Hospitals' strategies for orchestrating selection of physician preference items

How to objectively evaluate the impact of image-guided surgery technologies

PURPOSE

This manuscript aims to provide a better understanding of methods and techniques with which one can better quantify the impact of image-guided surgical technologies.

METHODS

A literature review was conducted with regard to economic and technical methods of medical device evaluation in various countries. Attention was focused on applications related to image-guided interventions that have enabled procedures to be performed in a minimally invasive manner, produced superior clinical outcomes, or have become standard of care.

RESULTS

The review provides examples of successful implementations and adoption of image-guided surgical techniques, mostly in the field of neurosurgery. Failures as well as newly developed technologies still undergoing cost-efficacy analysis are discussed.

CONCLUSION

The field of image-guided surgery has evolved from solely using preoperative images to utilizing highly specific tools and software to provide more information to the interventionalist in real time. While deformations in soft tissue often preclude the use of such instruments outside of neurosurgery, recent developments in optical and radioactive guidance have enabled surgeons to better account for organ motion and provide feedback to the surgeon as tissue is cut. These technologies are currently undergoing value assessments in many countries and hold promise to improve outcomes for patients, surgeons, care teams, payors, and society in general.

Effect of clinical engagement on value, standardisation, decision-making and savings in NHS product procurement

BACKGROUND

UK healthcare expenditure is now £193.8 billion a year. The procurement function is seen as central to driving efficiencies within the NHS. This comes with an increasing onus on clinicians, including nurses and allied health professionals, to accept procurement outcomes to realise efficiency savings, with or without prior engagement.

AIMS

This empirical study seeks to examine whether clinical engagement in the procurement of healthcare products in the NHS is necessary to achieve value, savings and standardisation; it will thereby address a gap in the research.

METHODS

A multi-method qualitative case study design was used, which included a survey and eight semi-structured interviews.

FINDINGS

Results identified three factors that influence the achievement of value, savings and standardisation around clinical engagement: micro-level processes for clinical engagement; clinical stakeholders and clinical procurement professionals as experts at the centre of procurement activity; and clinical value in standardisation. A shift away from standardisation to resilience was identified, resulting from current market supply pressures.

CONCLUSION

This research brings empirically derived findings to address gaps in research, supports the benefit of clinical engagement through specific forums for collaboration at a trust level and provides a clinical/expert impact/preference matrix as a resource for procurement professionals to facilitate clinical engagement.

Collecting Physicians' Preferences on Medical Devices: Are We Doing It Right? Evidence from Italian Orthopedists Using 2 Different Stated Preference Methods

OBJECTIVES

Physician preference items (PPIs) are high-cost medical devices for which clinicians express firm preferences with respect to a particular manufacturer or product. This study aims to identify the most important factors in the choice of new PPIs (hip or knee prosthesis) and infer about the existence of possible response biases in using 2 alternative stated preference techniques.

METHODS

Six key attributes with 3 levels each were identified based on a literature review and clinical experts' opinions. An online survey was administered to Italian hospital orthopedists using type 1 best-worst scaling (BWS) and binary discrete choice experiment (DCE). BWS data were analyzed through descriptive statistics and conditional logit model. A mixed logit regression model was applied to DCE data, and willingness-to-pay (WTP) was estimated. All analyses were conducted using Stata 16.

RESULTS

A sample of 108 orthopedists were enrolled. In BWS, the most important attribute was "clinical evidence," followed by "quality of products," while the least relevant items were "relationship with the sales representative" and "cost." DCE results suggested instead that orthopedists prefer high-quality products with robust clinical evidence, positive health technology assessment recommendation and affordable cost, and for which they have a consolidated experience of use and a good relationship with the sales representative.

CONCLUSIONS

The elicitation of preferences for PPIs using alternative methods can lead to different results. The BWS of type 1, which is similar to a ranking exercise, seems to be more affected by acquiescent responding and social desirability than the DCE, which introduces tradeoffs in the choice task and is likely to reveal more about true preferences.

HIGHLIGHTS

Physician preference items (PPIs) are medical devices particularly exposed to physicians' choice with regard to type of product and supplier.Some established techniques of collecting preferences can be affected by response biases such as acquiescent responding and social desirability.Discrete choice experiments, introducing more complex tradeoffs in the choice task, are likely to mitigate such biases and reveal true physicians' preferences for PPIs.

