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Central Surgical Association

49th Annual Meeting

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Value Improvement Initiatives in Thoracic Surgery: Impact of Cost Awareness Education and Surgeon-Led Positive Deviance to Reduce Intraoperative Costs of Thoracoscopic Lobectomy
Richard Liu2, Elisa Chand2, Biniam Kidane2, Sadeesh Srinathan2, Larry Tan2, Gordon Buduhan1
1Surgery, University British Columbia, Kelowna, British Columbia, Canada, 2Surgery, University of Manitoba, Winnipeg, Manitoba, Canada

Purpose
The use of disposable instruments during video-assisted thoracoscopic (VATS) lobectomy is a significant driver of hospital cost. As a novel approach to influence surgeon behavior and reduce intraoperative expenditure, we implemented a successive series of “value improvement initiatives" (VIIs): 1) posting of disposable instruments price list in operating room (OR); 2) educational presentation on intraoperative costs; 3) surgeon self-assessment with peer comparison followed by positive deviance seminar. The purpose of the study was to measure the impact of each successive VII in terms of cost reduction.

Methods
We prospectively collected disposable instrument usage data for all VATS lobectomies performed by 5 Board-certified thoracic surgeons in a single center academic teaching hospital. Four successive time periods / cohorts were analyzed: Period 1: Control group of consecutive VATS lobectomies performed prior to VIIs; Period 2: VATS lobectomies performed after displaying disposables price list in OR; Period 3: VATS lobectomies performed after educational slideshow presentation outlining disposable instrument price differences and cost reduction strategies given to thoracic surgeons; Period 4: VATS lobectomies performed following surgeon self-assessment of individual case costs with peer comparison of -per case cost data from Period 3, followed by positive deviance group seminar identifying the surgeon with the lowest median case costs to lead discussion of cost reduction strategies. A total of 375 lobectomy cases were analyzed over the 4 time periods. VATS lobectomy per-case costs were compared between the 4 groups using Kruskal-Wallis test. All monetary amounts were in Canadian dollars.

Results
Compared to Period 1, median stapler-related and total disposable instrument costs for VATS lobectomy cases decreased significantly following each successive VII, with lowest median per-case costs in Period 4 following surgeon self-assessment, peer comparison and positive deviance seminar (p<.0001; see Tables 1,2). Multiple linear regression analysis demonstrated highest -per lobectomy disposables cost reduction of $397.53 in Period 4, after controlling for individual surgeon and anatomic lobe (p<.0001). OR time was also significantly reduced following successive VIIs compared to Period 1 (p<.0001; see Figure 1).

Conclusion
A series of successive VIIs was associated with significant per-case cost reduction for VATS lobectomies. Surgeon self-assessment of individual aggregate case costs with peer comparison and positive deviance seminar was associated with the largest reduction in case costs. Further study is needed to assess the durability of cost savings over time. Significant cumulative cost savings may be realized through surgeon-led VIIs.

Table 1: Stapler Costs by Study Period

Table 2: Total Disposables Cost by Study Period

Figure 1: Operating Room Time (minutes) by Study Period


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