With advancements in technology offering increasingly versatile options for use of robotic surgery in the NHS, it’s important that we understand the potential impact these techniques could have for the costs involved. The Health Economics Unit (HEU) is being funded by the Midlands and Lancashire Commissioning Support Unit (MLCSU) to explore the use of multi-criteria decision analysis (MCDA) as a method for the economic evaluation of robotic surgery in the NHS which extends beyond the traditional cost-effectiveness analysis (CEA). This will culminate in a case study in which we will use MCDA to evaluate a particular application of robotic surgery in the NHS.

Here, Will Rawlinson, Senior Health Economist at HEU,  explains more.

What is robotic surgery?

Robotic surgery is a type of minimally invasive surgery where a surgeon operates on a patient using interactive, mechanical arms. The surgeon, positioned in the operating theatre, controls the arms using a remote user interface while viewing a high definition, 3D image inside the patient’s body. The system translates the movements of the surgeon’s hands into exact movements of the surgical instruments, providing more precision, flexibility and control than manual surgery. It is ergonomically beneficial too, removing the need for a surgeon to be hunched over an operating table for hours on end. For patients, robot-assisted surgery can result in faster recovery times and less time spent in hospital.

This type of surgery has evolved into a global industry since the first, American-made, DaVinci® robot was installed in St Mary’s Hospital, London back in 2001. More versatile models are now arriving on the market, offering a growing choice of technology and resulting in an increasing number of procedures being performed by robotic surgery in the NHS.

Why is it important to economically evaluate robotic surgery? What are the challenges?

Due to the high costs of these innovative systems, and the time needed for specialised training for the care teams involved, it’s essential that we carry out robust economic evaluations of robotic surgery to help stakeholders make informed decisions.

Existing economic evaluations of robotic surgery have mostly relied on traditional frameworks, such as cost effectiveness analysis or budget impact analysis. These frameworks provide decision makers with a limited range of decision criterion, such as the incremental cost effectiveness ratio.

However, there are characteristics of medical devices, and specifically robotic surgical tools, that are challenging to capture within a traditional framework.  MCDA readily accommodates a wide range of criterion, such as those characteristics of medical devices below:

• The ‘learning curve’. The performance of a robotic device depends in part on how familiar the surgeon is with the equipment; performance may be expected to increase as the user gains more experience
• Surgeon/device interaction. Surgeons spend a significant amount of time interacting with robotic devices, meaning that the usability and comfort provided by the devices is an important consideration
• Organisational impact. The introduction of a surgical robot may require substantial amounts of training or investment in infrastructure.

Why are we excited about MCDA?

Whilst it’s been used extensively in agriculture, energy and marketing science, MCDA is becoming more prevalent in healthcare.

Broadly speaking, MCDA involves eliciting judgments on the importance of different decision criteria from decision makers, allowing scores in these criteria to be combined into a total score awarded to each alternative. Total scores are then ranked, leading to a justified final verdict on the most valuable alternative.

Who are we working with?

For this project, we hope to collaborate with subject matter experts such as:

• Carlos A. Bana e Costa, Professor of Decision Science at the University of Lisbon, who wrote a paper on applying MCDA in robotic surgery .
• Professor Gilberto Montibeller, Professor of Management Science at Loughborough University, an expert on strategic risk and decision analysis.
• Professor Mόnica Oliveira, Professor in Decision Sciences at the Engineering and Management Department of Instituto Superior Técnico (University of Lisbon) whose research interests include the development of management science models to assist policy and decision-makers in health and clinical settings, including multi-criteria value modelling using participatory processes.

What will the outcomes be?

This work will contribute towards the literature on demonstrating the applicability of MCDA to evaluating technology and more broadly, the application of MCDA in healthcare. A literature review will be produced and published which will focus on identifying criteria to be used by stakeholders for assessing the value of robotics in the MCDA framework.

We will aim to publish our findings from the full MCDA in an appropriate journal and share findings across our network including MDSN.

This project will develop relationships with academic colleagues and other collaborators who have contributed to this work.

It will explore the use of decision conferencing (as part of the MCDA process) with a range of stakeholders (relevant for an ICB/ ICS approach).

This project will test the scalability of MCDA and use of associated tools in evaluating innovation such as medical technology and will also upskill our economists in using alternative decision analytic techniques for complex decision making in healthcare.