Reducing costs while maintaining quality in endovascular neurosurgical procedures

The Economic Impact of Standardization and Digitalization in the Operating Room: A Systematic Literature Review

Hospital face increased resource constraints and competition. This escalates the need for efficiency optimization especially in resource-intense areas, such as the Operating Room (OR). Efficiency cannot happen at expenses of patient outcomes. Innovative digital support systems (DSS) have been introduced into the market to support established standardization methods of intraoperative workflows further. This review aimed to analyze whether applied standardization methods and implemented DSS of intraoperative surgical workflows lead to increasing efficiency and demonstrate economic improvements. A systematic review of intraoperative surgical workflows standardization and digitalization was performed. Journal articles and reviews from 2000 to 2023 were retrieved from EBSCO, PubMed, and Scopus databases, as well as the internal database of Johnson & Johnson. 17 articles showed a significant increase in efficiency through standardization, which led to cost reductions between $70.20 to $3,516 per case without negatively impacting quality. Five additional articles on DSS demonstrated a significant positive impact on efficiency and quality. Reduction in OR-time between 6 to 22% per case was one main contributor. No literature on DSS revealed any correlated economic impact. Selected standardization methods and introduced DSS for intraoperative surgical workflows effectively increase efficiency while maintaining or even improving quality. Demonstrated cost-effectiveness of non-digital standardization methods across surgical areas requires more research on complex and resource-intensive procedures and the economic value of DSS to support hospital management's strategic decisions to overcome the increasing economic burden.

Saving Money and Reducing Waste With a Tailored Hand Surgery Kit

BACKGROUND AND OBJECTIVES

There is growing interest in containing cost and decreasing waste in the operating room. As part of a quality improvement initiative, we redesigned the supply kit used for 2 common surgical procedures (carpal tunnel release and trigger finger release) performed under local anesthesia.

METHODS

A hand surgeon, a medical student, and an operating room nurse examined each item that would be necessary for performing carpal tunnel release and trigger finger release. A new disposable supply kit was formulated on the basis of their recommendations and was implemented over a 7-month period. Cost savings and waste avoidance were calculated.

RESULTS

The streamlined kit ($43.40) produced a 53% cost savings relative to the standard hand pack ($92.83) per case. The local pack (2.896 kg) was 41% lighter than the standard pack (4.938 kg), translating to significant waste avoidance. The local hand pack was used for 46 cases from September 2020 to April 2021, saving a total of $2246.78 and avoiding 94 kg of waste. There have been no noted interruptions in delivery of surgical care.

CONCLUSION

Our redesign of the local hand pack led to substantial cost savings and waste avoidance. We believe there are many opportunities for surgical teams to use similar strategies to decrease cost and environmental waste.

Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis

BACKGROUND

In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVE

To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center.

METHODS

All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis.

RESULTS

Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance.

CONCLUSION

Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.

Nationwide trends in middle meningeal artery embolization for treatment of chronic subdural hematoma: A population-based analysis of utilization and short-term outcomes

Middle meningeal artery (MMA) embolization represents a promising novel treatment modality for chronic subdural hematoma (cSDH), yet utilization and efficacy data are limited. This study evaluates the utilization and short-term outcomes of MMA embolization for cSDH treatment in a large national inpatient registry. cSDH patients treated with MMA embolization and/or surgical evacuation (craniotomy/burr hole drainage) were identified using the National Inpatient Sample (NIS) during 2012-2018 period. Temporal trends, complications, and discharge disposition were evaluated, and propensity score matching was implemented for adjusted comparisons and to mitigate confounding by indication. Among 60,045 cSDH patients identified, 390 (0.6%) underwent MMA embolization. Embolized patients presented more with high acute illness severity subclasses in comparison with surgically evacuated patients (53% vs. 34%, p = 0.004) yet did not experience any procedure-related hemorrhagic or ischemic complications. Although discharge disposition did not differ from those surgically managed, embolized patients had longer mean hospital stays (13 vs. 8 days, p = 0.023) and accrued greater hospital charges (p < 0.001). Following propensity adjustment, length of stay and charges remained greater in the embolization cohort, yet rates of routine discharge increased appreciably (40% vs. 30%, p = 0.141) relative to surgically treated cSDH patients. The utilization of embolization increased exponentially after 2015, reaching an apex in 2018 (3.7% of treated cSDH). This population-based national assessment demonstrates exponential increases in utilization of MMA embolization for cSDH treatment in recent years. Embolized patients had uncomplicated clinical courses and similar discharge dispositions as surgical evacuation patients. Large-scale prospective trials are warranted to further assess the efficacy of this modality.

