Will cost transparency in the operating theatre cause surgeons to change their practice?

Price transparency in Iranian healthcare market

Insufficient price transparency has emerged as a pivotal contributor to patient dissatisfaction, escalating costs, and diminished productivity within Iran's health system. This study aims to delineate and elucidate a definition of price transparency, identify suitable strategies, and present the outcomes associated with establishing a health system that embraces transparent pricing while also addressing the challenges ahead. Employing a quantitative-qualitative research design, data were extracted from a semi-structured interviews with stakeholders. A purposive sampling method, encompassing sequential and snowball techniques, was employed to capture the perspectives of all stakeholders involved in the issue of price transparency in Iran. The interview data were analyzed using the grounded theory approach was classified into three categories: price transparency before, during, and after the receipt of healthcare services. Our findings reveal the causes of low price transparency, strategies to address the issue, and the consequences associated with increased levels of transparency. Ultimately, we contend that health systems can significantly enhance efficiency, patient satisfaction, and the performance of health insurance by adopting transparent pricing for health services, thus obviating the need for resource-intensive restructuring efforts.

Lack of Association of Pediatric Surgical Patient Outcomes With Increased Disposable Operating Room Supply Costs

INTRODUCTION

There is wide variation in the cost of disposable operating room supplies between surgeons performing the same operation at the same institution. The general relationship between variation in disposable supply cost and patient outcomes is unknown. We aimed to evaluate the relationship between disposable supply cost and patient outcomes for sixteen common operations.

METHODS

Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For procedure, the median disposable OR costs were calculated. Each operation performed was categorized as low cost (below the group median) or high cost (above the group median. We compared the rates of adverse events (clinic visit within 5 days, 30-day emergency department visit, unplanned reoperation, unplanned readmission, anesthesia complications, prolonged hospital length of stay, need for blood product transfusion, or death) between procedures with low and high disposable supply costs.

RESULTS

1139 operations performed by 48 unique surgeons from five specialties were included; 596 (52%) were low-cost and 543 (48%) high-cost. The low and high-cost groups did not differ regarding most demographic characteristics. Overall, 21.9% of children suffered any adverse outcome; this rate did not differ between the low and high-cost groups when evaluated individually or in aggregate (20.5% vs 23.6%, p = 0.23).

CONCLUSION

Our data demonstrate that across a wide range of pediatric surgical procedures, the cost of disposable operating room supplies was not associated with the risk of adverse outcomes.

LEVEL OF EVIDENCE

Level 3.

Codesign of health technology interventions to support best-practice perioperative care and surgical waitlist management

OBJECTIVES

This project aimed to determine where health technology can support best-practice perioperative care for patients waiting for surgery.

METHODS

An exploratory codesign process used personas and journey mapping in three interprofessional workshops to identify key challenges in perioperative care across four health districts in Sydney, Australia. Through participatory methodology, the research inquiry directly involved perioperative clinicians. In three facilitated workshops, clinician and patient participants codesigned potential digital interventions to support perioperative pathways. Workshop output was coded and thematically analysed, using design principles.

RESULTS

Codesign workshops, involving 51 participants, were conducted October to November 2022. Participants designed seven patient personas, with consumer representatives confirming acceptability and diversity. Interprofessional team members and consumers mapped key clinical moments, feelings and barriers for each persona during a hypothetical perioperative journey. Six key themes were identified: 'preventative care', 'personalised care', 'integrated communication', 'shared decision-making', 'care transitions' and 'partnership'. Twenty potential solutions were proposed, with top priorities a digital dashboard and virtual care coordination.

DISCUSSION

Our findings emphasise the importance of interprofessional collaboration, patient and family engagement and supporting health technology infrastructure. Through user-based codesign, participants identified potential opportunities where health technology could improve system efficiencies and enhance care quality for patients waiting for surgical procedures. The codesign approach embedded users in the development of locally-driven, contextually oriented policies to address current perioperative service challenges, such as prolonged waiting times and care fragmentation.

CONCLUSION

Health technology innovation provides opportunities to improve perioperative care and integrate clinical information. Future research will prototype priority solutions for further implementation and evaluation.

The role of human capital and stress for cost awareness in the healthcare system: a survey among German hospital physicians

BACKGROUND

Germany has the highest per capita health care spending among EU member states, but its hospitals face pressure to generate profits independently due to the government's withdrawal of investment cost coverage. The diagnosis related groups (DRG) payment system was implemented to address the cost issue, challenging hospital physicians to provide services within predefined prices and an economic target corridor to reduce costs. This study examines the extent of cost awareness among medical personnel in German hospitals and its influencing factors.

