Awareness of surgical costs: a multicenter cross-sectional survey

Comparison of current relative value unit-based prices and utility between common surgical procedures, including orthopedic surgeries, in South Korea

BACKGROUND

The medical pricing system strongly influences physicians' job satisfaction and patient health outcomes. This study aimed to investigate the current relative value unit (RVU)-based pricing and utility of patients in commonly performed surgical procedures in South Korea.

METHODS

Fifteen common surgical procedures were selected from OECD statistics, and three additional orthopedic procedures were examined. The current pricing of each surgical procedure was retrieved from the Korea National Health Insurance Service, and the corresponding utilities were obtained as quality-adjusted life year (QALY) gains from previous studies. The relationship between the current prices (RVUs) and the patients' utility (incremental QALY gains/year) was analyzed. Subgroup analysis was performed between fatal and non-fatal procedures and between orthopedic and non-orthopedic procedures.

RESULTS

A significant negative correlation (r = - 0.558, p < 0.001) was observed between RVU and incremental QALY among all 18 procedures. The fatal subgroup had a significantly higher RVU than the non-fatal subgroup (p < 0.05), while the former had a significantly lower incremental QALY than the latter (p < 0.001). Orthopedic procedures showed higher incremental QALY values than non-orthopedic procedures, but they did not show higher prices (RVU).

CONCLUSIONS

This paradoxical relationship between current prices and patient utility is attributed to the higher pricing of surgical procedures for fatal and urgent conditions. Orthopedic surgery has been found to be a cost-effective treatment strategy. These findings could contribute to a better understanding of the potential role of incremental QALY in pursuing value-based purchasing or reasonable modification of the current medical fee schedule.

Cost awareness amongst irish ophthalmologists

BACKGROUND

Healthcare systems have increasingly limited and stretched budgets. Clinicians have a key role in budget allocation. Awareness of the costs of high-use clinical items is important.

AIMS

Assess awareness of the cost of commonly utilised clinical items amongst Irish Ophthalmologists METHODS: Irish ophthalmologists were contacted and asked to fill out an anonymous survey. We assessed knowledge of hospital costs of surgical materials, medications and anti VEGF drugs as well as retail pharmacy costs of commonly prescribed medications. The cost of items to the hospital was recorded from pharmacy and ward order receipts from a single university hospital. The costs of items to the patient were calculated by taking an average of 3 prices charged by local retail pharmacies. For each estimate we calculated the absolute error from the true price. We calculated the mean absolute errors (MAE) and percentage errors (MAPE) across the different groups.

RESULTS

We received responses from 47 participants (15 Senior House Officers, 11 Registrars, 21 Consultant/Community Ophthalmologists). Despite 70% of respondents agreeing that the cost of an item should have a major role in its use, the average estimate was 124% inaccurate. Less than 50% of responses were within 50% of the true cost of the item. Self-perceived knowledge was acknowledged to be limited or very limited in 73% of responses.

CONCLUSIONS

We demonstrate variable and limited levels of cost awareness. Seniority and better self-perceived knowledge were not found to be associated with better estimate accuracy.

No longer a blank cheque: a narrative scoping review of physician awareness of cost

OBJECTIVES

Healthcare costs have been steadily rising, and attention to cost containment in healthcare systems is increasingly important. It has been previously established that physicians lack adequate awareness of cost in health care and that by increasing awareness, costs can be reduced. This scoping review examines cost awareness of medications, investigations and procedures and identifies potential interventions that may serve to improve physician awareness.

STUDY DESIGN

A scoping review was performed to evaluate the literature based on established Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

A review of electronic databases was performed for studies regarding physician awareness of cost, including PubMed, Embase, Cochrane Central Register of Controlled Trials and Google Scholar.

RESULTS

An initial 4350 citations were identified, and 76 articles were included for full text analysis. Combined, these studies assessed 18,901 physicians. The overwhelming majority (91%) found cost awareness in physicians was low and demonstrated significant room for cost reduction. Eighteen of the 76 studies assessed an intervention to improve physician awareness of cost and used either a price list (89%) or a teaching session (11%) as the primary intervention.