Operating Costs of Full-endoscopic Lumbar Spine Surgery in Japan

For full-endoscopic lumbar discectomy, operating costs are also important because expensive equipment are necessary. We surveyed the operating costs of surgical equipment necessary for full-endoscopic surgery together with surgical procedure reimbursement fees. A total of 295 cases of full-endoscopic surgery via a transforaminal approach were retrospectively analyzed. We calculated the frequency of damage and the unit purchase price of devices such as endoscopes, and surgical instruments such as grasping forceps for nucleotomy, high-speed drill bar, and bipolar forceps, and examined the operating costs in Japanese yen against the procedure fee per case. Endoscope breakage occurred seven times, and a payment of ¥760,000 was necessary for trade-in and purchase of a new endoscope. The total breakage number of grasping forceps was 58, and the purchase price per unit was ¥116,000. Therefore, a total of ¥12,020,000 was required for the 295 cases, and the calculated operating cost that accompanies equipment breakage was ¥40,000 per case. In addition, about ¥118,000 was required for disposable bipolar forceps and high-speed drill bar to be used intraoperatively for each case. Thus, for one case it is calculated that total ¥158,000 is utilized for equipment from the surgical reimbursement fee per case specified by the Japanese Ministry of Health being ¥303,900. Minimally invasive procedures provide great benefit to patients; however, the eventual contribution to hospital profits is small and may not be sufficient. To resolve this issue, the cost of surgical equipment should be lowered and/or the surgical reimbursement fee of the full-endoscopic surgery should be raised.

Implementing a perioperative efficiency initiative for orthopedic surgery instrumentation at an academic center: A comparative before-and-after study

Optimizing surgical instrumentation may contribute to value-based care, particularly in commonly performed procedures. We report our experience in implementing a perioperative efficiency program in 2 types of orthopedic surgery (primary total-knee arthroplasty, TKA, and total-hip arthroplasty, THA).A comparative before-and-after study with 2 participating surgeons, each performing both THA and TKA, was conducted. Our objective was to evaluate the effect of surgical tray optimization on operating and processing time, cost, and waste associated with preparation, delivery, and staging of sterile surgical instruments. The study was designed as a prospective quality improvement initiative with pre- and postimplementation operational measures and a provider satisfaction survey.A total of 96 procedures (38 preimplementation and 58 postimplementation) were assessed using time-stamped performance endpoints. The number and weight of trays and instruments processed were reduced substantially after the optimization intervention, particularly for TKA. Setup time was reduced by 23% (6 minutes, P = .01) for TKA procedures but did not differ for THA. The number of survey respondents was small, but satisfaction was high overall among personnel involved in implementation.Optimizing instrumentation trays for orthopedic procedures yielded reduction in processing time and cost. Future research should evaluate patient outcomes and incremental/additive impact on institutional quality measures.

Cost of coils for intracranial aneurysms: clinical decision analysis for implementation of a capitation model

OBJECTIVE

The price of coils used for intracranial aneurysm embolization has continued to rise despite an increase in competition in the marketplace. Coils on the US market range in list price from $500 to $3000. The purpose of this study was to investigate potential cost savings with the use of a price capitation model.