METHODS

We developed an online survey in which participants across all specialties in hospitals estimated the prices in euros of four common interventions and answered questions about their human capital and perceived stress on the workplace. As a measure of cost awareness, we used the probability of estimating the prices correctly within a reasonable margin. We employed logit logistic regression estimators to identify influencing factors in a sample of 86 participants.

RESULTS

The results revealed that most of the respondents were unaware of the costs of common interventions. General human capital, acquired through prior education, and job-specific human capital had no influence on cost awareness, whereas domain-specific human capital, that is, gaining economic knowledge based on self-interest, had a positive nonlinear effect on cost awareness. Furthermore, an increased stress level negatively influenced cost awareness.

CONCLUSIONS

This paper is the first of its kind for the German health care sector that contributes responses to the question whether health care professionals in German hospitals have cost awareness and if not, what reasons lie behind this lack of knowledge. Our findings show that the cost awareness desired by the introduction of the DRG system has yet to be achieved by medical personnel.

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.

No longer a blank cheque: a narrative scoping review of physician awareness of cost

OBJECTIVES

Healthcare costs have been steadily rising, and attention to cost containment in healthcare systems is increasingly important. It has been previously established that physicians lack adequate awareness of cost in health care and that by increasing awareness, costs can be reduced. This scoping review examines cost awareness of medications, investigations and procedures and identifies potential interventions that may serve to improve physician awareness.

STUDY DESIGN

A scoping review was performed to evaluate the literature based on established Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

A review of electronic databases was performed for studies regarding physician awareness of cost, including PubMed, Embase, Cochrane Central Register of Controlled Trials and Google Scholar.

RESULTS

An initial 4350 citations were identified, and 76 articles were included for full text analysis. Combined, these studies assessed 18,901 physicians. The overwhelming majority (91%) found cost awareness in physicians was low and demonstrated significant room for cost reduction. Eighteen of the 76 studies assessed an intervention to improve physician awareness of cost and used either a price list (89%) or a teaching session (11%) as the primary intervention.

CONCLUSIONS

Research demonstrates that there is still a lack of awareness among physicians of the costs of medications, investigations and procedures/consumables. Initial approaches using price display and teaching sessions have shown promise. Further research into best practices for education around cost, beginning in medical school and continuing into established medical and surgical practices, may lead to increased cost savings in health care.

Variable Accessibility to Consumer Pricing Among Breast Cancer Operations

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) mandate that every US hospital provide public online pricing information for services rendered. This allows patients to compare prices across hospital systems before establishing care. The goal of this project was to evaluate hospital compliance and patient-level accessibility to price transparency for common breast cancer surgical procedures.

METHODS

A sample case of a 62-year-old female with a T2N0 breast cancer was chosen. The patient would have the option of undergoing a partial mastectomy or mastectomy, both with sentinel lymph node biopsy (SLNB). Eight Massachusetts academic medical centers were evaluated. Searches were performed by authors for each hospital system and procedure using the sample case.

RESULTS

Every hospital had a cost calculator on its website. The average success rate of establishing a cost for partial mastectomy, mastectomy, and SLNB was 58, 35, and 25%, respectively. The median time to reach the cost calculator tool was 32 s (range 25-37 s). In successful attempts, the median pre-insurance estimated cost of a partial mastectomy was $16,509 (range $11,776-22,169), compared with $24,541 (range $16,921-25,543) for mastectomy and $12,342 (range $4034-20,644) for SLNB. SLNB costs varied significantly across hospitals (p = 0.025), but no statistically significant difference was observed for partial mastectomy or mastectomy.

CONCLUSION

Despite new regulatory requirements by CMS for increased price transparency for surgical procedures, our results demonstrate poor success rates in obtaining cost estimates and significant variability of reported hospital charges. Further efforts to improve the quality of hospital cost estimate calculators are necessary for informed decision-making for patients with breast cancer.

Variation in cost of disposable operating room supplies at a children's hospital

BACKGROUND

Operating room (OR) costs account for 40% of hospital costs. Disposable supplies make up a portion of OR costs and are the only cost that is under control of the surgeon. There are little data to explain how surgeons select surgical supplies and what factors predict supply selection. Our goal with the current work was to assess variation in cost of disposable OR supplies at the surgeon level, hypothesizing high variability would be observed.

STUDY DESIGN

Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For each procedure, the average disposable OR costs for each surgeon were tabulated and compared to the median supply cost for a given procedure at the group level.

