An analysis of surgical and nonsurgical operating room times in high-volume shoulder arthroplasty

Specific Factors Affecting Operating Room Efficiency: An Analysis of Case Time Estimates

PURPOSE

Operating room (OR) efficiency has an impact on surgeon productivity and patient experience. Accuracy of case duration estimation is important to optimize OR efficiency. The purpose of this study was to identify factors associated with inaccurate case time estimates in outpatient hand surgery. A better understanding of these findings may help to improve OR efficiency and scheduling.

METHODS

All outpatient hand surgical cases from 2018 to 2019 were reviewed. Poorly-estimated cases (i.e., poor scheduling accuracy) were defined as those cases where the actual operative time differed from the predicted time by >50% (either quicker by >50% or slower by >50% than the predicted time). The percentages of poorly-estimated cases were analyzed, categorized, and compared by surgeon, procedure type, and scheduled case length.

RESULTS

A total of 6,620 cases were identified. Of 1,107 (16.7%) cases with poorly estimated case durations, 75.2% were underestimated. There was no difference in the likelihood of poor estimation related to start time. Well-estimated cases tended to have longer scheduled case duration, but shorter realized case duration and surgical time. Our systems analysis identified specific surgeons and procedures as predictable outliers. Cases scheduled for 15-30 minutes frequently were inaccurate, whereas cases scheduled for 30-45 and 106-120 minutes had accurate estimates.

CONCLUSIONS

The accuracy of case time estimations in a standard outpatient hand surgery practice is highly variable. Nearly one-fifth of outpatient hand surgery case durations are poorly estimated, and inaccurate case time estimation can be predicted based on surgeon, procedure type, and case time.

CLINICAL RELEVANCE

Maximizing OR efficiency should be a priority for surgeons and hospital systems. With multiple surgeries done per day, the efficiency of the OR has an impact on surgeon productivity and patient experience.

Are Orthopaedic Trauma Surgeons Appropriately Compensated for Treating Acetabular Fractures? An Analysis of Operative Times and Relative Value Units

OBJECTIVES

To evaluate the work relative value units (RVUs) attributed per minute of operative time (wRVU/min) in fixation of acetabular fractures, evaluate surgical factors that influence wRVU/min, and compare wRVU/min with other procedures.

METHODS

DESIGN

Retrospective.

SETTING

Level 1 academic center.

PATIENT SELECTION CRITERIA

Two hundred fifty-one operative acetabular fractures (62 A, B, C) from 2015 to 2021.

OUTCOME MEASURES AND COMPARISONS

Work relative value unit per minute of operative time for each acetabular current procedural terminology (CPT) code. Surgical approach, patient positioning, total room time, and surgeon experience were collected. Comparison wRVU/min were collected from the literature.

RESULTS

The mean wRVU per surgical minute for each CPT code was (1) CPT 27226 (isolated wall fracture): 0.091 wRVU/min, (2) CPT 27227 (isolated column or transverse fracture): 0.120 wRVU/min, and (3) CPT 27228 (associated fracture types): 0.120 wRVU/min. Of fractures with single approaches, anterior approaches generated the least wRVU/min (0.091 wRVU/min, P = 0.0001). Average nonsurgical room time was 82.1 minutes. Surgeon experience ranged from 3 to 26 years with operative time decreasing as surgeon experience increased ( P = 0.03). As a comparison, the wRVU/min for primary and revision hip arthroplasty have been reported as 0.26 and 0.249 wRVU/min, respectively.

CONCLUSIONS

The wRVUs allocated per minute of operative time for acetabular fractures is less than half of other reported hip procedures and lowest for isolated wall fractures. There was a significant amount of nonsurgical room time that should be accounted for in compensation models. This information should be used to ensure that orthopaedic trauma surgeons are being appropriately supported for managing these fractures.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Trends in operative duration of total shoulder arthroplasty from 2008 to 2018: a national database study

Background

As total shoulder arthroplasty has emerged as the fastest growing joint replacement performed, optimizing surgical efficiency and patient outcomes is essential. The goals of the current study were to identify trends and factors affecting the operative time of total shoulder arthroplasty over a 10-year period.