CONCLUSIONS

Research demonstrates that there is still a lack of awareness among physicians of the costs of medications, investigations and procedures/consumables. Initial approaches using price display and teaching sessions have shown promise. Further research into best practices for education around cost, beginning in medical school and continuing into established medical and surgical practices, may lead to increased cost savings in health care.

A Cost Comparison Between Mohs Micrographic Surgery and Conventional Excision for the Treatment of Head and Neck Melanomas In Situ and Thin Melanomas

BACKGROUND

Variation in operative setting and surgical technique exists when treating specialty site melanomas. There are limited data comparing costs among surgical modalities.

OBJECTIVE

To evaluate the costs of head and neck melanoma surgery performed with Mohs micrographic surgery or conventional excision in the operating room or office-based settings.

METHODS

A retrospective cohort study was performed on patients aged 18 years and older with surgically treated head and neck melanoma in 2 cohorts, an institutional cohort and an insurance claims cohort, for the years 2008-2019. The primary outcome was total cost of care for a surgical encounter, provided in the form of insurance reimbursement data. A generalized linear model was used to adjust for covariates affecting differences between treatment groups.

RESULTS

In the institutional and insurance claims cohorts, average adjusted treatment cost was highest in the conventional excision-operating room treatment group, followed by the Mohs surgery and conventional excision-office setting (p < .001).

CONCLUSION

These data demonstrate the important economic role the office-based setting has for head and neck melanoma surgery. This study allows cutaneous oncologic surgeons to better understand the costs of care involved in head and neck melanoma treatment. Cost awareness is important for shared decision-making discussions with patients.

Implant Charge Differences Between Distal Radius Fixation Constructs (CPT 25607, 25608, and 25609)

BACKGROUND

Implants are a significant contributor to health care costs. We hypothesized that extra-articular fracture patterns would have a lower implant charge than intra-articular fractures and aimed to determine risk factors for increased cost.

METHODS

In total, 163 patients undergoing outpatient distal radius fracture fixation at 2 hospitals were retrospectively reviewed stratified by Current Procedural Terminology codes. Implants and associated charges were noted, as were sex, age, insurance status, surgeon specialty, and location. Bivariate and multivariable regression were used to determine associations.

RESULTS

Total implant charges were significantly lower for 25607 (extraarticular, $3,348) than 25608 (2-part intraarticular, $3,859) and 25609 (3+ part intraarticular, $3,991). In addition, intra-articular fractures had higher charges for distal screws/pegs and bone graft. Charge was lower when surgery was performed at a trauma center. There was no charge difference associated with insurance status, age, sex, hand surgery specialty, or fellow status. Substantial intersurgeon variation existed in all fracture types.

CONCLUSION

Distal radius fractures may represent a good model for examining implant costs. Extra-articular fractures had lower implant charges than intra-articular fractures. These data may be used to help construct pricing for distal radius fracture bundles and potential cost savings.

Outpatient Hysterectomy versus Inpatient Hysterectomy: A Systematic Review and Meta-analysis

OBJECTIVE

The aim was to investigate whether outpatient hysterectomy (OH) has benefits when compared with inpatient hysterectomy (IH) regarding postoperative complications, readmissions, operative outcomes, cost, and patient quality of life.

DATA SOURCES

A systematic search for studies comparing OH with IH was conducted through PubMed, SAGE, and Scopus from January 2010 to March 2020, without limitations regarding language and study design.

METHODS OF STUDY SELECTION

Studies reporting on the differences between same-day discharge and overnight stay after hysterectomy were included. The study outcomes were overall complication rate, type of complication, readmission after discharge, surgery duration, estimated blood loss, payer savings, hospital savings, and health-related quality of life (HrQoL). Median and range are used to describe non-normal data, while mean ± SD and confidence interval are used to descibe data with normal distribution. A meta-analysis with sensitivity analysis and subgroup analyses was performed.