RESULTS

For each procedure, the variation ranged from 149% (gastrostomy tube placement) to 758% (tonsillectomy and adenoidectomy). The median supply cost for an individual surgeon was not always above or below the median supply cost for that procedure for the group. No relationship was observed between whether the supply cost was above or below the median for a given case and a surgeon's case volume, years in practice, or operative length. There was also no relationship between surgeon volume and median cost, surgery length, and years of experience.

CONCLUSION

These data demonstrate variation in the cost of disposable OR supplies at the individual surgeon level at a single institution. This variation is not explained by case volume, years in practice, or operative length.

Operating Room Performance Optimization Metrics: a Systematic Review

Literature proposes numerous initiatives for optimization of the Operating Room (OR). Despite multiple suggested strategies for the optimization of workflow on the OR, its patients and (medical) staff, no uniform description of 'optimization' has been adopted. This makes it difficult to evaluate the proposed optimization strategies. In particular, the metrics used to quantify OR performance are diverse so that assessing the impact of suggested approaches is complex or even impossible. To secure a higher implementation success rate of optimisation strategies in practice we believe OR optimisation and its quantification should be further investigated. We aim to provide an inventory of the metrics and methods used to optimise the OR by the means of a structured literature study. We observe that several aspects of OR performance are unaddressed in literature, and no studies account for possible interactions between metrics of quality and efficiency. We conclude that a systems approach is needed to align metrics across different elements of OR performance, and that the wellbeing of healthcare professionals is underrepresented in current optimisation approaches.

Prediction of Admission Costs Following Anterior Cervical Discectomy and Fusion Utilizing Machine Learning

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Predict cost following anterior cervical discectomy and fusion (ACDF) within the 90-day global period using machine learning models.

BACKGROUND

The incidence of ACDF has been increasing with a disproportionate decrease in reimbursement. As bundled payment models become common, it is imperative to identify factors that impact the cost of care.

MATERIALS AND METHODS

The Nationwide Readmissions Database (NRD) was accessed in 2018 for all primary ACDFs by the International Classification of Diseases 10th Revision (ICD-10) procedure codes. Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics, such as volume of procedures performed and wage index, were also queried. Readmissions within 90 days were identified, and cost of readmissions was added to the total admission cost to represent the 90-day healthcare cost. Machine learning algorithms were used to predict patients with 90-day admission costs >1 SD from the mean.

RESULTS

There were 42,485 procedures included in this investigation with an average age of 57.7±12.3 years with 50.6% males. The average cost of the operative admission was $24,874±25,610, the average cost of readmission was $25,371±11,476, and the average total cost was $26,977±28,947 including readmissions costs. There were 10,624 patients who were categorized as high cost. Wage index, hospital volume, age, and diagnosis-related group severity were most correlated with the total cost of care. Gradient boosting trees algorithm was most predictive of the total cost of care (area under the curve=0.86).

CONCLUSIONS

Bundled payment models utilize wage index and diagnosis-related groups to determine reimbursement of ACDF. However, machine learning algorithms identified additional variables, such as hospital volume, readmission, and patient age, that are also important for determining the cost of care. Machine learning can improve cost-effectiveness and reduce the financial burden placed upon physicians and hospitals by implementing patient-specific reimbursement.

The process of estimating the cost of surgery: Providing a practical framework for surgeons

Over the last decades, health care costs have been increasing at an alarming, exponential rate which is considered unsustainable. Surgical care utilizes one-third of health care costs. Estimating, evaluating, and understanding the cost of surgery is a vital step towards cost management and reduction. Current cost estimation studies and cost-effectiveness studies have vast disparities in their methodology, with published costs of Operating Room varying from as low as $7 and as high as $113 per minute. Costs in surgery are distinguished as direct and indirect. Allocation of direct costs involves identification, measurement, and valuation processes. Allocation of indirect costs involves the allocation of capital and overhead costs and of indirect department costs. Annualised capital costs and overhead hospital costs are then allocated to surgery by either the cost-centre allocation or the activity-based allocation frameworks. Indirect department costs are allocated to a specific surgery by weighted service allocation or hourly rate allocation or inpatient day allocation, or marginal markup allocation. The growing societal, financial and political pressure for cost reduction has brought cost analysis to the forefront of healthcare discussions. Thus, we believe that almost every single surgeon will eventually enter the field of healthcare economics by necessity. This review aims to provide surgeons with a practical framework for engaging in cost estimation studies.

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.

