Robotic Surgery in Safety-Net Hospitals: Addressing Health Disparities and Improving Access to Care

Introduction

Disparate health outcomes in the United States have been present for centuries. Embedded in this country’s history are the incongruent ways individuals of different backgrounds, races, and creeds receive care, and unfortunately, such differential treatment has bled into our health care systems. In 1966, at a convention for human rights in Chicago, Dr. Martin Luther King Jr. stated, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” ¹ Where health should be a fundamental human right, false ideologies of our differences affect who is cared for and who matters. From the Tuskegee trials to the Cincinnati Radiation Experiments, care for the underrepresented in our society is often overlooked, and history demonstrates that, at times, the government has sanctioned disparate treatment. ² Health care disparities are largely no longer overtly present but are now weaved into our health care systems in more subtle and arguably more dangerous ways. These inequities are also presently evident in the utilization and access to advanced surgical technologies and the resulting benefits of such technology.

The benefits of minimally invasive surgery have been documented for many years. These benefits include fewer complications, shorter hospital stays, less narcotic use, and faster recovery times.^3,4 Robotic surgery, in particular, has become increasingly popular in the 21st century with added benefits of improved range of motion, ease of intracorporeal suturing, ambidexterity, improved safety, and decreased operator workload.^4,5 Robotic-assisted surgery has infiltrated specialties spanning general, colorectal, gynecology, thoracic, and urologic procedures. Despite its growing use and added benefits, significant disparities in access to this modality remain. ⁶

Disparities in Health Outcomes

Low socioeconomic populations and underrepresented minorities are twice as likely to have chronic diseases compared to their white counterparts. ⁷ The lack of access to routine preventative and medical services increases their propensity to present for medical care in a more advanced disease state. That, in combination with the fact that lower-income and minority communities have decreased access to cutting-edge technology, increases the likelihood of emergent repairs, risk of complications, poorer outcomes, readmissions, and reoperations. ⁸ In the setting of emergent surgery, an open procedure compared to a minimally invasive procedure is an independent factor for increased patient mortality. ⁹ In addition to increased mortality, open surgery is associated with increased length of hospital stays, increased wound complications, wounds that may require additional weeks to heal, higher levels of pain, increased need for opiate use, and greater risk for reoperation. These factors all translate into augmented financial costs being borne by local, state, and federal governments.^10,11 Therefore, access to minimally invasive surgical procedures for all populations, especially those at risk of worse outcomes, is both a regional and national problem.

The Role of Safety-Net Hospitals

Safety-net hospitals are vital for the underserved population and often bear the weight of caring for a large percentage of the uninsured, Medicaid, and other vulnerable groups. Surgical outcomes at these facilities are worse than their counterparts due to differences in the patient population and other factors.^12,13 For some of these safety-net hospitals, lack of access to minimally invasive interventions such as robotic surgery compounds the issues. Without being fully equipped to offer minimally invasive surgeries, they cannot translate the numerous benefits of these minimal access procedures to underserved communities who already stand at a disadvantage.

History of Surgical Robotic Technology

Using robots and automation dates back to 400 BC, with some early pioneers ascribed to philosophers and scientists such as Archytas Tarentum, Pierre Jaquet Droz, Gianello Toriano, and Leonardo da Vinci. ¹⁴ Over the years, multiple robot iterations were designed for varying purposes, such as writing and industrial welding. Robotics entered the field of medicine in 1978 through the works of Victor Scheinman. He developed a robotic arm called the Programmable Universal Manipulation Arm (PUMA) that eventually was used to orient a needle for brain biopsy using CT guidance. ¹⁵ This invention paved the way for robotic use in medicine. By 1980, another robot was designed to assist transurethral prostatectomies at the Imperial College in London. ¹⁶ In 1992, the field of orthopedic surgery used the ROBODOC to assist in total hip arthroplasty. ¹⁷ By the year 2000, and after many additional robotic system iterations and technological developments, the da Vinci system by Intuitive was approved by the FDA as an operative surgical robot in the United States. ¹⁸