Random effects modelling versus logistic regression for the inclusion of cluster-level covariates in propensity score estimation: A Monte Carlo simulation and registry cohort analysis

Purpose: Surgeon and hospital-related features, such as volume, can be associated with treatment choices and outcomes. Accounting for these covariates with propensity score (PS) analysis can be challenging due to the clustered nature of the data. We studied six different PS estimation strategies for clustered data using random effects modelling (REM) compared with logistic regression. Methods: Monte Carlo simulations were used to generate variable cluster-level confounding intensity [odds ratio (OR) = 1.01-2.5] and cluster size (20-1,000 patients per cluster). The following PS estimation strategies were compared: i) logistic regression omitting cluster-level confounders; ii) logistic regression including cluster-level confounders; iii) the same as ii) but including cross-level interactions; iv), v), and vi), similar to i), ii), and iii), respectively, but using REM instead of logistic regression. The same strategies were tested in a trial emulation of partial versus total knee replacement (TKR) surgery, where observational versus trial-based estimates were compared as a proxy for bias. Performance metrics included bias and mean square error (MSE). Results: In most simulated scenarios, logistic regression, including cluster-level confounders, led to the lowest bias and MSE, for example, with 50 clusters × 200 individuals and confounding intensity OR = 1.5, a relative bias of 10%, and MSE of 0.003 for (i) compared to 32% and 0.010 for (iv). The results from the trial emulation also gave similar trends. Conclusion: Logistic regression, including patient and surgeon-/hospital-level confounders, appears to be the preferred strategy for PS estimation.

Working Smarter, Not Harder: Using Data-Driven Strategies to Generate Front-End Cost Savings through Price Negotiation and Supply Chain Optimization

BACKGROUND

Supply chain optimization is an effective method of generating front-end cost savings and increasing hospital profits. Through the negotiation and renegotiation of supply chain contracts, plastic surgeons can dramatically change the price at which they purchase surgical supplies and implants. This study characterizes the potential impact of supply chain optimization and puts forth a generalizable, systematic approach for successful sourcing.

METHODS

From October of 2017 to September of 2018, the authors examined all patients taken to the operating room for either a facial fracture or a hand fracture. Cost data were collected, Supply Chain Information Management numbers were used to determine whether each item used during the study period was under contract, and cost savings based on contract negotiation were calculated. Potential cost savings were calculated using the BillOnly calculator.

RESULTS

For the 77 facial trauma cases and 63 hand trauma cases performed, a total of 330 items (70 distinct items) were used, 47 percent of which were under contract (47 percent contract use), with an average negotiated discount of 49 percent. Based on BillOnly material cost estimates, the authors' institution would need to increase its contract use to 70 percent to achieve a net savings of 19 percent, and to 90 percent to achieve a net savings of 39 percent. The authors also estimated that if contract use increased to 90 percent, net savings would increase commensurately with increases in the average discount negotiated.

CONCLUSION

Supply chain optimization offers plastic surgeons the potential to significantly decrease surgical costs while maintaining surgical quality.

Examining the Factors Influencing Orthopedic Physician’s Decision to Purchase Medical Devices: Evidence from Kuwait

Purpose

It is explanatory and descriptive research to explain the relationship among factors influencing the orthopedic physician’s decision of purchasing medical devices and equipment.

Methods

Quantitative method will be used in this study as all heads of departments in MOH hospitals refused to make one-to-one interviews and suggested only questionnaires that will be high in confidentiality.

Results

For the first question: What is the ranking of factors that influence orthopedic physician decision in purchasing medical devices and equipment in MOH hospitals in Kuwait? According to HB analysis, the most preferred attribute is implant review in a journal and the lowest preferred factor is product training. Moreover, Brand was the second preferred attribute followed by leader influence. Surprisingly, price came after all these attributes. Physicians ranked technical support and sponsorship in the fifth and sixth places. For the second question: How can marketing and sales management predict orthopedic physicians' decisions before designing product proposals? This will assist M&S department in creating proposals that satisfy orthopedic physicians through expecting their decisions on various alternatives.