Case costing in spine surgery: Can surgeons assist with accurate capture of operating room costs?

Surgical case costing is critical for health leaders to make decisions about resource utilization. Synoptic reporting offers the potential for surgeons to capture these costs and work with other leaders to make evidence-based decisions. The purpose of this study was to determine whether surgeons documented intra-operative cost drivers as part of their operative report. This article outlines a synoptic reporting system at a quaternary spine care centre. Data were captured from 2015 to 2020. Surgeon rates of documentation for specific devices, bone graft, and surgical adjuncts were evaluated. It is hoped that the results of this survey will help to guide programs to capture costs in other settings.

Surgeon cost feedback through a surgical receipt program reduces cost in sinonasal surgery

BACKGROUND

Operating room (OR) costs are a large portion of healthcare expenses. This study evaluates the impact of a surgeon-targeted surgical receipt cost feedback system on OR supply costs in sinonasal surgery and individual components contributing to procedural cost.

METHODS

Itemized weekly surgical receipts detailing individual case supply costs were analyzed before and after the implementation of a non-incentivized surgeon cost feedback system between January 2017 and June 2019. Supply cost data collected 15 months prior to intervention was compared to cost data 15 months after implementation of the weekly automated receipt dissemination to surgeons. Chi square test was used for categorical data and the Wilcoxon test was used to compare change in cost. Univariate and mediation analyses were performed to assess variables impacting cost.

RESULTS

Of 502 sinonasal procedures analyzed, 239 were before and 264 after cost feedback implementation. There were no significant differences in age/gender, or indication for surgery. The median OR supply cost decreased from $1229.64 to $1097.22 (p = 0.02) after receipt implementation. There were effects of procedure type (p = 0.02), circulating nurse specialization (p < 0.001), steroid eluting stent (p = 0.002), and sinus drill (p < 0.001) on cost. Mediation analysis confirmed full mediation by decreasing use of steroid-eluting stents.

CONCLUSION

Surgeon cost feedback in the form of individualized OR surgical receipts is an effective model to reduce supply cost per case in sinonasal surgery.

Cost Awareness of Common Supplies Is Severely Impaired Among All Members of the Surgical Team

BACKGROUND

Increased health care spending concerns have generated interest in reducing operating room (OR) costs, but the cost awareness of the surgical team selecting intraoperative supplies remains unclear. This work characterizes knowledge of supply cost among surgeons and OR staff in a large academic hospital and seeks to examine the role of experience and training with regards to cost insight.

METHODS

This work is a cross-sectional study of surgeons, trainees, nurses, and surgical technicians (n = 372) across all surgical specialties at a large academic hospital. Participants completed a survey reporting frequency of use and estimated cost for 11 common surgical supplies as well as opinions on access to cost information in the OR. Cost estimation error was expressed as the ratio of estimated-to-actual cost, and groups were compared with one-way analysis of variance and chi-squared testing. Spearman correlation (ρ) was used to describe the relationship between monotonic variables.

RESULTS

Overestimation error was universal and ranged widely (3.80-49.79). There was no significant difference in estimation accuracy when stratified by role or years of experience. Less expensive items had higher rates of estimation error than more expensive items (P < 0.001), and a moderately strong relationship was found between decreased item cost and increased estimation error (ρ: 0.49). The overwhelming majority (91%) of respondents expressed a desire to learn more about supply pricing.

CONCLUSIONS

Price knowledge of common supplies is globally impaired for entire surgical team but coexists with a strong desire to augment cost awareness. Improved access to cost information has a high potential to inform surgical decision-making and decrease OR waste.

Surgical instrument standardization - A pilot cost consciousness curriculum for surgery residents

INTRODUCTION

Surgical cost is astronomical in the US and instrument standardization is one potential mechanism for cost savings. This study describes a core competency based, multidisciplinary curriculum and evaluates resident attitudes towards operating room equipment standardization.

MATERIALS AND METHODS

As part of a quality improvement initiative, surgery residents participated in an hour-long mixed curriculum consisting of brief didactics and small group exercises. Participants developed an equipment standardization plan for laparoscopic appendectomy and cholecystectomy. Participants also completed surveys to assess their attitudes towards 11 potential barriers to implementation as "improves, no change, or worsens".

RESULTS

Fifteen general surgery residents participated. In general, participants felt that standardization improves or does not change metrics including surgeon autonomy, resident training experience, and patient safety.

CONCLUSION

Our pilot curriculum addresses a gap in resident education about surgical cost. Residents generally regard equipment standardization as either improving or not changing hospital metrics.