (9)
Southeast	7 (30)
Midwest	4 (17)
International	4 (17)
Practice Environment
Academic	18 (78)
Community	1 (4)
Hybrid*	4 (17)
Number of years in practice
< 5 years	5 (22)
5–10 years	7 (30)
10–15 years	5 (22)
15–20 years	4 (17)
20 years or more	2 (9)
Number of years performing MIS
< 5 years	7 (30)
5–10 years	11 (48)
10–15 years	3 (13)
15–20 years	2 (9)
Number of MIS HPB cases performed per year
< 20 cases	7 (30)
20–40 cases	3 (13)
40–60 cases	5 (22)
60–80 cases	3 (13)
80–100 cases	2 (9)
> 100 cases	3 (13)

^*Hybrid: a blend of both academic and community practice in which the surgeon works in a community setting while being affiliated with a local academic center

Key Questions

Barriers

Cost, followed by capacity building, disparities/risk of regionalization, lack of evidence, and time/effort were identified as the most significant barriers to implementation of a RAS program. Acquisition costs, increased operative times with initial low case volume, and reimbursement challenges were highlighted during the discussion of cost as a major barrier. In regard to surgeon uptake of RAS, participants identified inadequate access to necessary equipment and limited robot availability (57%), lack of institutional support (39%), and lack of adequate training (35%) as major barriers (Figure 1).

Figure 1.

Summary of barriers and facilitators to implementation and access to robotic HPB with illustrative quotations

Enablers and Facilitators

Over 85% of surgeons identified operating room efficiency (87%), having a dedicated operating room team (91%), and the overall hospital culture and openness to innovation (91%) as important enablers and facilitators of implementing a RAS program. Participants also emphasized the need for peer mentorship with proctors and reliable partners (48%), dedicated operating room block time (14%), institutional and financial support (14%), and adequate training and simulation time (14%) as summarized in Figure 1. Participants strongly agreed or agreed that surgeons (96%), administrators (87%), government bodies (health policy/health services support) (87%), and surgical societies (83%) are important stakeholders in encouraging uptake of RAS (Figure 2).

Figure 2.

Survey results of Question 5, “Who are the stakeholders that need to be engaged for successful uptake and equitable access to robotic surgery?”

Defining Metrics of Success and Future Research Opportunities

Over 80% of surgeons identified quality of life data (96%), patient reported outcomes including metrics of functional recovery and symptom management (87%), and long-term survival outcomes (83%) as important metrics to demonstrate the quality of RAS in HPB. Traditional surgical outcomes such as readmission rates (26%), length of stay (26%), and postoperative complications (22%) were also identified as important quality metrics (Figure 3). Furthermore, 82% of surgeons felt that additional evidence would promote adoption of RAS in HPB. Specifically, metrics that reflect efficacy (83%) and value (87%) would be the most beneficial.

Figure 3.

Survey results of Question 8a, “What metrics should be used to demonstrate the value of robotic HPB surgery?”

Opportunities to Improve Implementation

Nearly all participants (96%) agreed or strongly agreed that certain cases, such as distal pancreatectomy and minor liver resections, should be routinely offered to all patients via an MIS approach. The majority of surgeons (65%) believed that robotic HPB surgery should be regionalized to experienced centers, defined as those that achieve a minimum number of cases per year and have the necessary clinical resources to manage HPB patients.

Additionally, surgeons identified teleproctoring as a potential platform to improve access to RAS (35%). Surgeons agreed that time (87%), cost and reimbursement for the proctoring surgeon (78%), liability and risk (70%), and availability of the necessary technology and equipment (57%) were potential barriers to successful implementation of teleproctoring programs. Furthermore, 61% of participants agreed that in-person proctoring is more beneficial during the learning curve, which may be an additional barrier to widespread adoption of teleproctoring.

Priority Setting Question

After completion of the working group, all survey data were reviewed and a thematic analysis of free text responses was performed. Based on this analysis, the following major themes were identified as barriers to access to RAS in HPB: institutional support, cost, quality of supporting evidence, access to and availability of robotic equipment, and need for robotic training. Participants were then asked to prioritize the most important issues to address. Access and availability of the robot was identified as the most important factor followed by institutional support, cost, quality of supporting evidence, and need for robotic training.

Discussion

The adoption of, and subsequent access to MIS HPB have been variable nationally and internationally. Understanding barriers to both is essential to developing strategies for implementation, although existing literature on this topic is sparse. Thus, this study aimed to identify current barriers to access, potential solutions, and direction for future investigation. To do so, we assembled a diverse group of surgeons with varying MIS experience, including surgeons from Canada and Europe, which allowed us to explore common barriers that are faced while trying to increase the uptake of RAS for HPB procedures.