Advantages of Robotic Surgery

Many of the difficulties that surgeons experienced with laparoscopic surgery were decreased with the properties and utilization of the robot. Some of these included limited view due to the distance of the monitor, loss of depth perception due to the 2-D optics, and trusting your optimal surgical view in the hands of an assistant who operates the camera and vision for the case. In contrast, the robotic platform utilizes 3-D vision optics with up to 10× magnification, the camera is controlled by the surgeon, and it restores proper hand-eye coordination, which makes manipulating operative instruments intracorporeally more instinctive. Laparoscopy also offers a limited 4 degrees of freedom of motion. In contrast, the robot provides up to 7 degrees of freedom, just like the human wrist, which improves dexterity and accuracy of movements. ¹⁹ Compared to laparoscopy, robotic surgery significantly improves the ability of the surgeon to suture intracorporeally and decreases the surgeon’s workload while improving the safety of the patient. ⁵

Impact of Robotic Surgery on Patient Outcomes

Many studies have shown improvement in patient outcomes with robotic surgery. In a 2021 publication, Brunes et al showed improvements in open conversion rates and intraoperative bleeding in obese women undergoing hysterectomy. ²⁰ Yanagawa et al showed improved outcomes in all complications, length of stay in the hospital, costs, and mortality with robotic-assisted cardiac surgery. ²¹ In the field of thoracic surgery, a review of the national database showed that robotic surgery was associated with a significant reduction in mortality, length of stay, and morbidity when compared with an open thoracotomy for pulmonary resections, and trending towards similar associations when compared with video-assisted thoracic surgery. ²² In bariatric surgery, the use of the robot to perform gastric bypass procedures showed a significant improvement in gastrointestinal leakage, ²³ stricture rate, hospital length of stay, and readmission rate. ²⁴ These improved outcomes demonstrate that not only the surgeon has benefited since the advent and use of robotics in surgery but also the patients.

Access to Robotic Surgical Care Disparities

Mitigating disparities by improving access for patients is crucial. Socioeconomic disparities exist in robotic surgery usage. A study published in 2022 by Horsey et al revealed the preferential use of the robot in managing patients with colon cancer. The study showed that patients who were white, younger, privately insured, had a higher education status, and lived in metropolitan areas of high income were more likely to undergo robotic surgery. ²⁵ In a study looking at endometrial cancer surgical management, women who were white, older, and privately insured were more likely to have robotic surgery. ²⁶ Similarly, a study looking at robotic hernia repairs also noted increased odds in the use of the robot for patients who were male, non-Hispanic race, of a higher income, and had private insurance. ²⁷ Thus, the disparities in surgical technology utilization for patients, which in turn offer the benefits of this advanced surgical care only to certain sub-groups, further perpetuate disparities in health care delivery and outcomes. Surgeons must propose the most efficient and, most importantly, the safest means of surgical care for their patients, make diligent efforts to recognize and counter potential biases, and advocate for increased access and standard of care for all patients.

Safety-Net Hospital Access and Outcomes With Robotic Technology

Of the more than 5000 robotic systems in hospitals nationwide, safety-net hospitals possess a minute fraction of these systems, further demonstrating the inequitable distribution of resources and a significant disparity in access to care. ²⁸ This effect is magnified for the underserved populations these hospitals serve, which translates into health disparities due to decreased access to care.

The largest safety-net hospital in Georgia is Grady Hospital (GH), which serves a significant underserved population and exemplifies the aforementioned disparities. The population served is constituted largely of underrepresented minorities and low-income patients within the Atlanta Metropolitan area. GH sees more than 150,000 patients through the emergency room annually, with over 25% being uninsured and an additional 57% of patients relying primarily on government insurance as of 2019. ²⁹ The service area of GH primarily includes the 2 most populous counties, Fulton and DeKalb counties, both of which have significant indigent or underserved populations.

