Improving Affordability Through Innovation in the Surgical Treatment of Mitral Valve Disease Rakesh M. Suri, MD, DPhil; Jeffrey E. Thompson, MHA, MPT; Harold M. Burkhart, MD; Marianne Huebner, PhD; Bijan J. Borah, PhD; Zhuo Li, MSc; Hector I. Michelena, MD; Sue L. Visscher, PhD; Veronique L. Roger, MD, MPH; Richard C. Daly, MD; David J. Cook, MD; Maurice Enriquez-Sarano, MD; and Hartzell V. Schaff, MD Abstract Objective: To determine whether technically innovative cardiac surgical platforms (ie, robotics) deployed in conjunction with surgical process improvement (systems innovation) influence total hospital costs to address the concern that expanding adoption might increase health care expenses. Patients and Methods: We studied 185 propensity-matched patient pairs (370 patients) undergoing isolated conventional open vs robotic mitral valve repair with identical repair techniques and care teams between July 1, 2007, and January 31, 2011. Two time periods were considered, before the imple- mentation of system innovations (pre-July 2009) and after implementation. Generalized linear mixed models were used to estimate the effect of the type of surgery on cost while adjusting for a time effect. Results: Baseline characteristics of the study patients were similar, and all patients underwent successful mitral valve repair with no early deaths. Median length of stay (LOS) for patients undergoing open repair was unchanged at 5.3 days (P¼.636) before and after systems innovation implementation, and was lower for robotic patients at 3.5 and 3.4 days, respectively (P¼.003), throughout the study. The overall median costs associated with open and robotic repair were $31,838 and $32,144, respectively (P¼.32). During the preimplementation period, the total cost was higher for robotic ($34,920) than for open ($32,650) repair (P<.001), but during the postimplementation period, the median cost of robotic repair ($30,606) became similar to that of open repair ($31,310) (P¼.876). The largest decrease in robotic cost was associated with more rapid ventilator weaning and shortened median intensive care unit LOS, from 22.7 hours before July 2009 to 9.3 hours after implementation of systems innovations (P<.001). Conclusion: Following the introduction of systems innovation, the total hospital cost associated with robotic mitral valve repair has become similar to that for a conventional open approach, while facilitating quicker patient recovery and diminished utilization of in-hospital resources. These data suggest that innovations in techniques (robotics) along with care systems (process improvement) can be cost-neutral, thereby improving the affordability of new technologies capable of improving early patient outcomes. ª 2013 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2013;88(10):1075-1084 W ith unprecedented escalation in US health care spending and forth- coming implementation of the Patient Protection and Affordable Care Act, incre- mental health care expenditures will be increas- ingly scrutinized to ensure that they optimize value and preserve future viability of the health care system. 1 Although quality and innovation have been heralded as important attributes to maintain and foster, estimates suggest that to re- main sustainable, American health care spending must contract by nearly 3% per year. 2,3 Surgical mitral valve repair is the guideline- sanctioned standard of care for severe mitral regurgitation (MR) 4,5 ; however, patients often must undergo costly and complicated “rescue” operations because of delayed referral and incipient heart failure, which increases health care cost burden. In addition, some patients and cardiologists defer early surgery to avoid the presumed morbidity of traditional surgi- cal intervention performed via open chest procedures. To address these barriers, less in- vasive approaches leveraging high-definition From the Division of Car- diovascular Surgery (R.M.S., H.M.B., R.C.D., H.V.S.), Division of Sys- tems and Procedures (J.E.T.), Division of Biomedical Statistics and Informatics (M.H., Z.L.), Division of Health Care Policy and Research Affiliations continued at the end of this article. Mayo Clin Proc. n October 2013;88(10):1075-1084 n http://dx.doi.org/10.1016/j.mayocp.2013.06.022 www.mayoclinicproceedings.org n ª 2013 Mayo Foundation for Medical Education and Research 1075 ORIGINAL ARTICLE