The working group identified several challenges for surgeons wanting to offer robotic HPB surgery to patients, with cost remaining the primary barrier. Importantly, access to new technologies is often limited until costs decline [33]. Existing cost analyses suggest that RAS is cost-effective in the longer term when accounting for patient outcomes, but high acquisition costs remain an initial barrier to implementation [35, 36]. Fortunately, given the growing availability of new robotic platforms in the global market, we anticipate lower costs in the near future, which may enable adoption of RAS platforms by surgeons who currently do not have access. Additionally, several surgeons reported that reimbursement for RAS can be challenging given lack of specific procedure codes for robotic assisted surgeries and barriers at the insurance level. Outside of the United States, this often means that increased costs associated with RAS are often shifted to patients who are willing and able to pay, further widening disparities in access. This has been demonstrated in prostate and lung cancer studies, with under-insured patients being less likely to undergo RAS [7, 37]. Thus, reimbursement structure reform including appropriate coding and increased acceptance at the hospital and insurance level are essential to improving access to RAS.

Participants emphasized the ongoing need for high quality data that support the value of RAS, such as long-term outcomes, quality of life data, and patient reported outcomes, as these were seen as critical evidence needed to support increasing adoption of robotic HPB surgery. This is in line with prior work that identified clinical outcomes as the most important domain influencing the early adoption of new surgical techniques [11]. Many participants in our study also supported the collection of postoperative outcomes and quality metrics from large datasets (e.g. national registries, administrative datasets) to expand this body of literature. Of note, the experts believed that studies comparing MIS and open approaches would be more impactful than those comparing different MIS approaches (i.e. robotic versus laparoscopic procedures). As new research studies are developed, it is important to consider these specific types of evidence that have been identified as necessary to support continued uptake of RAS.

Although the majority of participants agreed with regionalization, they also acknowledged that this may exacerbate differential access to care and may not be necessary, or appropriate, for all HPB procedures. For example, some operations, such as distal pancreatectomy, may already be commonly performed via a laparoscopic approach and thus may not require regionalization for RAS. In contrast, procedures that are more commonly performed via an open approach, such as pancreatoduodenectomy, may benefit from regionalization to a high-volume center with the experience and resources necessary to support the RAS counterpart. Importantly, surgeons noted that other factors in addition to volume alone are important to consider when defining an “experienced” center or “center of excellence,”; these included the availability of specialty support (e.g., advanced gastrointestinal and interventional radiology services) and certain benchmarks based on patient outcomes. Furthermore, for RAS in particular, institutional support through dedicated operating room staff and skilled first assistants were noted as essential.

Finally, participants highlighted the need for dedicated training, additional operating room time early in their learning, and mentorship and oversight for surgeons starting an RAS HPB program. Participants felt that teleproctoring was a feasible strategy to fill this gap but acknowledged a few barriers including liability for the proctoring surgeon. Furthermore, the in-person and longitudinal aspects of a mentor/mentee relationship were considered important, emphasizing the need for intraoperative proctoring and preoperative planning. Despite such limitations, teleproctoring is deemed a cost effective and feasible way to expand exposure and training for surgeons who otherwise have the necessary institutional support for RAS in HPB. The need for additional training highlights the fact that while RAS in general surgery has increased significantly in the past decade, it remains a step behind the adoption seen in other specialties such as urology or gynecology [6]. In addition, compared to other general surgery procedures, RAS uptake for complex cancer resections has been particularly slow [38]. Thus, there are a unique set of challenges that must be overcome to improve access to RAS for HPB [6].

After thorough review of the body of information collected, an action item list was synthesized to emphasize critical next steps towards improved access to and implementation of RAS HPB surgery, summarized in Figure 4. These items highlight the need for sufficient resources for successful implementation, opportunities for innovation to increase RAS access, and the importance of long-term outcome evaluation to ensure high quality care with use of RAS. Utilizing an organized approached to ensure successful implementation, we hope to achieve widespread equitable access.

Figure 4.

Summary of identified action items

Some limitations of the study must be acknowledged. We focused heavily on RAS due to the extensive resources required for implementation and scaling of a robotics program in comparison to other MIS techniques. However, it is important to note that RAS is not currently feasible in many resource deprived areas, and laparoscopy remains an important MIS alternative to open surgical approaches. Additionally, we asked our participants to consider the entire field of HPB surgery, which means that we did not account for variation based on case complexity. Furthermore, although healthcare innovations should be widely available, it is also critical to ensure that new technology is implemented in a safe and deliberate manner. This topic is addressed in a separate issue in this series.

Conclusions

This study investigated barriers to equitable access and implementation of robotic HPB surgery through qualitative research methods in a cohort of expert surgeons. Cost and capacity building needs were identified as major barriers, whereas operating room efficiency, dedicated RAS staff, and a culture of innovation were identified as facilitators. The expert panel also noted that further research in the areas of value and efficacy in RAS are needed. In addition, key stakeholders, including surgical societies such as SAGES, can use the action items generated to provide guidance for RAS implementation, help develop targeted strategies to overcome barriers, disseminate high quality RAS techniques to its members, and promote a culture of innovation.