TABULATION, INTEGRATION, AND RESULTS

Eight studies published between 2011 and 2019 with 104,466 patients who underwent hysterectomy were included in this systematic review and meta-analysis. All included studies except 1 were found to have a high risk of bias. OH in comparison with IH had a lower overall complication rate (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.60-0.82) and lower rates of wound infection (OR 0.60; 95% CI, 0.43-0.84), urinary tract infection (OR 0.64; 95% CI, 0.52-0.78), need for transfusion (OR 0.36; 95% CI, 0.22-0.59), sepsis (OR 0.33; 95% CI, 0.17-0.64), uncontrolled pain (OR 0.79; 95% CI, 0.66-0.95), and bleeding requiring medical attention (OR 0.82; 95% CI, 0.73-0.94). In addition, patients who underwent OH had a lower readmission rate (OR 0.81; 95% CI, 0.75-0.87), surgery duration (standardized mean difference -0.35; 95% CI, -0.61 to -0.08), and estimated blood loss (standardized mean difference -0.63; 95% CI, -0.93 to -0.33) than those who underwent IH. A qualitative analysis found that OH had a poorer patient HrQoL and a lower cost for the hospital as well as the payer.

CONCLUSION

OHs present fewer complications and have a lower readmission rate and estimated blood loss as well as a shorter surgery duration than IHs. OHs also have a cost benefit in comparison with IHs. But patients seem to have a worse HrQoL in the first postoperative week after OH. The high risk of bias of the included studies indicates that well-designed clinical trials and standardization of surgical complication reporting are essential to better address this issue.

Attitudes and awareness of suture anchor cost: a survey of shoulder surgeons performing rotator cuff repairs

BACKGROUND

The cost of health care in the United States accounts for 18% of the nation's gross domestic product and is expected to reach 20% by 2020. Physicians are responsible for 60%-80% of decisions resulting in health care expenditures. Rotator cuff repairs account for $1.2-$1.6 billion in US health care expenditures annually. The purpose of this study is to assess surgeons' cost awareness in the setting of rotator cuff repairs. The hypothesis is that practice environment and training affect cost consciousness and incentivization will lead to more cost-effective choices.

METHODS

In this cross-sectional study, a 21-item survey was distributed via the email list services of the American Shoulder and Elbow Surgeons and Arthroscopy Association of North America. Data collected included demographics, variables regarding rotator cuff repair (technique, number of companies used, procedures per month), and knowledge of costs.

RESULTS

Responses from 345 surgeons in 23 countries were obtained with the majority (89%) being from the United States. Most surgeons were "cost-conscious" (275, 70.7%). Of these surgeons, 62.9% are willing to switch suture anchors brands to reduce overall costs if incentivized. Cost-conscious surgeons were more likely to be fellowship trained in shoulder and elbow (51.81% vs. 38.57%, P = .048), be paid based on productivity (73.53% vs. 61.43%, P = .047), and receive shared profits (85.4% vs. 75%, P = .02).

CONCLUSION

The majority of orthopedic surgeons are both cost-conscious and willing to change their practice to reduce costs if incentivized to do so. A better understanding of implant costs combined with incentives may help reduce health care expenditure.

The Direct Costs of Microsurgical Resection of Vestibular Schwannomas

OBJECTIVE

To determine and itemize surgical costs associated with the translabyrinthine (TL), retrosigmoid (RS), and middle cranial fossa (MCF) approaches for microsurgical excision of vestibular schwannoma (VS).

STUDY DESIGN

Retrospective cost analysis study.

SETTING

Tertiary referral center.

PATIENTS

Thirty consecutive adult patients underwent microsurgical excision of VS by either TL, RS, or MCF approach (10 per approach).

INTERVENTIONS

Microsurgical excision of VS by one of the three major approaches. Medical and financial data were collected.

MAIN OUTCOME MEASURES

Total operating room time (minutes), skin-to-skin time (minutes), operating room cost ($US), and surgical supplies cost ($US).

RESULTS

The MCF approach was associated with the shortest skin-to-skin time (230.3 min, p < 0.001). Mean overall nonsurgical room time was 94.7 minutes and not significantly different among approaches (p = 0.55). Mean total surgical supplies cost was $5,028 and was the highest for the RS ($7,116; p < 0.001) but not significantly different between TL and MCF. Mean operating room services charges were $68,417 overall and were the lowest for the MCF group ($53,306; p = 0.01). Tumor size was not correlated with surgical supplies cost (p = 0.74). The items associated with the highest average cost per case were the surgical aspirator ($1,062), drill burs ($928), and titanium implants ($575). There was redundancy in multiple surgical items such as drill burs, hemostatic agents, and sutures.

