Speaker Presentation from U.S. News Healthcare of Tomorrow leadership summit, Nov. 1-3, 2017 in Washington, DC. Find out more about this forum at www.usnewshot.com.

1. The U.S. News Rankings:
Examining Minimally Invasive Surgery
MICHAEL MACK, MD
BAYLOR SCOTT & WHITE HEALTH
DALLAS, TX

2. The World Is Becoming Minimal!
Should Surgery Do the Same?

3. 3
My Introduc<on to Minimally Invasive Surgery
1989
“Lapcholy”

6. “Consultants”
General “laparoscopic” surgeons
Orthopedic surgeons
Spine surgeons
Urologists
Plas<c surgeons
ENT surgeons
Industry
Investment Community

7. The Future of Surgery !
Ablation over excision
Image-guided over visual
Reconstruction without suturing
Access via natural orifice or blood vessel over incision

8. 2002-TAVR (Transcatheter AorTc Valve Replacement)
Image-guided over visual
Reconstruction without suturing
Access via blood vessel over incision

9. Key Concept
In Baseball, Tie Goes to the Runner !
In surgery, Less Invasive Beats More Invasive
as Long as the Outcomes are Equivalent !

10. 10

11. TAVR vs Open Surgical AorTc Valve Replacement
28.8
30.6
29.8
29.4
29
4.6
9.1
16.3
22.4
35
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2012 2013 2014 2015 2016
SAVR TAVR
Thousands

12. Open “Big Case” vs. Minimally Invasive Surgery

13. Start of My Surgical Residency
-1976
Acute MI- one month hospital stay
Surgical hip opera<ons- 6 weeks recovery
No knee replacements
Acute leukemia-no cure
Cholecys<<s-6 week return to work
Heart transplants- headlines to
abandonment
No interven<onal cardiology
Heart valve surgery rare

14. Fast Forward 41 Years
Mortality from heart disease declined by 50%
Minimally invasive total hip replacements rou<ne
Bilateral total knee replacements outpa<ent
procedure
Most leukemia is cured
Lapcholy is an outpa<ent procedure
Heart transplant and VAD’s now rou<ne
Percutaneous Heart Valves with same day discharge

15. Premise!
Surgeons Generally Want to do What’s in the Best Interest of Their Pa<ents!

16. So if that’s the case, why doesn’t every surgeon perform
a minimally invasive procedure on every pa<ent undergoing surgery?

17. Reasons Why Most Surgery Should Be Done Minimally Invasively !
Less physiologic and systemic insult to the pa<ent
In general…
• quicker recovery
• shorter hospital stay (or outpa<ent)
• quicker return to normal ac<vi<es

18. Reasons Why Surgeons May Not Adopt
Minimally Invasive Surgery
• Requires a different skill set
• May have trained before the MI procedure was developed
• There is oben a “learning curve”
• Forces adop<on of a new technique when one has already been mastered
• May force operators to get out of their “comfort zone”
• May not be rigorous scien<fic evidence of a posi<ve benefit/risk
• Beger? (or even equivalent)? (oncologic surgery)

19. Other Reasons Why a Reluctance or ReTcence to Adopt MI Procedures
• Procedure may be less efficacious (fewer lymph nodes during VATS lobectomy)
• May be associated with a new set of complica<ons
• Risk averseness in face of public repor<ng of outcomes
• Financial incen<ves may not be aligned (may take longer and pay less)
• May require more extensive and expensive equipment (robo<cs) not readily available
(cost effec<veness)
• Higher percent of MI surgery may be done by subspecialists but most surgery is done by
“generalists” (access to care)
• VATS lobectomy
• Laparoscopic esophagectomy or colectomy

20. Should U.S News Drive a Culture of Adop<on of MIS?

21. Why YES!
• USNWR is a powerful force for change
• Surgical prac<ce is not gekng there rapidly enough as it is
• All things being equal, pa<ents prefer the less invasive approach (PCI
vs. CABG)
• In general, less invasive surgery is more cost effec<ve (higher
procedural costs offset by shorter hospital stay and quicker
recovery)
• Risk adjusted metrics can be developed

22. Why NOT Make MI Surgery a Quality Metric
(or What are Possible “Unintended Consequences”)
May force surgeons out of their “comfort zone”
May result in worse outcomes in the short term
Adequate “risk stra<fica<on” models may not exist
Not every procedure can be done minimally invasively
If a MI procedure is adopted too early and outcomes are not
equivalent, nega<ve halo effect on the field
Can create turf wars when a less invasive procedure is performed by
another specialty

23. Final Thoughts !
USN ra<ngs are a powerful driver of healthcare prac<ces
Incorpora<on of a ”minimally invasive metric” into quality ra<ngs would be
a significant driver
There may well be unintended consequences (at least in the short term)
A thoughmul approach with input from all stakeholders can be successful