Conclusion

There is a good opportunity for all medical devices companies, after discussion with SMEs, either for growth or leaving stagnation phase. However, SMEs have no real understanding of what factors matter to the orthopedic physicians’ decision in purchasing medical devices and equipment. Thus, one of the goals of this research is to give M&S departments in medical devices companies with recommendations that will help them in forming attractive product offers to orthopedic physicians in MOH hospitals in Kuwait. Moreover, predicting the response from them in the future. In addition, four simulation scenarios have been conducted in this research to reach the best economic offer that maintains physicians attracted.

Smoothing It Out: Military Health Care Supply Chain in Transition

Health care provision in the US can be characterized by its ongoing consolidation of systems and facilities in its efforts to achieve clinical and business integration. An important goal in health care systems is integration to reduce fragmentation and gain value. Functional integration has a long history of association with clinical performance. Supply chain can dramatically support the goals of cost avoidance, improved clinical outcomes, and buffer the system from external dependencies. This paper examines the efforts by the Department of Defense to consolidate the medical supply chain and explores lessons for and from the civilian health sector supply chain.

Should I Buy This? A Decision-Making Tool for Surgical Value-Based Purchasing

Many considerations affect the value that a new instrument or product may generate in a surgical practice. This review serves as a guide for surgeons considering new purchases and/or wishing to advocate for hospital acquisition of new items. A summary of data from academic and industry practices is presented, with pertinent examples using relevant surgical devices such as disposable devices, laparoscopic trocars, and otologic endoscopes. Surgeons considering incorporating a new instrument or technology within their practice should weigh the following factors before decision making: patient and clinical care factors, surgeon and care team factors, and hospital factors such as cost, revenue, and sourcing. A surgeon well-versed in stakeholder interests who is involved in the purchase of a new instrument may have significant influence in value-based decision making that not only affects his or her practice but ultimately maximizes value for the patient.

Analysing actual prices of medical products: a cross-sectional survey of Dutch hospitals

OBJECTIVES

To assess whether there is a difference between the net prices of medical products used by Dutch hospitals and, if there is, how this difference can be explained.

DESIGN

Cross-sectional self-administered electronic survey.

SETTING

We surveyed the prices paid for 17 commonly used medical products, such as pacemakers, gloves and stents in 38 Dutch hospitals (including general, specialised and academic hospitals) in 2017. Hospitals voluntarily and anonymously provided these data and received a personalised free benchmark tool in return. This tool provides information about the variance in prices of the medical products they buy.

PARTICIPANTS

38 out of 79 hospitals entered and completed the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Actual price paid excluding Value Added Tax (VAT) per item, the order size per year, total spending for an assortment group and total spending for all products purchased from a specific supplier were measured.

RESULTS

We found large price variations for the medical products surveyed (average coefficient of variation of 71%). In general, these differences were hard to explain (average R² of 26%). Only purchasing volume (for 8 out of 17 products) was significantly associated with the net price paid by a hospital. Total spending for an assortment group (in euros with a specific supplier) and total spending (for all products in euros with a specific supplier) were not related to the net price paid.

CONCLUSIONS

We conclude that only purchasing volume is associated with lower prices paid. Total spending for an assortment group and total spending for all products purchased from a specific supplier are not. These results are in stark contrast to expectations based on economic theory. Other sources of differences in bargaining power might explain these findings. Further research might involve comparing prices across countries.

Association of Cost Savings and Surgical Quality With Single-Vendor Procurement for Spinal Implants

IMPORTANCE

Significant cost savings can be achieved from consolidating purchases of spinal implants with a single vendor. However, it is currently unknown whether sole-source contracting or vendor rationalization more broadly affects patient care.

OBJECTIVES

To describe the single-vendor procurement of spinal implants, characterize the economic benefits of sole-source contracting, and gauge whether vendor rationalization is associated with a diminished quality of care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study assessed adult patients receiving single-level lumbar interbody fusions at a single institution from January 1, 2009, to July 31, 2017. Exclusion criteria included multilevel fusions and prior spinal fusions.

EXPOSURES

Patients were analyzed based on the number of vendors available to surgeons at the time of the patient's surgery. January 1, 2009, to December 31, 2010, was defined as the multivendor period (10 vendors); January 1, 2011, to December 31, 2014, was defined as the dual-vendor period; and January 1, 2015, to July 31, 2017, was defined as the single-vendor period.

