Surgical Cost Disclosure May Reduce Operating Room Expenditures

Investigating the sterile surgical supply waste in laparotomy surgery

BACKGROUND

Operating rooms contribute to over 40% of hospital expenses, with a portion attributed to waste from single-use, sterile surgical supplies (SUSSS). This research aimed to determine the amount of cost wastage due to not using SUSSS during laparotomy procedures.

METHODS

A descriptive-analytical investigation was conducted in two prominent teaching hospitals in Mashhad, Iran 2018. Seventy-seven laparotomy surgeries were scrutinized, documenting both used and unused disposable devices, with their respective costs being assessed. Data analysis was performed using SPSS version 16 software.

RESULTS

The study revealed that during surgery in the operating rooms, waste of SUSSS averaged 5.9%. Betadine solution and sterile Gauze types were the top two contributors to resource wastage. Sterile Gauze types incurred the highest cost loss. The study found a significant correlation between cost wastage and surgeon experience (r = 0.296, P < 0.001) as well as surgery duration (r = 0.439, P < 0.001).

CONCLUSION

Inadequate management of available and commonly used disposable supplies leads to increased hospital expenses. Enhancing the surgical team's knowledge of sterile surgical supplies usage and making thoughtful selections can play a vital role in curbing health costs by minimizing waste of SUSSS in the operating rooms.

Operating Room Supply Cost and Value of Care after Implementing a Sustainable Quality Intervention

BACKGROUND

Variability in operating room supply cost is a modifiable cause of suboptimal resource use and low value of care (outcomes vs cost). This study describes implementation of a quality improvement intervention to decrease operating room supply costs.

STUDY DESIGN

An automated electronic health record data pipeline harmonized operating room supply cost data with patient and case characteristics and outcomes. For inpatient procedures, predicted mortality and length of stay were used to calculate observed-to-expected ratios and value of care using validated equations. For commonly performed (1 or more per week) procedures, the pipeline generated figures illustrating individual surgeon performance vs peers, costs for each surgeon performing each case type, and control charts identifying out-of-control cases and surgeons with more than 90th percentile costs, which were shared with surgeons and division chiefs alongside guidance for modifying case-specific supply instructions to operating room nurses and technicians.

RESULTS

Preintervention control (1,064 cases for 7 months) and postintervention (307 cases for 2 months) cohorts had similar baseline characteristics across all 16 commonly performed procedures. Median costs per case were lower in the intervention cohort ($811 [$525 to $1,367] vs controls: $1,080 [$603 to $1,574], p < 0.001), as was the incidence of out-of-control cases (19 (6.2%) vs 110 (10.3%), p = 0.03). Duration of surgery, length of stay, discharge disposition, and 30-day mortality and readmission rates were similar between cohorts. Value of care was higher in the intervention cohort (1.1 [0.1 to 1.5] vs 1.0 [0.2 to 1.4], p = 0.04). Pipeline runtime was 16:07.

CONCLUSIONS

An automated, sustainable quality improvement intervention was associated with decreased operating room supply costs and increased value of care.

Orthopaedic surgery residents report little subjective or objective familiarity with healthcare costs

PURPOSE

Residents have limited education regarding the cost of orthopaedic interventions. Orthopaedic residents' knowledge was surveyed in three scenarios involving an intertrochanteric femur fracture: 1) uncomplicated course with 2-day hospital stay; 2) complicated course necessitating ICU admission; and 3) readmission for pulmonary embolism management.

METHODS

From 2018 to 2020, 69 orthopaedic surgery residents were surveyed. Respondents estimated hospital charges and collections; professional charges and collections; implant cost; and level of knowledge depending on the scenario.

RESULTS

Most residents (83.6%) reported feeling "not knowledgeable". Respondents reporting "somewhat knowledgeable" did not perform better than those who reported "not knowledgeable". In the uncomplicated scenario, residents underestimated hospital charges and collections (p < 0.01; p = 0.87), and overestimated hospital charges and collections and professional collections (all p < 0.01) with an average percent error of 57.2%. Most residents (88.4%) were aware the sliding hip screw construct costs less than a cephalomedullary nail. In the complex scenario, while residents underestimated the hospital charges (p < 0.01), the estimated collections were closer to the actual figure (p = 0.16). In the third scenario, residents overestimated the charges and collections (p = 0.04; p = 0.04).

CONCLUSIONS

Orthopaedic surgery residents receive little education regarding healthcare economics and feel unknowledgeable therefore a role for formal economic education during orthopaedic residency may exist.

