Health system leaders are feeling the pressure to accomplish more with less.
To achieve this, some are shifting to minimally invasive surgeries with Intuitive's da Vinci technology. Da Vinci surgery is associated with greater precision for surgeons, speedier recovery time for patients and fewer staff in the operating room.
Becker's Hospital Review spoke with three leaders at Minneapolis-based Allina Health — Bill Evans, vice president of surgical services and orthopedics; Christopher Macomber, MD, general surgeon and medical director for Allina Health's Robotic Surgery and Technology Program; and Jolene Singh, MD, general surgeon and system director of acute care robotic surgery — to learn how they addressed demand in their general surgery line and bolstered acute care with a da Vinci-assisted strategy. They also shared how they're scaling the program across the health system and are realizing favorable outcomes to support the "quintuple aim."
Note: Responses edited for length and clarity.
Question: In your view, what is the clinical value of applying minimally invasive techniques to benign general surgeries, such as hernia procedures, cholecystectomies and appendectomies?
Bill Evans: Our surgeons are strong proponents of using the da Vinci system to improve outcomes for their patients in benign general surgery. This system has proven the ability to reduce the number of open surgery cases and conversions to open from laparoscopic. It is also shown to improve multiple quality metrics, such as reduced surgical site infections, reduced length of stay, etc. As a result, we are deliberately trying to reduce the number of open surgery cases, which we believe is one of the key value propositions for da Vinci.
Dr. Christopher Macomber: In the first quarter of 2023 we doubled our infrastructure, leveraging the Accelerated Minimally Invasive Program (AMP) to increase our total da Vinci fleet. As a result, we have seen an overall increase in our da Vinci adoption across these benign general surgery procedures with a concurrent decline in open surgery.
Specifically, our da Vinci adoption in inguinal hernia surgery has risen from 25 percent to 58 percent. At the same time, open surgeries have dropped from 32 percent to 22 percent. We are seeing similar trends in ventral hernia surgeries with this newfound access.
Even more promising is how the increase in da Vinci access has impacted our outcomes and thereby our contribution margin. For example, in cholecystectomy, a surgical procedure that historically is minimally invasive, we have seen our conversion-to-open rates decline; our operating room time is nearly equivalent to laparoscopy; and our LOS has dropped by half a day.
Dr. Jolene Singh: Leveraging da Vinci in my acute care practice has led to shorter LOS and reductions in open surgery conversion rates, complications and readmissions.
Da Vinci also enables us to replicate open techniques in a minimally invasive environment. In the case of appendectomy, I now perform these common emergent procedures without a need for stapling or advanced energy. This enables a drop in my intraoperative cost, as I can complete the procedure by ligating the stump with a silk tie.
Q: Can you describe the financial impact of leveraging da Vinci for benign general surgery at Allina Health? How have you assessed it?
BE: Historically, we analyzed the financial impact of da Vinci in silos — direct cost in the OR, reimbursement and LOS or complication impact. Recently, in collaboration with the da Vinci Market Access and Custom Analytics (MACA) team, we pulled these metrics together for a holistic view of the financial impact.
From this perspective, we see higher contribution margin in our da Vinci procedures (compared to open and laparoscopic) driven by lower LOS, complications and readmissions.
Q: What programmatic infrastructure have you implemented at Allina Health to support cross-departmental alignment and data-driven best practices?
BE: Last year, we recognized our existing da Vinci infrastructure could not support the demands of our growing program, so we worked with Intuitive to explore solutions other health systems implemented to rapidly expand their fleets to meet clinical demand. We met with several surgical leaders across the nation to better understand their programs, and we also attended multiple Intuitive events like Intuitive 360 and the Connect Robotics Forum. These conversations gave us confidence to acquire multiple Xi systems in an innovative, financially manageable manner.
CM: During this expansion, we made a concerted effort to formally organize our da Vinci program. Each hospital within our health system has a local robotic steering committee with surgical, care team and executive representation.