Methods

The National Surgical Quality Improvement Program database was analyzed to determine the operative time and 30-day complications of total shoulder arthroplasty from 2008 to 2018. Factors affecting total shoulder arthroplasty operative time were also assessed. Multivariable linear regression was used to analyze operative time over years studied while controlling for patient demographics and comorbidities.

Results

A total of 20,587 total shoulder arthroplasty cases from 2008 to 2018 were included. Mean operative time in 2008 was 139.0 min, while in 2018, mean operative time decreased to 105.6 min (P < .001). Male sex, outpatient surgery, increased body mass index, and low preoperative hematocrit were associated with longer operative times, while elevated international normalized ratio, resident involvement, and elective surgeries were associated with decreased operative duration.

Discussion

Operative time for total shoulder arthroplasty has decreased from 2008 to 2018. Patient factors and comorbidities are associated with operative time, and such factors are important to consider in operative planning to ensure appropriate patient and surgeon expectations.

The effect of overlapping surgical scheduling on operating theatre productivity: a narrative review

This article reviews the background to overlapping surgery, in which a single senior surgeon operates across two parallel operating theatres; anaesthesia is induced and surgery commenced by junior surgeons in the second operating theatre while the lead surgeon completes the operation in the first. We assess whether there is any theoretical basis to expect increased productivity in terms of number of operations completed. A review of observational studies found that while there is a perception of increased surgical output for one surgeon, there is no evidence of increased productivity compared with two surgeons working in parallel. There is potential for overlapping surgery to have some positive impact in situations where turnover times between cases are long, operations are short (<2 h) and where 'critical portions' of surgery constitute about half of the total operation time. However, any advantages must be balanced against safety, ethical and training concerns.

Development of a decision analytical framework to prioritise operating room capacity: lessons learnt from an empirical example on delayed elective surgeries during the COVID-19 pandemic in a hospital in the Netherlands

OBJECTIVE

To develop a prioritisation framework to support priority setting for elective surgeries after COVID-19 based on the impact on patient well-being and cost.

DESIGN

We developed decision analytical models to estimate the consequences of delayed elective surgical procedures (eg, total hip replacement, bariatric surgery or septoplasty).

SETTING

The framework was applied to a large hospital in the Netherlands.

OUTCOME MEASURES

Quality measures impacts on quality of life and costs were taken into account and combined to calculate net monetary losses per week delay, which quantifies the total loss for society expressed in monetary terms. Net monetary losses were weighted by operating times.

RESULTS

We studied 13 common elective procedures from four specialties. Highest loss in quality of life due to delayed surgery was found for total hip replacement (utility loss of 0.27, ie, 99 days lost in perfect health); the lowest for arthroscopic partial meniscectomy (utility loss of 0.05, ie, 18 days lost in perfect health). Costs of surgical delay per patient were highest for bariatric surgery (€31/pp per week) and lowest for arthroscopic partial meniscectomy (-€2/pp per week). Weighted by operating room (OR) time bariatric surgery provides most value (€1.19/pp per OR minute) and arthroscopic partial meniscectomy provides the least value (€0.34/pp per OR minute). In a large hospital the net monetary loss due to prolonged waiting times was €700 840 after the first COVID-19 wave, an increase of 506% compared with the year before.

CONCLUSIONS

This surgical prioritisation framework can be tailored to specific centres and countries to support priority setting for delayed elective operations during and after the COVID-19 pandemic, both in and between surgical disciplines. In the long-term, the framework can contribute to the efficient distribution of OR time and will therefore add to the discussion on appropriate use of healthcare budgets. The online framework can be accessed via: https://stanwijn.shinyapps.io/priORitize/.

Resource evaluation framework for total knee arthroplasty

PURPOSE

This article describes a framework for evaluating efficiency of OR procedures incorporating time measurement, personnel activity, and resource utilization using traditional industrial engineering tools of time study and work sampling.

METHODS

The framework measures time using time studies of OR procedures and work sampling of personnel activities, ultimately classified as value-added or non-value-added. Statistical methods ensure that the collected samples meet adequate levels of confidence and accuracy. Resource utilization is captured through documentation of instrument trays used, defects in instruments, and trash weight and classification at the conclusion of surgeries.

FINDINGS

A case study comprising 12 observations of total knee arthroplasty surgeries illustrates the use of the framework. The framework allows researchers to compare time, personnel, and resource utilization simultaneously within the OR setting.