Cost Disclosure of Surgeon "Scorecards": Effects on Operating Room Costs for Total Hip and Knee Arthroplasty

Background: Rising health care costs, coupled with an emphasis on cost containment, continue to gain importance. Surgeon cost scorecards developed to track case-based expenditures can help surgeons compare themselves with their peers and identify areas of potential quality improvement. Purpose: We sought to investigate what effect surgeon scorecards had on operating room (OR) costs in orthopedic surgery. Methods: Our hospital distributed OR cost scorecards to 4 adult reconstruction fellowship-trained orthopedic surgeons beginning in 2012. The average direct per-case supply cost of procedures was calculated quarterly and collected over a 5-year period, and each surgeon's data were compared with that of their peers. All 4 surgeons were made aware of the costs of other surgeons at the 2-year mark. The initial 2 years of data was compared with that of the final 2 years. Results: The average direct per-case supply cost ranged from $4955 to $5271 for total knee arthroplasty (TKA) and $5469 to $5898 for total hip arthroplasty (THA) during the initial 2-year period. After implementing disclosures, the costs for TKA and THA, respectively, ranged from $4266 to $4515 (14% annual cost savings) and from $5073 to $5727 (5% annual cost savings); 3 of the 4 surgeons said that cost transparency altered their practice. Conclusion: Our comparison suggests that orthopedic surgeons' participation in a program of operative cost disclosure may be useful to them; we found a possible association with reduced per-case costs for TKA and THA at our institution over a 5-year period. More rigorous study that incorporates the effects of the scorecards on patient outcomes is warranted.

The Mandated Publication of Individual Hospital Charge Description Masters Does Not Permit the Estimation of Complex Procedure Charges

BACKGROUND

As healthcare spending continues to rise, price transparency is crucial for patients to calculate a reasonable cost estimate for tests and procedures. Legislative efforts have been successful at mandating increased hospital price transparency, including publishing charge description masters (CDMs), but their usefulness in permitting patients to assess the cost for complex procedures is unclear. We sought to determine CDM and diagnosis-related group (DRG) prevalence and evaluate whether these are effective tools for patients to preemptively ascertain the costs for simple and complex tests and procedures.

METHODS

Cross-sectional analysis of publicly available 2019 CDMs and DRGs from 122 hospitals in the United States, including the top-20 as ranked by the US News & World Report Honor Roll and two top-ranked hospitals per state. We first determined the availability of CDMs and DRGs and then determined the ability to estimate the hospital charge for a three-view knee radiograph and a primary total knee arthroplasty (TKA) using CDM and DRG data.

RESULTS

One hundred fifteen of 122 (94.3%) hospitals published a CDM, and 78 (63.9%) published a DRG. Top-ranked hospitals published DRGs more frequently than those outside of the Honor Roll designation (P = 0.04). The estimated charge for a three-view knee radiograph could be calculated from 113/115 (98.3%) CDMs. The estimated total charge for a primary TKA could not be obtained from any of the available CDMs. By comparison, the estimated charge for a primary TKA could be obtained from 76/78 (97.4%) of the available DRGs.

DISCUSSION

CDMs are available as currently mandated for most hospitals and generally can be used to identify the charges for simple procedures, but they are ineffective tools for patients to estimate the charges associated with a multifaceted healthcare procedure, such as TKA. Although DRGs are less frequently available, they are a more effective resource for patients to estimate charges.

Reducing Operating Room Cost: Comparing Attending and Surgical Trainee Perceptions About the Implementation of Supply Receipts

BACKGROUND

As operating room (OR) expenditures increase, faculty and surgical trainees will play a key role in curbing future costs. However, supply cost utilization varies widely among providers and, despite requirements for cost education during surgical training, little is known about trainees' comfort discussing these topics. To improve OR cost transparency, our institution began delivering real-time supply "receipts" to faculty and trainees after each surgical case. This study compares faculty and surgical trainees' perceptions about supply receipts and their effect on individual practice and cultural change.

STUDY DESIGN

Faculty and surgical trainees (residents and fellows) from all adult surgical specialties at a large academic center were emailed separate surveys.

RESULTS

A total of 120 faculty (30.0% response rate) and 119 trainees (35.7% response rate) completed the survey. Compared with trainees, faculty are more confident discussing OR costs (p < 0.001). Two-thirds of trainees report discussing OR costs with faculty as opposed to 77.0% of faculty who acknowledge having these conversations (p = 0.08). Both groups showed a strong commitment to reduce OR expenditures, with 87.3% of faculty and 90.0% of trainees expressing a responsibility to curb OR costs (p = 0.84). After 1 year of implementation, faculty continue to have high interest levels in supply receipts (82.4%) and many surgeons review them after each case (67.7%). In addition, 74.3% of faculty are now aware of how to lower OR costs and 52.5% have changed the OR supplies they use. Trainees, in particular, desire additional cost-reducing efforts at our institution (p < 0.001).