MAIN OUTCOMES AND MEASURES

Rates of 12-month revision surgery, complications, 30-day readmissions, and postoperative patient-reported outcomes, as measured by 5-dimension European Quality of Life (EQ-5D) and Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) utilities. Propensity score weighting was performed to control for confounding. The Holm method was used to correct for multiple testing. Annual cost savings associated with the dual-vendor and single-vendor periods were also reported.

RESULTS

A total of 1373 patients (mean [SD] age, 59.2 [12.6] years; 763 [55.6%] female; 1161 [84.6%] white) were analyzed. Rates of revisions after adjusting for confounding were 3.2% (95% CI, 1.5%-6.7%) for the multivendor period, 4.5% (95% CI, 3.1%-6.5%) for the dual-vendor period, and 3.0% (95% CI, 1.7%-5.0%) for the single-vendor period. Complication rates were 5.3% (95% CI, 2.7%-10.1%) for the multivendor period, 7.2% (95% CI, 5.4%-9.6%) for the dual-vendor period, and 6.4% (95% CI, 4.6%-8.8%) for the single-vendor period. Readmission rates were 14.2% (95% CI, 9.7%-20.2%) for the multivendor period, 12.6% (95% CI, 10.1%-15.5%) for the dual-vendor period, and 9.7% (95% CI, 7.4%-12.7%) for the single-vendor period. Revisions, complications, and patient-reported outcomes were statistically equivalent across all periods. Readmissions were not statistically equivalent but not statistically different. The savings attributable to vendor rationalization were 24% for the dual-vendor and 21% for the single-vendor periods.

CONCLUSIONS AND RELEVANCE

The single-vendor procurement of spinal implants was associated with significant cost savings without evidence of an associated decline in the quality of care. Large hospital systems may consider sole-source purchasing as a viable cost reduction strategy.

Motivations Influencing the Surgeon's Healthcare Unit Choice to Perform Surgery: A Confirmatory Study in Portugal

Quality surgical practice is a fundamental subject in health institutions, and it is important to understand the structural and organizational conditions of the operating room (OR). The present exploratory study sought to understand the motivations that underlie the choice of surgeons for the best healthcare unit to perform surgery, as well as the characteristics of those professionals regarding age, years of work experience, and sex. A questionnaire survey was administered to a convenience sample of 99 surgeons, 67.3% male and 32.7% female, aged 37 to 66 (M = 23.7; Std = 8.92). The results show that at the top of the surgeons' motivations to perform surgery is the 77.8% attributed to the human resources and equipment available and at the other extreme the 3% to the previous online visit to facilities. This study opens important clues to the development of more in-depth and comparative approaches, necessary for the continuous improvement of the healthcare provided in the context of surgical practice.

Current Practice Patterns of Fellowship-Trained Arthroplasty Surgeons: Has the Influence of Fellowship Training Been Undervalued?

BACKGROUND

As the clinical and financial environments of total joint arthroplasty (TJA) have evolved over the last several decades so has the role of the surgeon in providing this care to patients. Our objective was to examine current practices and influential factors among fellowship-trained arthroplasty surgeons.

METHODS

An electronic survey was sent to all surgeons who had completed one of the three high-volume adult reconstruction fellowships from the years 2007-2016. The survey consisted of 34 questions regarding current practice characteristics, case volumes for primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA), use of advanced technologies, choice of surgical approach and implant design, factors influencing their choices, and their involvement in implant selection and contract negotiations.

RESULTS

Questionnaires were sent to 53 surgeons; 52 were completed. Sixty percent of respondents performed at least 100 TKAs and 84% performed at least 50 THAs annually. Ninety-four percent use a single company's implant for more than 90% of primary TKA and THA. Fellowship or residency experience was the most significant influence on TKA and THA implant selection for 62% and 45% of surgeons, respectively, while contracts of their current institution were the primary influence for 17% and 12%, respectively. Fifty-five percent of surgeons used some advanced technology of which 16% said this influenced their implant choice. Eighty-six percent perform the majority of cases at centers performing at least 200 TJAs per year, and 39% participate in implant contract negotiations.