PRACTICAL IMPLICATIONS

The framework provides a holistic evaluation of methods, instrumentation and resources, and staffing levels and allows researchers to identify areas for efficiency improvement.

ORIGINALITY/VALUE

The methods presented in this article are rooted in traditional industrial engineering work measurement methods but are applied to a healthcare setting in order to efficiently identify areas for improvement including time, personnel, and processes in operating rooms.

Preparatory Time-Related Hand Surgery Operating Room Inefficiency: A Systems Analysis

Background: No study exists on preparatory time-from patient's entrance into the operating room to skin incision-and its role in hand surgery operating room inefficiency. The purpose of this study was to investigate the length and variability of preparatory time and assess the relationship between several variables and preparatory time. Methods: Consecutive upper extremity cases performed for a period of 1 month by hand surgeons were reviewed at 3 surgical sites. Preparatory time was compared across locations. Cases at one location were further analyzed to assess the relationship between preparatory time and several variables. Both traditional statistical methods and Shewhart control charts, a quality control tool, were used for data analysis. Results: A total of 288 cases were performed. The mean preparatory times at the 3 sites were 25.1, 25.7, and 20.7 minutes, respectivley. Aggregated preparatory time averaged 24.4 (range 7-61) minutes, was 75% the length of the surgical time, and accounted for 34% of total operating room time. Control charts confirmed substantial variability at all locations, signifying a poorly defined process. At a single site, where 189 cases were performed by 14 different surgeons, there was no difference in preparatory time by case type, American Society of Anesthesiologists status, or case start time. Preparatory time varied by surgeon and anesthesia type. Conclusions: Preparatory time was found to be a source of inefficiency, independent of the surgical site. Control charts reinforced large variations, signifying a poorly designed process. Surgeon seemingly plays an important, albeit likely indirect, role. Efforts to improve operating room workflow should include preparatory time.

Barriers to Revision Total Hip Service Lines: A Surgeon's Perspective Through a Deterministic Financial Model

BACKGROUND

Revision THA represents approximately 5% to 10% of all THAs. Despite the complexity of these procedures, revision arthroplasty service lines are generally absent even at high-volume orthopaedic centers. We wanted to evaluate whether financial compensation is a barrier for the development of revision THA service lines as assessed by RVUs.

QUESTIONS/PURPOSES

Therefore, we asked: (1) Are physicians fairly compensated for revision THA on a per-minute basis compared with primary THA? (2) Are physicians fairly compensated for revision THA on a per-day basis compared with primary THA?

METHODS

Our deterministic financial model was derived from retrospective data of all patients undergoing primary or revision THA between January 2016 and June 2018 at an academic healthcare organization. Patients were divided into five cohorts based on their surgical procedure: primary THA, head and liner exchange, acetabular component revision THA, femoral component revision THA, and combined femoral and acetabular component revision THA. Mean surgical times were calculated for each cohort, and each cohort was assigned a relative value unit (RVU) derived from the 2018 Center for Medicaid and Medicare assigned RVU fee schedule. Using a combination of mean surgical time and RVUs rewarded for each procedure, three models were developed to assess the financial incentive to perform THA services for each cohort. These models included: (1) RVUs earned per the mean surgical time, (2) RVUs earned for a single operating room for a full day of THAs, and (3) RVUs earned for two operating rooms for a full day of primary THAs versus a single rooms for a full day of revision THAs. A sixth cohort was added in the latter two models to more accurately reflect the variety in a typical surgical day. This consisted of a blend of revision THAs: one acetabular, one femoral, and one full revision. The RVUs generated in each model were compared across the cohorts.

RESULTS

Compared with primary THA by RVU per minute, in revision THA, head and liner exchange demonstrated a 4% per minute deficit, acetabular component revision demonstrated a 29% deficit, femoral component revision demonstrated a 32% deficit, and full revision demonstrated a 27% deficit. Compared with primary service lines with one room, revision surgeons with a variety of revision THA surgeries lost 26% potential relative value units per day. Compared with a two-room primary THA service, revision surgeons lost 55% potential relative value units per day.