CONCLUSIONS

Supply receipts have been well received and have led to meaningful cultural changes. However, trainees are less confident discussing these issues and desire a greater emphasis on OR cost in their curriculum.

Surgeon education through a surgical cost feedback system reduces supply cost in endoscopic skull base surgery

OBJECTIVE

A large proportion of healthcare expense is operating room (OR) costs. As a means of cost mitigation, several institutions have implemented surgeon education programs to bring awareness about supply costs. This study evaluates the impact of a surgical cost feedback system (surgical receipt) on the supply costs of endoscopic skull base surgery (ESBS) procedures.

METHODS

The supply costs of each ESBS surgical case were prospectively collected and analyzed before and after the implementation of a nonincentivized, automated, and itemized weekly surgical receipt system between January 2017 and December 2019. Supply cost data collected 15 months prior to intervention were compared with cost data 21 months after implementation of the surgical receipt system. Demographics, surgical details, and OR time were collected retrospectively.

RESULTS

Of 105 ESBS procedures analyzed, 36 preceded and 69 followed implementation of cost feedback. There were no significant differences in patient age (p = 0.064), sex (p = 0.489), surgical indication (p = 0.389), or OR anesthesia time (p = 0.51) for patients treated before and after implementation. The mean surgical supply cost decreased from $3824.41 to $3010.35 (p = 0.002) after implementation of receipt feedback. Usage of dural sealants (p = 0.043), microfibrillar collagen hemostat (p = 0.007), and oxidized regenerated cellulose hemostat (p < 0.0001) and reconstructive technique (p = 0.031) significantly affected cost. Mediation analysis confirmed that the overall cost reduction was predominantly driven by reduced use of dural sealant; this cost saving exceeded the incremental cost of greater use of packing materials such as microfibrillar collagen hemostat.

CONCLUSIONS

Education of surgeons regarding surgical supply costs by a surgical receipt feedback system can reduce the supply cost per case of ESBS operations.

Optimization of Orthopedic Surgical Instrument Trays: Lean Principles to Reduce Fixed Operating Room Expenses

BACKGROUND

Optimization of surgical instrument trays improves efficiency and reduces cost. The purpose of this study is to assess the economic impact of optimizing orthopedic instrument trays at a tertiary medical center.

METHODS

Twenty-three independent orthopedic surgical instrument trays at a single academic hospital were reviewed from 2017 to 2018. Using Lean methodology, surgeons agreed upon the fewest number of instruments needed for each of the procedure trays. Instrument usage counts, cleaning times, room turnover times, tray weight, holes in tray wrapping, wet trays, and time invested to optimize each tray were tracked. Cost savings were calculated. Student's t-test was used to determine statistical significance, with P < .05 considered significant.

RESULTS

The mean instrument usage before and after Lean optimization was 23.4% and 54.2% (P < .0001). By Lean methods, 433 of 792 instruments (55%) were removed from 11 unique instrument trays (102 total trays), resulting in a reduction of 3520 instruments. Total weight reduction was 574.3 pounds (22%), ranging from 2.1-16.2 pounds per tray. The number of trays with wrapping holes decreased from 13 to 1 (P < .0001). The process of examining and removing instruments took an average of 7 minutes 35 seconds per tray. The calculated total annual savings was $270,976 (20% overall cost reduction).

CONCLUSION

In addition to substantial cost savings, tray optimization decreases tray weights and cleaning times without negatively impacting turnover times. Lean methodology improves efficiency in instrument tray usage, and reduces hospital cost while encouraging surgeon and staff participation through continuous process improvement.

LEVEL OF EVIDENCE

Economic Quality Improvement, Level III.

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.

Hospital variation in mortality after emergent bowel resections: The role of failure-to-rescue

BACKGROUND

Hospital variation in failure-to-rescue (FTR) rates has partially explained nationwide differences in mortality after elective surgeries. To examine the role of FTR among emergency general surgery, we compared nationwide risk-adjusted mortality, complications, and FTR rates after emergent bowel resections.

METHODS

We identified patients who underwent emergent small or large bowel resections in the 2010 to 2011 Nationwide Inpatient Sample using the American Association for the Surgery of Trauma criteria. We then calculated risk-adjusted mortality rates for each hospital using multivariable logistic regressions and postestimation, which adjusted for patient age, sex, race and ethnicity, payer status, comorbidities, and hospital clustering. After excluding hospitals with fewer than 10 resections per year, we ranked the remaining hospitals by their risk-adjusted mortality rates and divided them into five quintiles. We compared both risk-adjusted complication rates and FTR rates between the top (lowest mortality) and bottom (highest mortality) quintiles.