METHODS

The authors built a clinical decision analytical tree and compared their institution’s current expenditure on endovascular coils to the costs if a capped-price model were implemented. They retrospectively reviewed coil and cost data for 148 patients who underwent coil embolization from January 2015 through September 2016. Data on the length and number of coils used in all patients were collected and analyzed. The probabilities of a treated aneurysm being ≤/> 10 mm in maximum dimension, the total number of coils used for a case being ≤/> 5, and the total length of coils used for a case being ≤/> 50 cm were calculated, as was the mean cost of the currently used coils for all possible combinations of events with these probabilities. Using the same probabilities, the authors calculated the expected value of the capped-price strategy in comparison with the current one. They also conducted multiple 1-way sensitivity analyses by applying plausible ranges to the probabilities and cost variables. The robustness of the results was confirmed by applying individual distributions to all studied variables and conducting probabilistic sensitivity analysis.

RESULTS

Ninety-five (64%) of 148 patients presented with a rupture, and 53 (36%) were treated on an elective basis. The mean aneurysm size was 6.7 mm. A total of 1061 coils were used from a total of 4 different providers. Companies A (72%) and B (16%) accounted for the major share of coil consumption. The mean number of coils per case was 7.3. The mean cost per case (for all coils) was $10,434. The median total length of coils used, for all coils, was 42 cm. The calculated probability of treating an aneurysm less than 10 mm in maximum dimension was 0.83, for using 5 coils or fewer per case it was 0.42, and for coil length of 50 cm or less it was 0.89. The expected cost per case with the capped policy was calculated to be $4000, a cost savings of $6564 in comparison with using the price of Company A. Multiple 1-way sensitivity analyses revealed that the capped policy was cost saving if its cost was less than $10,500. In probabilistic sensitivity analyses, the lowest cost difference between current and capped policies was $2750.

CONCLUSIONS

In comparison with the cost of coils from the authors’ current provider, their decision model and probabilistic sensitivity analysis predicted a minimum $407,000 to a maximum $1,799,976 cost savings in 148 cases by adapting the capped-price policy for coils.

Analysis of cerebrovascular aneurysm treatment cost: retrospective cohort comparison of clipping, coiling, and flow diversion

OBJECTIVE

With the continuous rise of health care costs, hospitals and health care providers must find ways to reduce costs while maintaining high-quality care. Comparing surgical and endovascular treatment of intracranial aneurysms may offer direction in reducing health care costs. The Value-Driven Outcomes (VDO) database at the University of Utah identifies cost drivers and tracks changes over time. In this study, the authors evaluate specific cost drivers for surgical clipping and endovascular management (i.e., coil embolization and flow diversion) of both ruptured and unruptured intracranial aneurysms using the VDO system.

METHODS

The authors retrospectively reviewed surgical and endovascular treatment of ruptured and unruptured intracranial aneurysms from July 2011 to January 2017. Total cost (as a percentage of each patient’s cost to the system), subcategory costs, and potential cost drivers were evaluated and analyzed.

RESULTS

A total of 514 aneurysms in 469 patients were treated; 273 aneurysms were surgically clipped, 102 were repaired with coiling, and 139 were addressed with flow diverter placements. Middle cerebral artery aneurysms accounted for the largest portion of cases in the clipping group (29.7%), whereas anterior communicating artery aneurysms were most frequently involved in the coiling group (30.4%) and internal carotid artery aneurysms were the majority in the flow diverter group (63.3%). Coiling (mean total cost 0.25% ± 0.20%) had a higher cost than flow diversion (mean 0.20% ± 0.16%) and clipping (mean 0.17 ± 0.14%; p = 0.0001, 1-way ANOVA). Coiling cases cost 1.5 times as much as clipping and flow diversion costs 1.2 times as much as clipping. Facility costs were the most significant contributor to intracranial clipping costs (60.2%), followed by supplies (18.3%). Supplies were the greatest cost contributor to coiling costs (43.2%), followed by facility (40.0%); similarly, supplies were the greatest portion of costs in flow diversion (57.5%), followed by facility (28.5%). Cost differences for aneurysm location, rupture status, American Society of Anesthesiologists (ASA) grade, and discharge disposition could be identified, with variability depending on surgical procedure. A multivariate analysis showed that rupture status, surgical procedure type, ASA status, discharge disposition, and year of surgery all significantly affected cost (p < 0.0001).