CONCLUSION

This study is the first to provide a detailed itemization of the surgical expenses specific to VS resection. Elevated nonsurgical room time and supply redundancy provides the opportunity for decreasing surgical costs and waste.

Can a simple 'cost-awareness' campaign for laparoscopic hysterectomy change the use and costs of disposable surgical supplies? Pre-post non-controlled study

OBJECTIVES

Does a cost-awareness campaign for gynaecologists lead to a change in use and costs of disposable surgical supplies for laparoscopic hysterectomy (LH) without increasing hospital utilisation measures (operating room (OR) time or hospital length of stay (LOS))?

DESIGN

Pre-post non-controlled study. The OR database was used to identify relevant cases before and after the cost-awareness intervention, and provided information on quantity of each supply item, operative details and LOS.

SETTING

Lois Hole Hospital for Women, Edmonton, Alberta, Canada.

PARTICIPANTS

12 laparoscopic trained gynaecologists (7 female, 5 male) participated in both phases of the study. Eligible surgical cases were all LH cases for any indication for women aged ≥18 years. 201 cases were undertaken before the intervention (2011-2013) and 229 cases after the intervention (2016-2017).

INTERVENTION

The cost-awareness intervention for gynaecologists included site meetings and rounds providing information on costs of disposable and reusable instruments, a full day skills lab, OR posters about cost and effectiveness of disposable and reusable surgical supplies and demonstrations of reusable equipment (2015-2016).

PRIMARY OUTCOME MEASURE

Disposable supplies costs per case (standardised for 2016 unit costs).

RESULTS

There was a significant (p<0.05) reduction (unadjusted) in disposable supplies cost per case for LH between cases before and after the intervention: from $C1073, SD 281, to $C943 SD 209. Regression analysis found that the adjusted cost per case after the intervention was $C116 lower than before the intervention (95% CI -160 to -71). Neither OR time nor hospital LOS differed significantly between cohorts.

CONCLUSIONS

Our study suggests that cost-awareness campaigns may be associated with reduction in the cost of surgery for LH. However, many other factors may have contributed to this cost reduction, possibly including other local initiatives to reduce costs and emerging evidence indicating lack of effectiveness of some surgical practices.

Awareness of surgical expenditure amongst UK trainees and consultants: A questionnaire study

INTRODUCTION

Limited knowledge of surgical device and service costs restricts a surgeon's ability to make cost efficient choices and contribute to the efficiency savings required by the NHS to reduce the financial deficit. This study aims to assess how aware surgeons are of surgical equipment and regularly used services.

METHODS

A single sided hard copy questionnaire asking for the estimate cost of 24 surgical devices/services was handed out to individuals at two separate UK annual conferences. Items and services which are regularly used and/or clinically significant were selected and, where possible, alternatives to those items were included for comparison. Participants were also asked for their grade and specialty. An estimate was deemed correct if it was within 20% of the actual cost. Planned subgroup analyses for grade and specialty were performed.

RESULTS

The 143 participants consisted of 23 (16%) consultants, 39 (27%) registrars, 33 (23%) SHOs and 48 (34%) foundation doctors. Of the 95 participants who were SHO grade or more senior, 67 (71%) work within general surgery. Across all items, only 9.6% of estimates were correct. There was no statistically significant difference between training levels (consultant 11.5%, registrar 10.1%, SHO 8.6%, foundation 8.9%; p = 0.253). Participants were significantly less successful in correctly estimating the cost of high value (>£150 [USD $198; EUR €175]) items (8.5% vs. 11.1%); p = 0.011, and the cost of devices as compared to the cost of services (7.4% vs. 15.0%); p = 0.001.

CONCLUSION

Surgeons across all grades and specialties have poor knowledge of device and service costs. It is important that this improves in order to allow surgeons to make a meaningful contribution to NHS efficiency savings by making informed decisions about their use of devices and services.

