‘Highly implementable’ price sheet strategy sparks cost reduction in vascular procedures

Drew Goldberg

A simple cost reduction strategy implemented among providers in an academic vascular surgery practice yielded data demonstrating sometimes significant cost savings—in the case of common femoral endarterectomy of nearly 70%.

The researchers behind the study found significant savings made across a composite of open vascular procedures in three areas—total supply and implant cost (-17.5%; p=0.008), supply cost (-2%; p=0.049), and total cost per minute (-28.2%; p=0.015)—across the 2105–2018 study period.

Findings from the study were delivered by Drew Goldberg, MD, a general surgery resident at the Hospital of the University of Pennsylvania in Philadelphia during a scientific session at the Society for Clinical Vascular Surgery (SCVS) Annual Symposium in Miami (March 13–17).

Goldberg and colleagues set out to assess whether preoperatively distributing a surgical supply cost sheet could both increase financial awareness among surgeons and reduce overall cost.

“Surgical care comprises of approximately 30% of the expanding and growing healthcare costs in today’s economy,” Goldberg told the hybrid SCVS gathering. “Unsurprisingly, vascular surgery contributes significantly to this expenditure as its patients are a cohort of increasing age, comorbidities, complexity of operation, need for reoperations and use of relatively expensive devices.”

Goldberg noted that various vascular surgery groups had assessed cost-saving strategies in the vascular surgery domain, highlighting the need for novel methods to mitigate costs.

Cost calculation

The research team’s retrospective analysis recorded supply and implant costs both before and after the study period, with total operative cost defined as the accumulated implant and supply costs during a procedure.

“We assessed total implant and disposable supply cost, supply cost alone, and cost per time. Cost was analyzed over two periods: the 24 months prior to the tool implementation and 24 months following with a 1-month washout,” Goldberg explained.

From the 1,372 included procedures, the authors found varying numbers for each, with the highest being carotid endarterectomy, common femoral endarterectomy, and combined endovascular aneurysm repairs (EVARs) and thoracic endovascular aneurysm repairs (TEVARs).

The data showed that greatest total operative costs reductions during the study period were recorded for common femoral endarterectomy (-68.6%; p= 0.0107), abdominal aortic aneurysm (AAA) repair (-17%; p=0.037), and carotid endarterectomy (-10.3%; p= 0.012).

“The total supply cost alone—which is important to assess because of the dilutional effects of expensive device implant cost—demonstrated significant decreasing costs for common femoral endarterectomy, with a cost change of 42% [p<0.0001],” Goldberg said. “Interestingly, temporal artery biopsy saw a two-fold increase, which was also significant [99.5%; p=0.0003].”

In terms of cost per time, which Goldberg identified as “an important standardization for differences in complexity of procedures,” data similarly showed significant decreases for carotid endarterectomy (-8.9%; p=0.001), AAA repair (-16.2%; p=0.019), and carotid-subclavian bypass grafting (-9.9%), with a “trend toward significance” for common femoral endarterectomy (-41.2%; p=0.06). Additionally, Goldberg et al recorded non-significant cost reductions for arteriovenous grafting and rib resections. Relative price increases of 31%, 8% and 3% were calculated for temporal artery biopsy, vein transposition and distal bypass, respectively.

Meanwhile, the research team discovered large total operative cost increases with minimal changes in supply cost, and non-significant changes in cost per time, for a composite of all endovascular procedures (EVARs and TEVARs).

“We demonstrate that a low-cost, highly implementable cost sheet is effective at reducing cost in vascular surgery,” Goldberg concluded. “Further investigations should assess how and why surgeons choose supplies and implants in order to target further intraoperative cost savings.”

Under scrutiny

Moderating the session, Johann M. Lohr, MD, a general and vascular surgeon at Wm. Jennings Bryan Dorn VA Medical Center in Columbia, South Carolina, asked Goldberg how the study findings had changed practice at his institution.

“Feedback at the attending level was that in seeing the cost of some of the more routinely used devices, attendings were no longer having scrub techs open certain things—like wires, rubber shots, things of that nature—and it was driving costs down,” he revealed. “There is certainly a behavioral effect to be cognizant of the prices of each of these, not only the expensive devices, but the cheaper disposable items intraopertively.”

Alan Lumsden, MD, medical director at Houston Methodist DeBakey Heart and Vascular Center at The Methodist Hospital, Houston, asked whether the cost data was available in real-time or after completion of procedures. “Because I really want to know real-time, when I pull a guidewire off the shelf, how much it costs,” he elaborated. “I don’t really see why that information is not available to us.”

Goldberg responded: “With the integration of the electronic health record, with the ORs [operating rooms] today, the way that it works is when a device is used or opened, it gets scanned, and at that point it gets registered in the electronic health record, then after the fact, after the case, there’s a cost sheet that’s generated, so that an attending or a surgeon can review that, and then have that knowledge for the next case. That’s how it would be implemented in a prospective manner.”


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