CONCLUSION

Despite changes in the economic environment of TJA, this study demonstrates that experience with a specific implant during training, particularly fellowship, is the most influential factor for implant selection among fellowship-trained arthroplasty surgeons.

Development and pilot of a multicriteria decision analysis (MCDA) tool for health services administrators

INTRODUCTION

Health administration is complex and serves many masters. Value, quality, infrastructure and reimbursement are just a sample of the competing interests influencing executive decision-making. This creates a need for decision processes that are rational and holistic.

METHODS

We created a multicriteria decision analysis tool to evaluate six fields of healthcare provision: return on investment, capacity, outcomes, safety, training and risk. The tool was designed for prospective use, at the beginning of each funding round for competing projects. Administrators were asked to rank their criteria in order of preference. Each field was assigned a representative weight determined from the rankings. Project data were then entered into the tool for each of the six fields. The score for each field was scaled as a proportion of the highest scoring project, then weighted by preference. We then plotted findings on a cost-effectiveness plane. The project was piloted and developed over successive uses by the hospital's executive board.

RESULTS

Twelve projects competing for funding at the Royal Brisbane and Women's Hospital were scored by the tool. It created a priority ranking for each initiative based on the weights assigned to each field by the executive board. Projects were plotted on a cost-effectiveness plane with score as the x-axis and cost of implementation as the y-axis. Projects to the bottom right were considered dominant over projects above and to the left, indicating that they provided greater benefit at a lower cost. Projects below the x-axis were cost-saving and recommended provided they did not harm patients. All remaining projects above the x-axis were then recommended in order of lowest to highest cost-per-point scored.

CONCLUSION

This tool provides a transparent, objective method of decision analysis using accessible software. It would serve health services delivery organisations that seek to achieve value in healthcare.

How Procurement Judges The Value of Medical Technologies: A Review of Healthcare Tenders

OBJECTIVES

Procurement's important role in healthcare decision making has encouraged criticism and calls for greater collaboration with health technology assessment (HTA), and necessitates detailed analysis of how procurement approaches the decision task.

METHODS

We reviewed tender documents that solicit medical technologies for patient care in Canada, focusing on request for proposal (RFP) tenders that assess quality and cost, supplemented by a census of all tender types. We extracted data to assess (i) use of group purchasing organizations (GPOs) as buyers, (ii) evaluation criteria and rubrics, and (iii) contract terms, as indicators of supplier type and market conditions.

RESULTS

GPOs were dominant buyers for RFPs (54/97) and all tender types (120/226), and RFPs were the most common tender (92/226), with few price-only tenders (11/226). Evaluation criteria for quality were technical, including clinical or material specifications, as well as vendor experience and qualifications; "total cost" was frequently referenced (83/97), but inconsistently used. The most common (47/97) evaluative rubric was summed scores, or summed scores after excluding those below a mandatory minimum (22/97), with majority weight (64.1 percent, 62.9 percent) assigned to quality criteria. Where specified, expected contract lengths with successful suppliers were high (mean, 3.93 years; average renewal, 2.14 years), and most buyers (37/42) expected to award to a single supplier.

CONCLUSIONS

Procurement's evaluative approach is distinctive. While aiming to go beyond price in the acquisition of most medical technologies, it adopts a narrow approach to assessing quality and costs, but also attends to factors little considered by HTA, suggesting opportunities for mutual lesson learning.

An exploration of NHS clinical staff perceptions of changes to clinical products and their procurement

The NHS in England is working to reduce variation and waste in the use of clinical products, which requires collaboration between those directly involved in procurement and clinical staff. The procurement process is becoming centralised and standardised, and the involvement of, and consultation with, clinical staff is vital to avoid compromising patient care and safety. This article reports the results of a survey of clinical staff and clinical procurement specialist nurses undertaken as part of a master's degree. Its aim was to capture staff experiences and perceptions of changes to clinical products.

Physician preference items: what factors matter to surgeons? Does the vendor matter?