Cost of open and laparoscopic distal gastrectomy: surgeon perceptions versus the reality of hospital spending

BACKGROUND

Rising health care costs have led to increasing focus on cost containment and accountability from health care providers. We sought to explore surgeon awareness of supply costs for open and laparoscopic distal gastrectomy.

METHODS

Surveys were sent in 2015 to surgeons at 8 academic hospitals in Toronto who performed distal gastrectomy for gastric adenocarcinoma. Respondents were asked to estimate the total cost, type and number of disposable equipment pieces required to perform open and laparoscopic distal gastrectomy. We determined the accuracy of estimates through comparisons with procedural invoices for distal gastrectomy performed between Jan. 1, 2011, and Dec. 31, 2015. All values are in 2015 Canadian dollars.

RESULTS

Of the 53 surveys sent out, 12 were completed (response rate 23%). Surgeon estimates of total supply costs ranged from $500 to $3000 and from $1500 to $5000 for open and laparoscopic cases, respectively. Estimated supply costs for requested equipment ranged from $464 to $2055 for open cases and from $1870 to $2960 for laparoscopic cases. Invoices for actual equipment yielded a mean of $821 (standard deviation $543) (range $89-$2613) for open cases and $2678 (standard deviation $958) (range $835-$4102) for laparoscopic cases. Estimates of total cost were within 25% of the median invoice total in 1 response (9%) for open cases and 3 (27%) of those for laparoscopic cases.

CONCLUSION

Respondents failed to accurately estimate equipment costs. The variation in true total costs and estimates of supply costs represents an opportunity for intraoperative cost minimization, efficient equipment selection and value-based purchasing arrangements.

Cost awareness of disposable surgical equipment and strategies for improvement: cross sectional survey and literature review

A significant healthcare funding gap has been predicted over the coming years. NHS England has made transparency and cost efficiency a key priority. Healthcare technology accounts for a large portion of healthcare expenditure. The aim of the study was to establish the cost awareness of theatre staff for disposable surgical equipment and to review the current evidence around improving cost awareness. A cross sectional survey was performed. A questionnaire was distributed to consultants, registrars, core surgical trainees and theatre scrub practitioners within an NHS foundation trust and analysed using Microsoft excel 2010. Following the results, which indicated poor cost awareness amongst theatre staff, a literature review was performed to identify strategies to improving cost awareness in healthcare. The results showed that only 22% of all participants (n = 48) were able to estimate cost correctly. There was no significant difference in cost accuracy between surgeons or scrub practitioners. Strategies for improvement in cost awareness were identified. A lack of cost awareness was identified amongst theatre healthcare professionals for common disposable surgical equipment. This is an area which must improve through the use of proven strategies such as national programs, education, visible pricing and price feedback, as highlighted in this paper.

Reducing Surgical Infections and Implant Costs via a Novel Paradigm of Enhanced Physician Awareness

BACKGROUND

Studies have demonstrated that physicians are often unaware of prescription drug, laboratory, diagnostic, and surgical supply costs.

OBJECTIVE

To investigate the effects of increased physician awareness on infection incidence and surgical device cost containment.

METHODS

Within our institution, physicians were informed of individual, independently adjudicated, craniotomy and ventricular shunt infection incidence and rankings among peers, after which a protocol aimed at reducing skin bacterial burden was implemented for craniotomies. Physicians were also made aware of the costs for shunts and dural substitutes as well as available alternatives.

RESULTS

The combined craniotomy and ventricular shunt infection incidence significantly decreased by 37.5% from 3.2% over May 2011 to April 2015 (132 infections/4137 procedures) to 2.1% over May 2015 to April 2016 (26 infections/1250 procedures; P = .041). The average annual cost savings was $234 175 from preventing postoperative craniotomy infections and $121 125 from preventing postoperative ventricular shunt infections. Total supply costs of ventricular shunts significantly decreased by 26% from $2345 per procedure in fiscal year 2015 to $1747 per procedure in fiscal year 2016 (P &lt; .001). Total supply cost of dural grafts significantly decreased by 54% from $191 per procedure in fiscal year 2015 to $88 per procedure in fiscal year 2016 (P &lt; .001). In total, all initiatives in this study resulted in an estimated annual savings of $567 062.

