Wall-Wieler, Elizabeth

BACKGROUND: Despite the widespread adoption of minimally invasive surgery in the US, disparities in its use persist. One unexplored contributor is geographic access to robotic surgical systems. This study evaluates the geospatial association between: (1) Social Vulnerability Index (SVI) and open surgery rates, (2) availability of robotic systems and open surgery, and (3) open surgery rates in demographically similar areas with differing robotic access. STUDY DESIGN: Data from 6 sources were linked at the ZIP Code Tabulation Area (ZCTA) level to identify hospitals and to extract procedure modality, presence of robotic systems, and area characteristics. Regression analysis assessed the association between SVI and open surgery rates. Open rates were then compared between hospitals with and without robotic systems. Propensity score matching was used to compare open rates across matched ZCTAs by robotic access and SVI levels. RESULTS: Higher social vulnerability was associated with increased open surgery rates (estimate = 0.20; p < 0.01), with rates ranging from 18.3% in low-vulnerability areas to 32.7% in high-vulnerability areas. Among 3,446 eligible ZCTAs, 57% had at least 1 robotic system. ZCTAs without robotic systems had higher open surgery rates (42.9 vs 19.4 per 100 procedures; relative rate = 2.21; p < 0.01). This association remained significant after matching (relative rate = 1.66; p < 0.01), for the low-mid- and high-SVI strata, and 3 of the 5 procedures examined. CONCLUSIONS: When correcting for geographic variation, the availability of robotic surgery was associated with a decrease in open surgery rates.

Abstract Objective To evaluate 2-year cost to insured patients treated with Roux-en-Y gastric bypass (RYGB) or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for type 2 diabetes (T2D) and obesity. Methods Using the 2017 to 2023 Merative™ claims database, we identified adult patients with severe obesity and T2D who were treated with a RYGB or GLP-1 RAs. Patients with RYGB had no treatment with GLP-1 RAs, and those who received GLP-1 RA therapy with tirzepatide or semaglutide for ≥ 2 years had no metabolic and bariatric surgery (MBS) procedures. The study cohorts were matched on demographics including obesity, associated medical problems, and baseline direct or out-of-pocket (OOP) costs to patients in the year prior to treatment initiation. Direct costs included those from outpatient services, inpatient admissions, and outpatient prescription filled that were paid directly by patients. We compared this cost up to two years after treatment initiation using paired t-tests. Results 1012 matched RYGB and GLP-1 RA patients were analyzed, including 35% male. At 1-year after treatment initiation, healthcare costs paid directly by patients were similar for the RYGB ($2,301) and GLP-1 RA ($2,179) (delta = $122, p = 0.15) cohorts. From one to two years after index treatment date, OOP costs were significantly lower in the RYGB treatment group ($1,277 vs. $2,104, p < 0.01). Two years after treatment initiation, RYGB patients spent $704 less in OOP costs than similar patients treated with GLP-1 RA medications (p < 0.01). Conclusions Direct OOP healthcare costs were lower for RYGB compared to GLP-1 RA use patients 2-years after treatment initiation.