Background

The USA devotes roughly $200 billion (6%) of annual national health expenditures to medical devices. A substantial proportion of this spending occurs during orthopedic (eg, hip and knee) arthroplasties – two high-volume hospital procedures. The implants used in these procedures are commonly known as physician preference items (PPIs), reflecting the physician’s choice of implant and vendor used. The foundations for this preference are not entirely clear. This study examines what implant and vendor characteristics, as evaluated by orthopedic surgeons, are associated with their preference. It also examines other factors (eg, financial relationships and vendor tenure) that may contribute to implant preference.

Methods

We surveyed all practicing orthopedic surgeons performing 12 or more implant procedures annually in the Commonwealth of Pennsylvania. The survey identified each surgeon’s preferred hip/knee vendor as well as the factors that surgeons state they use in selecting that primary vendor. We compared the surgeons’ evaluation of multiple characteristics of implants and vendors using analysis of variance techniques, controlling for surgeon characteristics, hospital characteristics, and surgeon–vendor ties that might influence these evaluations.

Results

Physician’s preference is heavily influenced by technology/implant factors and sales/service factors. Other considerations such as vendor reputation, financial relationships with the vendor, and implant cost seem less important. These findings hold regardless of implant type (hip vs knee) and specific vendor.

Conclusion

Our results suggest that there is a great deal of consistency in the factors that surgeons state they use to evaluate PPIs such as hip and knee implants. The findings offer an empirically derived definition of PPIs that is consistent with the product and nonproduct strategies pursued by medical device companies. PPIs are products that surgeons rate favorably on the twin dimensions of technology and sales/service.

Hospital Supply Expenses: An Important Ingredient in Health Services Research

The purpose of this article is to shed light on hospital supply expenses, which form the second largest expense category after payroll and hold more promise for improving cost-efficiency compared to payroll. However, limited research has rigorously scrutinized this cost category, and it is rarely given specific consideration across cost-focused studies in health services publications. After reviewing previously cited estimates, we examine and independently validate supply expense data (collected by the American Hospital Association) for over 3,500 U.S. hospitals. We find supply expenses to make up 15% of total hospital expenses, on average, but as high as 30% or 40% in hospitals with a high case-mix index, such as surgery-intensive hospitals. Future research can use supply expense data to better understand hospital strategies that aim to manage costs, such as systemization, physician–hospital arrangements, and value-based purchasing.

Biomedical innovation in the era of health care spending constraints

Insurers, hospitals, physicians, and consumers are increasingly weighing price against performance in their decisions to purchase and use new drugs, devices, and other medical technologies. This approach will tend to affect biomedical innovation adversely by reducing the revenues available for research and development. However, a more constrained funding environment may also have positive impacts. The passing era of largely cost-unconscious demand fostered the development of incremental innovations priced at premium levels. The new constrained-funding era will require medical technology firms to design their products with the features most valued by payers and patients, price them at levels justified by clinical performance, and manage distribution through organizations rather than to individual physicians. The emerging era has the potential to increase the social value of innovation by focusing industry on design, pricing, and distribution principles that are more closely aligned with the preferences-and pocketbooks-of its customers.

Salespeople in the Surgical Suite: Relationships between Surgeons and Medical Device Representatives

Background

Industry payments to surgeons have received public attention, but little is known about the relationships between surgeons and medical device representatives. Medical device representatives ("device reps") have become an integral part of operating room personnel. The effect of their presence on patient care deserves discussion.

Study Design

We conducted a qualitative, ethnographic study to explore relationships between surgeons and medical device representatives, and characterize industry involvement in the training of surgeons. We used group and individual open-ended interviews to gain insight into the beliefs, values, and perspectives of surgeons and device reps. We conducted two focus groups, one with ear, nose, and throat surgeons, and one with hospital-based attending orthopedic surgeons. We also conducted individual interviews with three former or current medical device representatives, a director of a surgical residency program at an academic medical center, and a medical assistant for a multi-physician orthopedic practice.

Results

While surgeons view themselves as indisputably in charge, device reps work hard to make themselves unobtrusively indispensable in order to establish and maintain influence, and to imbue the products they provide with personalized services that foster a surgeon's loyalty to the reps and their companies. Surgeons view industry-funded training opportunities as a necessary service. Device reps and some surgeons believe that reps benefit patient care, by increasing efficiency and mitigating deficiencies among operating room personnel (including the surgeons themselves).