CONCLUSION

Physician awareness of outcomes and costs resulted in increasing the quality of care, while at the same time reducing the cost.

Awareness of Surgeons in Saudi Arabia About the Surgical Costs and Investigations: Multicenter Study

OBJECTIVE

To investigate the level of knowledge and awareness of the cost of the currently used blood investigations, imaging studies, admission cost, and surgical instrument among surgeons in Saudi Arabia.

DESIGN

It was a cross-section study conducted in Riyadh city, the capital of Saudi Arabia.

SETTING

Multihealth centers including main University hospital, Military hospitals, and Ministry of health hospitals. All surgeons in the health facilities were invited to participate in the study. A questionnaire has been formulated, and distributed to all participants. It was composed of 3 sections such as: demographic data, awareness about the cost, and physicians' perception about the cost and the attitude of their institution toward cost practice.

RESULT

Totally, 296 participants were enrolled in the study. More than half of the respondents were females (53.3%). Nearly two-thirds were in the young age group (30-40 years), 41.2% were residents. Only 4.4%, 3.4%, 8.4%, and 3.7% of the surgeons were fully aware of the cost of blood investigations, imaging studies, surgical instruments/prosthesis, and the medication that they prescribe, respectively. Most of them mentioned that their institute neither encourages them to consider a cost-effective practice (86.9%) nor monitor how cost effective is their practice (86.2%).

CONCLUSION

Surgeon's knowledge and awareness about the cost of different medical procedures were insufficient. Surgeons' knowledge and attitudes about costs of care can be improved through the use of audit and feedback with patient cost and charge data, which could be attained through the inclusion of audit and feedback as part of a curriculum teaching.

Cost consciousness among physicians in the neonatal intensive care unit

OBJECTIVE

The objectives of this study were (1) to describe the prevalence and correlates of cost consciousness among physician providers in neonatology and (2) to describe knowledge of cost of common medications, laboratory/imaging evaluations, hospitalization costs and reimbursements.

STUDY DESIGN

A 54-item survey was administered to members of the Section on Neonatal-Perinatal Medicine of the American Academy of Pediatrics.

RESULTS

Of the 602 participants, 37% reported cost consciousness in decision making. Adjusting for years in practice, gender, training level, type of practice setting and region of practice, formalized education about costs was associated with increased cost consciousness in practice (adjusted odds ratio (AOR): 3.4; 95% confidence interval (CI): 1.2 to 9.8). Working in a private practice setting was also associated with increased cost consciousness when ordering laboratory (AOR: 3.0; (95% CI: 1.2 to 7.6)) or imaging tests (AOR: 2.0; 95% CI: 1.0 to 4.8).

CONCLUSIONS

We found variation in knowledge of cost. Formal education about costs and working in a private practice setting were associated with increased cost consciousness.

Surgeon Awareness of Operating Room Supply Costs

BACKGROUND

The extent to which surgeons understand costs associated with expensive operative procedures remains unclear. The goal of the study was to better understand surgeon cost awareness of operating room supplies and implants.

METHODS

This was a cross-sectional study of faculty (n = 24) and trainees (fellow and residents, n = 27) in the Department of Otolaryngology. Participants completed surveys to assess opinions on importance of cost and ease in accessing cost data and were asked to estimate the costs of operating room (OR) supplies and implants. Estimates within 20% of actual cost were considered correct. Analyses were stratified into faculty and trainee surgeons.

RESULTS

Cost estimates varied widely, with a low percentage of correct estimations (25% for faculty, 12% for trainees). Surgeons tended to underestimate the cost of high-cost items (55%) and overestimate the cost of low-cost items (77%). Attending surgeons were more accurate at correctly estimating costs within their own subspecialty (33% vs 16%, P < .001). Self-rated cost knowledge and years in practice did not correlate with cost accuracy (P < .05).

CONCLUSIONS

A majority of surgeons were unable to correctly estimate the costs of items/implants used in their OR. An opportunity exists to improve the mechanisms by which cost data are fed back to physicians to help promote value-based decision making.