RESULTS

We identified 21,564 emergent bowel resections, weighted to 105,925 procedures nationwide. The bottom quintile of hospitals had an overall risk-adjusted mortality rate that was 10.9 times higher than that of the top quintile of hospitals (15.3% vs. 1.4%). While risk-adjusted complication rates were similarly high for both the bottom and the top quintiles of hospitals (22.5% vs. 15.7%), the risk-adjusted FTR rates were 10.8 times higher in the bottom quintile of hospitals relative to the top quintile of hospitals (33.4% vs. 3.1%). Using larger hospital volume thresholds yielded similar findings. Furthermore, large variations existed in complication-specific FTR rates (surgical site infection [6.6%] to myocardial infarction [29.4%]).

CONCLUSION

Nationwide hospital variation in risk-adjusted mortality rates exist after emergent bowel resections. As complication rates were similar across hospitals, the significantly higher FTR rates at higher-mortality hospitals may drive this variation in mortality. System-level initiatives addressing the management of postoperative complications may improve patient care and reduce variation in outcomes.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, level IV.

Effects of a Surgical Receipt Program on the Supply Costs of Five General Surgery Procedures

BACKGROUND

Surgical supplies occupy a large portion of health care expenditures but is often under the surgeon's control. We sought to assess whether an automated, surgeon-directed, cost feedback system can decrease supply expenditures for five common general surgery procedures.

MATERIALS AND METHODS

An automated "surgical receipt" detailing intraoperative supply costs was generated and emailed to surgeons after each case. We compared the median cost per case for 18 mo before and after implementation of the surgical receipt. We controlled for price fluctuations by applying common per-unit prices in both periods. We also compared the incision time, case length booking accuracy, length of stay, and postoperative occurrences.

RESULTS

Median costs decreased significantly for open inguinal hernia ($433.45 to $385.49, P < 0.001), laparoscopic cholecystectomy ($886.77 to $816.13, P = 0.002), and thyroidectomy ($861.21 to $825.90, P = 0.034). Median costs were unchanged for laparoscopic appendectomy and increased significantly for lumpectomy ($325.67 to $420.53, P < 0.001). There was an increase in incision-to-closure minutes for open inguinal hernia (71 to 75 min, P < 0.001) and laparoscopic cholecystectomy (75 to 96 min, P < 0.001), but a decrease in thyroidectomy (79 to 73 min, P < 0.001). There was an increase in booking accuracy for laparoscopic appendectomy (38.6% to 55.0%, P = 0.001) and thyroidectomy (32.5% to 48.1%, P = 0.001). There were no differences in postoperative occurrence rates and length of stay duration.

CONCLUSIONS

An automated surgeon-directed surgical receipt may be a useful tool to decrease supply costs for certain procedures. However, curtailing surgical supply costs with surgeon-directed cost feedback alone is challenging and a multimodal approach may be necessary.

Variation in Laparoscopic Nephrectomy Surgical Costs: Opportunities for High Value Care Delivery

Introduction

Rising health care costs are leading to efforts to minimize costs while maintaining high quality care. Practice variation in the operating room that is not dictated by patient necessity or clinical guidelines presents an opportunity for cost containment. We identified variation in surgical supply costs among urological surgeons performing laparoscopic nephrectomy and evaluated whether this variation was associated with patient outcomes.

Methods

A total of 211 consecutive laparoscopic nephrectomies performed at an academic center between September 1, 2012 and December 31, 2015 were identified and surgical supply costs for each case were determined from the institutional negotiated rate. Patient and surgical factors relevant to case complexity, comorbidity and perioperative outcomes were obtained. Univariate and multivariable analysis of predictors of surgical supply costs and patient outcome as determined by length of stay was conducted.

Results

Median supply cost was $2,537, with individual medians ranging from $1,642 to $4,524, representing a significant variation among surgeons (p <0.01). On multivariable analysis, accounting for patient factors and case complexity, most surgeons remained significant predictors of surgical supply costs. Case supply cost was not a significant predictor of patient outcomes as measured by length of stay on univariate or multivariable analysis controlling for surgeon, patient factors and case complexity.

Conclusions

Significant variation in surgeons' surgical supply costs for laparoscopic nephrectomy exists and is driven by surgeons, and this does not correlate with length of stay. Targeting variation in surgical supply costs in this setting represents an opportunity for cost savings without adversely impacting patient outcomes.