CONCLUSIONS

Facility utilization and supplies constitute the majority of total costs in aneurysm treatment strategies, but significant variation exists depending on surgical approach, rupture status, and patient discharge disposition. Developing and implementing approaches and protocols to improve resource utilization are important in reducing costs while maintaining high-quality patient care.

Picking apart surgical pick lists - Reducing variation to decrease surgical costs

BACKGROUND

Average costs associated with common procedures can vary by surgeon without a corresponding variation in outcome or case complexity.

METHODS

De-identified cost and equipment utilization data were collected from our hospital for elective laparoscopic cholecystectomy performed by 17 different surgeons over a 6-month period. A group of surgeons used this data to design a standardized equipment pick list that became optional (not mandated) for laparoscopic cholecystectomy. Cost and consumable surgical supply utilization data were collected for six months prior to and following the creation of the standardized pick-list.

RESULTS

280 elective laparoscopic cholecystectomies were performed during the study interval. In the 6 months after standardized pick list creation, the cost of disposable supplies utilized per case decreased by 32%.

CONCLUSIONS

Surgical cost savings can be achieved with standardized procedure pick lists and attention to the cost of consumable surgical supplies.

Cost analysis of robotic versus laparoscopic general surgery procedures

BACKGROUND

Robotic surgical systems have been used at a rapidly increasing rate in general surgery. Many of these procedures have been performed laparoscopically for years. In a surgical encounter, a significant portion of the total costs is associated with consumable supplies. Our hospital system has invested in a software program that can track the costs of consumable surgical supplies. We sought to determine the differences in cost of consumables with elective laparoscopic and robotic procedures for our health care organization.

METHODS

De-identified procedural cost and equipment utilization data were collected from the Surgical Profitability Compass Procedure Cost Manager System (The Advisory Board Company, Washington, DC) for our health care system for laparoscopic and robotic cholecystectomy, fundoplication, and inguinal hernia between the years 2013 and 2015. Outcomes were length of stay, case duration, and supply cost. Statistical analysis was performed using a t-test for continuous variables, and statistical significance was defined as p < 0.05.

RESULTS

The total cost of consumable surgical supplies was significantly greater for all robotic procedures. Length of stay did not differ for fundoplication or cholecystectomy. Length of stay was greater for robotic inguinal hernia repair. Case duration was similar for cholecystectomy (84.3 robotic and 75.5 min laparoscopic, p = 0.08), but significantly longer for robotic fundoplication (197.2 robotic and 162.1 min laparoscopic, p = 0.01) and inguinal hernia repair (124.0 robotic and 84.4 min laparoscopic, p = ≪0.01).

CONCLUSIONS

We found a significantly increased cost of general surgery procedures for our health care system when cases commonly performed laparoscopically are instead performed robotically. Our analysis is limited by the fact that we only included costs associated with consumable surgical supplies. The initial acquisition cost (over $1 million for robotic surgical system), depreciation, and service contract for the robotic and laparoscopic systems were not included in this analysis.

International survey on neuroradiological interventional and therapeutic devices and materials

A web-based survey was performed among the members of the World Federation of Interventional and Therapeutic Neuroradiology to determine the differences in availability, pricing, and performance of endovascular devices with special focus on coils, intra-arterial stroke devices, detachable balloons, and liquid embolic materials. The results of this survey show that the quality of the majority of interventional neuroradiology devices is good and compatibility issues are limited. Individual action towards suppliers is recommended to discuss the availability and pricing of devices and embolization materials.