CONCLUSIONS

In a comparison of relative value units of a typical two-room primary THA service line versus those of a dedicated revision THA service line, we found that revision specialists may lose between 28% and 55% of their RVU earnings. The current Centers for Medicare and Medicaid Services reimbursement model is not viable for the arthroplasty surgeon and limits patient access to revision THA specialists.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

Sex differences in complications and readmission rates following shoulder arthroplasty in the United States

Introduction

Shoulder arthroplasty (SA) procedures are increasingly performed in the United States. However, there is a lack of data evaluating how patient sex may affect perioperative complications. The purpose of this study was to evaluate sex-based differences in 30-day postoperative complication and readmission rates after SA.

Methods

Total SA and reverse SA cases between 2012-2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. The 30-day complication rate, readmission rate, operation time, length of stay, and mortality were compared between women and men. Multivariable logistic regression analysis was performed to identify independent perioperative complications associated with patient sex.

Results

Of 12,530 SA cases, 6949 (55.4%) were female and 5499 (44.5%) were male. Compared with women, on average men were significantly younger, had lower body mass index, and were less likely to be functionally dependent, and less likely to have an American Society of Anesthesiologists score of 3+ (P < .001). Although overall complications and readmission rates between women and men were similar (3.4% vs. 3.7%, P = .489; 3.0% vs. 2.8%, P = .497), men were significantly less likely to develop urinary tract infections (UTIs; odds ratio [OR] 0.58, P = .032) and require transfusions (OR 0.49, P < .001) and had shorter lengths of stay (P < .001). However, men were significantly more likely to have a superficial surgical site infection (OR 2.63, P = .035) and 6.8 minute longer operating time (P < .001) compared with women.

Conclusion

Though the overall complication risk is similar between the sexes, their risk profiles are distinct. Men had decreased risk of UTI, blood transfusions, and shorter length of stay but increased risk of surgical site and longer operating time compared with women. This disparity should be discussed when counseling and risk-stratifying patients for SA.

The effect of an orthopedic specialty hospital on operating room efficiency in shoulder arthroplasty

BACKGROUND

Operating room (OR) time is a major cost to the health care system. Therefore, increasing OR efficiency to save time may be a cost-saving tool. This study analyzed OR efficiency in shoulder arthroplasty at an orthopedic specialty hospital (OSH) and a tertiary referral center (TRC).

METHODS

All primary shoulder arthroplasties performed at our OSH and TRC were identified (2013-2015). Manually matched cohorts from the OSH and TRC were compared for OR times. Three times (minutes) were recorded: anesthesia preparation time (APT; patient in room to skin incision), surgical time (ST; skin incision to skin closed), conclusion time (CT; skin closed to patient out of room).

RESULTS

There were 136 primary shoulder arthroplasties performed at the OSH and matched with 136 at the TRC. OSH and TRC patients were similar in age (P = .95), body mass index (P = .97), Charlson Comorbidity Index (P = 1.000), sex (P = 1.000), procedure (P = 1.000), insurance status (P = .714), discharge destination (P = .287), and diagnoses (P = .354). These matched populations had similar ST (OSH: 110.0 ± 26.6 minutes, TRC: 113.4 ± 28.7 minutes; P = .307). APT (39.2 ± 8.0 minutes) and CT (7.6 ± 3.8 minutes) were shorter in the OSH patients than APT (46.3 ± 8.8 minutes; P < .001) and CT (11.2 ± 4.7 minutes; P < .001) in TRC patients. Total nonoperative time (sum of APT and CT) at the OSH (46.8 ± 8.9 minutes) was shorter than at the TRC (57.5 ± 10.4 minutes; P < .001).

CONCLUSIONS

Despite similar patient populations and case complexity, the OR efficiency at an OSH was superior to a TRC. Further analysis is needed to determine the financial implications of this superior OR efficiency.

The Volume-Value Relationship in Shoulder Arthroplasty

Improving value in shoulder arthroplasty has gained increasing importance as procedure volume increases. To enhance the value of shoulder arthroplasty, an improvement of outcomes or a decrease in associated costs must occur. With the recent shift to a value-based care delivery model, analysis of the effects of surgical volume presents an opportunity to improve outcomes and reduce costs in shoulder arthroplasty. There are multiple reports in the literature expanding on the relationship between increased surgeon and hospital procedure volume and increased value for shoulder arthroplasty, by way of improved outcomes or decreased cost. This article highlights these studies.