Campaign for Laparoscopic Hysterectomy Change the Use and Costs of Disposable Surgical Supplies? Pre–Post Non-Controlled Study
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Open access Original research BMJ Open: first published as 10.1136/bmjopen-2018-027099 on 11 December 2019. Downloaded from Can a simple ‘cost- awareness’ campaign for laparoscopic hysterectomy change the use and costs of disposable surgical supplies? Pre–post non-controlled study Sue Ross ,1 Douglas Lier,1 Goldie Mackinnon,1 Christine Bentz,1 Gloria Rakowski,2 Valerie A Capstick1 To cite: Ross S, Lier D, ABSTRACT Strengths and limitations of this study Mackinnon G, et al. Can a Objectives Does a cost- awareness campaign for simple ‘cost- awareness’ gynaecologists lead to a change in use and costs of ► Our study investigated disposable surgical supply campaign for laparoscopic disposable surgical supplies for laparoscopic hysterectomy hysterectomy change the costs before and after the implementation of a cost- (LH) without increasing hospital utilisation measures use and costs of disposable awareness campaign for gynaecologists who carry (operating room (OR) time or hospital length of stay (LOS))? surgical supplies? Pre–post out laparoscopic hysterectomy: this work adds to Design Pre–post non- controlled study. The OR database non- controlled study. BMJ Open the surgical literature in which net costs are rarely was used to identify relevant cases before and after the 2019;9:e027099. doi:10.1136/ evaluated. bmjopen-2018-027099 cost- awareness intervention, and provided information on ► The cost- awareness intervention was a strength— quantity of each supply item, operative details and LOS. Prepublication history and the intervention incorporated several strategies in- ► Setting Lois Hole Hospital for Women, Edmonton, Alberta, additional material for this cluding a skills lab, and operating room (OR) posters Canada. paper are available online. To and equipment demonstrations. Participants 12 laparoscopic trained gynaecologists (7 view these files, please visit ► The main outcomes were cost per case of dispos- female, 5 male) participated in both phases of the study. the journal online (http:// dx. doi. able surgical supplies (all costs standardised to mid- Eligible surgical cases were all LH cases for any indication org/ 10. 1136/ bmjopen- 2018- 2016 to avoid impact of unit cost changes over time) 027099). for women aged ≥18 years. 201 cases were undertaken and hospital utilisation measures (OR time or hospi- before the intervention (2011–2013) and 229 cases after tal length of stay) during the index admission, for the Received 20 October 2018 the intervention (2016–2017). cohorts of patients before and after the intervention. Revised 23 October 2019 Intervention The cost- awareness intervention for Accepted 14 November 2019 ► Data were recorded in ‘real- time’ in the same OR gynaecologists included site meetings and rounds http://bmjopen.bmj.com/ database before and after the intervention—data providing information on costs of disposable and reusable were complete for surgical details and devices used. instruments, a full day skills lab, OR posters about cost and ► Limitations were lack of a control group of patients effectiveness of disposable and reusable surgical supplies and data were available only for index admission— and demonstrations of reusable equipment (2015–2016). longer-term follow-up was not available. Primary outcome measure Disposable supplies costs per case (standardised for 2016 unit costs). Results There was a significant (p<0.05) reduction 1 (unadjusted) in disposable supplies cost per case for LH of resources, physicians are increasingly between cases before and after the intervention: from expected to take on an additional role as on October 1, 2021 by guest. Protected copyright. $C1073, SD 281, to $C943 SD 209. Regression analysis guardians of resources.2 3 This role has even found that the adjusted cost per case after the intervention been incorporated into physician training,4 © Author(s) (or their was $C116 lower than before the intervention (95% CI and physicians are encouraged to be aware of employer(s)) 2019. Re- use −160 to −71). Neither OR time nor hospital LOS differed permitted under CC BY-NC. No the costs of treatment options so that they can significantly between cohorts. 