Value in Single-level Lumbar Discectomy: Surgical Disposable Item Cost and Relationship to Patient-reported Outcomes

Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures

OBJECTIVE

The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures.

SUMMARY BACKGROUND DATA

Reducing surgical costs is paramount to the viability of hospitals.

METHODS

Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons.

RESULTS

The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy.

CONCLUSIONS

Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

Processing and Handling Cost of Single-use Versus Traditional Instrumentation for 1 Level Lumbar Fusions

STUDY DESIGN

A single center, observational prospective clinical study.

OBJECTIVE

The aim of this study was to compare the instrumentation-related cost and efficiency of single-use instrumentation versus traditional reusable instrument trays.

SUMMARY OF BACKGROUND DATA

Single-use instrumentation provides the opportunity to reduce costs associated with cleaning and sterilizing instrumentation after surgery. Although previous studies have shown single-use instrumentation is effective in other orthopedic specialties, it is unclear if single-use instrumentation could provide economic advantages in spine surgery.

MATERIALS AND METHODS

A total of 40 (20 reusable instrumentation and 20 single-use instrumentation) lumbar decompression (1-3 level) and fusion (1 level) spine surgeries were collected. Instrument handling, opening, setup, re-stocking, cleaning, sterilization, inspection, packaging, and storage were recorded by direct observation for both reusable and single-use instrumentation. The rate of infection was noted for each group.

RESULTS

Mean time of handling instruments by the scrub nurse was 11.6 (±3.9) minutes for reusable instrumentation and 2.1 (±0.5) minutes for single-use instrumentation. Mean cost of handling reusable instruments was estimated to be $8.52 (±$2.96) per case, and the average cost to reprocess a single tray by Sterilization Processing Department (SPD) was $58. Thus, the median cost for sterilizing 2 reusable trays per case was $116, resulting in an average total Costresuable of $124.52 (±$2.96). Mean cost of handling single-use instrumentation was estimated to be $1.57 ($0.38) per case.

CONCLUSION

Single-use instrumentation provided greater cost savings and reduced time from the opening of instrumentation to use in surgery when compared with reusable instrumentation.

Evaluating Surgeons on Intraoperative Disposable Supply Costs: Details Matter

BACKGROUND

Cost report cards have demonstrated variation in intraoperative supply costs and may allow comparisons between surgeons. However, cost data are complex and, if not properly vetted, may be inaccurate.

METHODS

A retrospective assessment of intraoperative supply costs for consecutive laparoscopic cholecystectomies (2013-2017) at a 4-facility academic center was performed. Using unadjusted data (akin to an auto-generated report card), surgeons were ranked and highest to lowest-cost ratios were calculated. Then, four stepwise adjustments were performed: (1) excluded non-comparable operations and low volume (< 10 cases) surgeons, (2) eliminated outlier cases based on instrument profiles, (3) stratified by facility, and (4) adjusted prices (assigned one price; corrected aberrant/missing prices). Surgeon rank and highest to lowest-cost ratios were then re-calculated.

RESULTS

The unadjusted data identified 1392 cases for 33 surgeons (range, 1-317 cases). The ratio between the highest cost and lowest cost surgeon was 4.13. Steps 1 and 2 excluded 272 cases and 15 surgeons. Facility sample sizes ranged from 144 to 621 (step 3). Adjusting prices (step 4) required manual review of 472 unique items: 45% had > 1 price and 16 had missing prices. After all adjustments, surgeons had different rankings and highest to lowest-cost ratios within sites were smaller (ratio range, 1.17-2.10).

CONCLUSIONS

Evaluating surgeons based on intraoperative supply costs is sensitive to analytic methods. Surgeons who were initially considered cost outliers became the least expensive within a given site. Auto-generated cost report cards may require additional analyses to produce accurate comparative assessments.