We concurrently developed a governance committee for our AMP, which includes our health system executives, supply chain and da Vinci program leadership. This gives us a smaller space to analyze our da Vinci infrastructure, assess the appropriate placement of incremental systems and find opportunities to improve quality and reduce cost. It also created a key partnership with Intuitive that allowed us to rapidly solve problems and address key operational issues.
Q: What initiatives are you currently assessing and implementing through this structure?
CM: At each meeting, we analyze the current state of our business with data from the da Vinci system, our EHR and the MACA team. This allows us to identify outliers in cost, outcomes and efficiency, and ultimately scale best practices to reduce variability where applicable.
We have generally seen that surgeons and care teams performing da Vinci procedures are more consistently associated with lower costs, higher efficiency and better outcomes, leading to higher contribution margins. We attribute this to a simple philosophy: Consistency and frequency leads to proficiency and efficiency in skill development. We are now expanding our work with the MACA team to look at ways to reduce procedure variability and cost within the different specialties.
Q: What influenced your decisions to acquire a dedicated Xi system and recruit Dr.Singh to develop a da Vinci acute care program? What value have you seen in this strategic initiative so far?
BE: We standardized our entire platform to the Xi system many years ago to drive efficiency improvements and consistency in our operating rooms. We were thrilled to have Dr. Singh join our team, in part because we knew that having a dedicated da Vinci Xi and a surgical team to support her 24/7 was the next evolution of our program to deliver better care in our communities. Now, we can ensure the patients who will benefit from the use of a da Vinci-trained surgeon have access, regardless of the time of day they present. We are confident this will also have numerous benefits for the teams supporting our surgeons as this becomes standard practice.
JS: I knew that if I was going to assume a position that was entirely focused on da Vinci emergency general surgery, we needed to have true, unfettered Xi access. Emergency procedures are unpredictable in time and procedure type, but they do consistently occur during prime operating hours. Expanded access on nights and weekends would not sufficiently support a robust acute care da Vinci program.
In our specialty, there is precedent for dedicated equipment and ORs to facilitate emergency access, so we believed the most logical and scalable path forward was to place a dedicated Xi system in our emergency general surgery room. Through Bill’s leadership and partnership with Intuitive, Allina Health leveraged the AMP program to achieve this prior to my arrival.
Q: How are you partnering with Intuitive or leveraging da Vinci to support your pursuit of the "quintuple aim"?
JS: Health equity is specifically relevant to my acute care practice. Emergency room patients historically do not have equal opportunity to receive minimally invasive care. By dedicating an Xi system to the acute care service, we are fundamentally improving access to high-quality MIS surgery for this underserved population. In turn, we are impacting the other pillars of the quintuple aim by improving quality and thereby lowering the total cost of care, which boosts surgeon and care team satisfaction and allows us to operate more autonomously.
BE: In addition to Dr. Singh's vital comments, we believe collaborating with Intuitive enables us to fully leverage the entire robotics ecosystem more effectively, thus enabling better support of our surgeons and their patients. Moving from a transactional-style relationship to a partnership has greatly enabled us to improve the entire da Vinci experience and performance.
CM: On the care team and surgeon satisfaction side, da Vinci enables us to use less staff in the OR and gain more surgeon autonomy. We currently use a reduced staffing model, scaling down to just a circulator and scrub technician in our da vinci ORs. The patient experience has dramatically improved as they recover more rapidly with fewer complications. Our patients also experience less pain, enabling our providers to prescribe fewer narcotics.
Q: What is one piece of advice you'd share with a health system adopting benign general surgery with da Vinci systems?
BE: Listen to your surgeons, and engage with the Intuitive ecosystem. Our surgeons were the ones telling us we needed to change our approach to better support our patients and community. We have been thrilled to see the immediate results of our new approach, and I think we are only beginning to realize the benefits of what our surgeons have been telling us.
CM: Build out an organized, programmatic infrastructure that includes clinical, operational and executive stakeholders. This has fundamentally improved our communication streams, programmatic analysis and ability to make sound decisions regarding our da Vinci program through the lens of the quintuple aim.
JS: Be clear on why you want to leverage da Vinci in your practice and proactively communicate this vision with all stakeholders in your program. This means everyone from your staff to your executives. Have a positive attitude and be solutions oriented.