2 commercial re- use. See rights provide cost-effective and safe treatments. Our study suggests that cost- awareness and permissions. Published by Conclusions Despite these expectations, awareness of campaigns may be associated with reduction in the cost BMJ. healthcare costs is poor in a variety of surgical 1 of surgery for LH. However, many other factors may have Obstetrics and Gynecology, disciplines including gynaecology,5–7 with University of Alberta, Edmonton, contributed to this cost reduction, possibly including other local initiatives to reduce costs and emerging evidence physicians consistently underestimating the Alberta, Canada 8–10 2Women's Health, Lois Hole indicating lack of effectiveness of some surgical practices. cost of more expensive items. Hospital for Women, Alberta Published research has demonstrated that Health Services, Edmonton, two types of intervention can reduce intra- Alberta, Canada INTRODUCTION operative costs. One effective intervention Correspondence to Given increasing financial constraints in reduces costs by increasing standardisation 11 Dr Sue Ross; sjross@ ualberta. ca healthcare systems worldwide, with growing of operative supplies. Providing physician concerns about responsible stewardship feedback on their own operating room (OR) Ross S, et al. BMJ Open 2019;9:e027099. doi:10.1136/bmjopen-2018-027099 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-027099 on 11 December 2019. Downloaded from costs compared with their peers has also been found collected on supply item use for each patient throughout effective.11 Increasing individual surgeon cost-awareness the time they were in the OR including details about is also an intervention that could be adopted locally. the type and number of each supply item used for that At the Lois Hole Hospital for Women (LHHW), a specific patient. This ‘point of use’ data entry formed part major acute care hospital in Edmonton, Canada, varia- of the OR supply management and control system, and tions in OR surgical costs were observed specifically for ensured that the data were as complete and accurate as laparoscopic hysterectomy (LH). This procedure became possible for the purpose of this research. The database the most common approach for hysterectomy because of also identified the type of hysterectomy performed, and perceived advantages such as excellent patient outcomes, other procedure- related information including OR time. earlier return to normal activities, shorter hospital stays In addition, patient- specific data were collected from and fewer wound infections.12–14 As well, increasing avail- hospital charts, for example: age, body mass index (BMI) ability of training in minimally invasive surgery accounted and data related to previous pregnancies and births, for growth in the number of laparoscopic gynaecologists, and hospital LOS of the index admission. Measures with 12 (of 18) gynaecologists performing LH by 2011. of hospital utilisation were OR time and hospital LOS. Consequently, the number of LHs also increased each year, Patient follow- up was to the time of hospital discharge. from 40 cases in 2008 to ~90 LH in 2013. Some LHHW Data collection before and after the intervention was surgeons favoured disposable laparoscopic instruments, approved by the University of Alberta Health Research while others preferred reusable instruments, resulting in Ethics Board (HREB) and the consent of participating variation in OR supply costs, perhaps as a result of lack physicians (the research subjects) was obtained. The of standardisation and lack of physician awareness of HREB provided a waiver of consent for individual patients costs. We hypothesised that a cost- awareness campaign on the basis that it would be impractical to collect indi- for LH incorporating exposure to reusable instruments vidual patient consent for this study. Strict data confiden- may influence gynaecologists’ choice of instruments and tiality practices were implemented in accordance with the could reduce the costs of LH. Alberta Health Information Act. Research question Surgeon participants and surgical cases Does a cost- awareness campaign for gynaecologists lead to To reduce any impact of a learning curve on the study a change in use and costs of disposable surgical supplies outcomes, only surgeons trained in laparoscopic surgical for LH without increasing hospital utilisation measures techniques, and who had undertaken four or more LH in (OR time or hospital length of stay (LOS))? the year before the intervention were invited to take part in the study. The 12 eligible surgeons who performed LH during the periods before and after the intervention all METHODS gave consent to use data related to their practice. We used a pre and post non-controlled study design, based All surgery was performed in the LHHW Women’s http://bmjopen.bmj.com/ on two non- concurrent retrospective cohorts of surgical OR suite. The eligibility criteria for cases included: all cases undertaken by eligible surgeons who consented to women aged ≥18 years having a LH for any indication participate, to study the impact of a cost- awareness inter- and all types of LH procedures. Only cases starting as vention campaign at LHHW. Surgical cases completed LH were eligible, including total laparoscopic hysterec- between January 2011 and August 2013 comprised the tomy (TLH), subtotal laparoscopic