Conclusions

Our study raises ethical questions about the reliance of surgeons on device reps and device companies for education and surgical assistance and practical concerns regarding existing levels of competence among OR personnel.

Economics of All-Polyethylene Versus Metal-Backed Tibial Prosthesis Designs

With the large number of total knee arthroplasties being performed and expectations that these numbers will be on the rise over the coming decades, efforts to provide cost-efficient care are of greater interest. The preferred design of knee arthroplasty implants has changed over time, with the original all-polyethylene tibial (APT) design being replaced by metal-backed tibial (MBT) components, as well as more recent considerations of newer APT designs. Modern APT components have been shown to have similar or superior outcomes than MBT components. Despite their limitations, APT components can be used to reduce the economic burden to the provider, medical institution, and health care system as a whole. There is a paucity of evidence-based literature directly comparing the cost associated with APT and MBT components. The purpose of this report is to review the literature to assess the available data regarding direct and indirect costs of both designs so that orthopedic surgeons can account for economic differences in everyday practice. [Orthopedics. 2016; 39(3):S61-S66.].

Hospital employment of physicians and supply chain performance: An empirical investigation

BACKGROUND

As hospital employment of physicians becomes increasingly common in the United States, much speculation exists as to whether this type of arrangement will promote hospital operating efficiency in such areas as supply chain management. Little empirical research has been conducted to address this question.

PURPOSE

The aim of this study was to provide an exploratory assessment of whether hospital employment of physicians is associated with better supply chain performance. Drawing from both agency and stewardship theories, we examined whether hospitals with a higher proportion of employed medical staff members have relatively better supply chain performance based on two performance measures, supply chain expenses and inventory costs.

APPROACH

We conducted the study using a pooled, cross-sectional sample of hospitals located in California between 2007 and 2009. Key data sources were hospital annual financial reports from California's Office of Statewide Health Policy and Development and the American Hospital Association annual survey of hospitals. To examine the relationship between physician employment and supply chain performance, we specified physician employment as the proportion of total employed medical staff members as well as the proportion of employed medical staff members within key physician subgroups. We analyzed the data using generalized estimating equations.

FINDINGS

Study results generally supported our hypothesis that hospital employment of physicians is associated with better supply chain performance.

PRACTICAL IMPLICATIONS

Although the results of our study should be viewed as preliminary, the trend in the United States toward hospital employment of physicians may be a positive development for improved hospital operating efficiency. Hospital managers should also be attentive to training and educational resources that medical staff members may need to strengthen their role in supply chain activities.

Case studies of orthopedic surgery in California: the virtues of care coordination versus specialization

Two overarching frameworks compete to address the organizational ills of the health care system. One framework diagnoses lack of coordination and prescribes integration and global payment. The other diagnoses loss of focus and prescribes specialization and episode payment. This article, based on research and interviews, assesses how the two frameworks manifest themselves at two high-volume orthopedic hospitals in Irvine, California. The Kaiser Permanente Irvine Medical Center is part of a large and diversified health system. The Hoag Orthopedic Institute is a single-specialty facility jointly owned by the physicians and the hospital. Market outcomes, such as the merger of the Hoag specialty hospital into a larger diversified health system, suggest that Kaiser's focus on coordination of patient care from preadmission to postdischarge is a key factor in its success. But Hoag's specialization also leads to improved efficiencies. The integrated approach appears to be prevailing. At the same time, large diversified organizations might obtain further efficiencies by pursuing service-line strategies as described in this article--for instance, by providing incentives for efficiency and quality for each specialty and type of care.

Variations in the use of an innovative technology by payer: the case of drug-eluting stents

BACKGROUND

Despite receiving identical reimbursement for treating heart disease patients with bare metal stents (BMS) or drug-eluting coronary stents (DES), cardiologists' use of the new technology (DES) may have varied by patient payer type as DES diffused. Payer-related factors that differ between hospitals and/or differential treatment inside hospitals might explain any overall differences by payer type.

OBJECTIVES

To assess the association between payer and DES use and to examine between-hospital and within-hospital variation in DES use over time.

METHODS

We conducted a retrospective analysis of 4.1 million hospitalizations involving DES or BMS from 2003 to 2008 Nationwide Inpatient Sample. We estimated hybrid-fixed effects logit models and calculated the adjusted within-quarter, cross-payer differences in DES use.