GH made tremendous strides in 2016 when it acquired a surgical robot and successfully implemented this technology for the surgical care of patients under a multidisciplinary and multi-institutional initiative led by Dr. Shaneeta Johnson, Morehouse School of Medicine, Grady, Emory, and Intuitive Surgical. ³⁰ This made GH one of only a handful of safety-net teaching centers with access to robotic surgical technology at the time. Dr. Johnson and the Morehouse School of Medicine surgical education team implemented a comprehensive, multidisciplinary robotic surgery program and an educational curriculum at the Morehouse School of Medicine Department of Surgery focusing on patient safety, resident education, and the positive impact of this advanced surgical technology. This program has grown remarkably demonstrating significantly improved outcomes within the underserved patient populations served. These outcomes included reduced length of stay, decreased pain, decreased wound complications, earlier return to work, and lower overall cost. These benefits are significant among the underserved and lower-income populations served by GH, who may depend heavily on their daily ability to work. Long absences from work may be crippling to their income and ability to provide basic needs for themselves and their dependents. The successful implementation of this program has made significant strides in alleviating the disparities of care for this underserved community.

During the first year of implementing the robotic system, approximately three times (3×) the projected number of cases were completed robotically by the Grady robotic surgeons. The projected case volume in the first year of implementation was fifty, but one hundred seventy-eight cases were completed. 654 cases were completed in the first 3 years, exceeding any initial projected case volume. Most cases were general surgical cases, the remainder being gynecological oncology and urological cases. Since those initial years, the scope of the robotic system has spread across numerous other surgical subspecialties, including hepatobiliary surgery, colorectal surgery, thoracic surgery, acute care surgery, and additional surgical specialties.

The initial results have been encouraging. Compared to open and laparoscopic surgery, the patient length of stay (LOS) postoperatively was significantly reduced. Robotic surgery has the potential to advance health equity and reduce disparities. In addition to the aforementioned benefits of robotic surgery, it is clear that robotic surgery offers a meaningful pathway toward reducing and potentially eliminating many disparities that currently exist in the availability of these advanced technologies and their potential benefits. The challenge remains to provide safety net hospitals on a national level with the resources to offer these services to the underserved populations that desperately need them, thereby diminishing and ultimately eliminating these disparities.

In 2016, coincidentally the same year Grady Hospital acquired its first robot. Tatebe et al looked at the socioeconomic factors and parity of access to robotic surgery in a county health system. Interestingly, they found no disparity in access to robotic surgery offered in the county hospital based on age, gender, reported ethnicity, estimated income, or insurance payer. Patients with higher income and private insurers were more likely to present to the private hospital setting where robotic surgery is utilized more often. ³¹ These results are unsurprising, as the problem already aforementioned, is the disparate allocation of resources to equip safety-net hospitals with the tools needed to provide the appropriate level of care.

Impact of Robotic Surgical Education in Training Programs

A significant effort to mitigate these disparities relies on improving surgical education and increasing access of trainees to robotic surgery. In 2007, the Board of Governors of the Society of Gastrointestinal and Endoscopic Surgeons released a consensus stating, “It is recommended that specialty training programs include exposure to therapeutic robotic interventions as part of their curriculum.” ³² Access to robotic surgery training for trainees improves their knowledge and learning. The improved 3D optics allow for better visualization of structures and tissue planes that are not always as apparent during laparoscopy or even open surgery. ³²

Unfortunately, not all training programs offer robotic surgery training at the same depth of exposure. Of the programs that offer training, the components vary widely, and so do the requirements for formal credentialing. A 2017 survey of general surgery residency training programs demonstrated that 96% of programs believed the training was vital. However, only 44% tracked trainees’ experience, and only 55% formally recognized a trainee’s expertise upon graduating. ³³ Standardizing the curriculum and making robotic surgery training a standard part of surgical training increase the number of physicians able to provide this mode of care to patients. Ensuring that a diverse group of trainees are robustly educated in a comprehensive manner, including robotic surgery, increases diverse representation, decreases health disparities, and increases the number of physicians who are likely to serve communities that are underrepresented and underinsured.^34,35

Conclusion

The introduction of robotic-assisted surgery has shown significant benefits. Access to these benefits by marginalized patient populations is important to extend these benefits and reduce disparities in health outcomes and the care of these patient populations. Safety-net hospitals play an important role in providing access and decreasing disparities for marginalized patients, so it is essential to allocate resources equitably to allow these institutions to provide optimal care.