RESULTS

Coronary stent patients with Medicaid or without insurance were significantly less likely to receive DES than were patients with private insurance throughout the study period. The differences fluctuated over time as the popularity of DES relative to BMS increased and decreased. The within-hospital gaps paralleled the overall differences, and were largest in Q3 2003 (Medicaid: 11.9, uninsured: 10.9% points) and Q4 2008 (Medicaid: 12.8, uninsured: 20.7% points), and smallest in Q4 2004 (Medicaid: 1.4, uninsured: 1.1% points). The between-hospital adjusted differences in DES use by payer were small and rarely significant.

CONCLUSIONS

We found substantial differences in DES use by payer within hospitals, suggesting physicians selected the new technology for patients in a manner associated with patients' payer type.

Professionalism in 21st century professional practice: autonomy and accountability in orthopaedic surgery

Orthopaedic surgical practice is becoming increasingly complex. The rapid change in pace associated with new information and technologies, the physician-supplier relationship, the growing costs and growing gap between costs and reimbursements for orthopaedic surgical procedures, and the influences of advertising on the patient, challenge all involved in the delivery of orthopaedic care. This paper assesses the concepts of professionalism, autonomy, and accountability in the 21st century practice of orthopaedic surgery. These concepts are considered within the context of the complex value chain surrounding orthopaedic surgery and the changing forces influencing clinical decision making by the surgeon. A leading impetus for challenge to the autonomy of the orthopaedic surgeon has been cost. Mistrust and lack of understanding have characterized the physician-hospital relationship. Resource dependency has characterized the physician-supplier relationship. Accountability for the surgeon has increased. We suggest implant surgery involves shared decision making and "coproduction" between the orthopaedic surgeon and other stakeholders. The challenge for the profession is to redefine professionalism, accountability, and autonomy in the face of these changes and challenges.

Implant vendors and hospitals: competing influences over product choice by orthopedic surgeons

BACKGROUND

Vendors of hip and knee implants court orthopedic surgeons to adopt their products. Hospitals, which have to pay for these products, now court the same surgeons to help reduce the number of vendors and contain implant costs.

PURPOSES

This study measures the surgeon's perceived alignment of interests with both vendors and hospitals and gauges surgeons' exposure and receptivity to hospital cost-containment efforts.

METHODOLOGY/APPROACH

We surveyed all practicing orthopedists performing 12 or more implant procedures annually in Pennsylvania. The survey identified the surgeon's preferred vendor, tenure with that vendor, use of the vendor during residency training, receipt of financial payments from the vendor, alignment of interests with both vendor and hospital stakeholders, and exposure and receptivity to hospital cost-containment efforts.

FINDINGS

Surgeons have long-standing relationships with implant vendors, but only a small proportion receive financial payments. Surgeons align most closely with the vendor's sales representative and least closely with the hospital's purchasing manager. Paradoxically, surgeons support hospital efforts to limit the number of vendors but report that their own choice of vendor is not constrained. The major drivers of surgeons' alignment and stance toward cost containment are their tenure with and receipt of financial payments from the vendor.

PRACTICE IMPLICATIONS

Hospitals face a competitive disadvantage in capturing the attention of orthopedists, compared with implant vendors. The vendors' advantage stems from historical, financial, and service benefits offered to surgeons. Hospital executives now seek to offer comparable benefits to surgeons.

Hip and knee implants: current trends and policy considerations

This paper constitutes an analysis of the issues, relationships, emerging hospital strategies, and policy needs surrounding hip and knee implants. Demand for hip and knee replacements is rising annually, and growth is expected to be substantial. Costs are high, reaching $11 billion for hospitals in 2004 and $5 billion for Medicare in 2006. Relationships among stakeholders add complexity. Case studies reveal emerging strategies by hospitals for management of implants. Policy considerations include development of a national council for data and technology assessment, a national joint registry, price transparency, and incentives.

Challenges in evaluating and standardizing medical devices in health care facilities

Advances in medical technologies have led to improved diagnoses and treatments, but medical devices do not always undergo the rigorous review process that is applied to drugs. To control costs, some health care facilities are becoming more selective in how they evaluate new devices.