The Impact of Surgeon Behavior on the Cost of Performing Laparoscopic Appendectomy

While laparoscopic appendectomy (LA) can be performed using a myriad of techniques, the cost of performing each method can vary considerably. The purpose of this study is to analyze the effects of the surgeon’s choice of technique on the costs of performing LA.
The surgeon operative notes, hospital invoice list, and surgeon instrumentation preference sheets were obtained for all LA (open cases excluded) cases in 2008 at Cambridge Health Alliance (CHA). Only the cases (N=89) performed by the fulltime staff general surgeons (N=8) were included in this study. The operative note from each LA case was analyzed and then cross-referenced with the surgeon’s instrumentation preferences to determine the specific type and amount of each disposable used during each case for the following components of LA: port access; mesoappendix division; and management of the appendiceal stump. Using the invoice records from 2008, the cost of each disposable was calculated based on the hospital’s actual cost of acquisition. Moreover, only the most recent acquisition cost values from the invoice were used in order to ensure up-to-date pricing of the disposables. Laparoscopic appendectomy hospital reimbursements in 2008 were also obtained for all payers. Actual hospital reimbursement data for each case was then reviewed.
In theory, the costs to CHA for these portions of the procedure can range from $96 to $888 and were plotted on a cost curve for 126 different methods we priced out. Of the 89 cases analyzed the actual cost per case for access, mesenteric division and stump control ranged from $184 to $742. The predominant LA technique for each surgeon was then plotted onto the cost curve. The two main payers for LA patients at CHA were Medicaid and Health Safety Net, whose total hospital reimbursements ranged from $264-$504 and $0-$545 respectively for patients discharged on day 1.
The surgeon with the lowest average disposable cost per case ($329.18) utilized clips, pre-tied loops, and hand-ties as their predominant techniques. The surgeon with the highest average disposable cost per case ($552.33) predominantly used a linear stapler with 3 cartridges.
Disposable costs incurred during each case frequently exceeded the hospital reimbursement. Currently, there is no scientific literature that suggests a superior surgical method for performing these portions of LA. Therefore additional costs are incurred without demonstrable clinical benefit. Practice amongst individual surgeons can be quite variable. This study suggests surgeons should review the cost implications of their practice and to find ways to provide the same effective care without unwarranted expenditures. Certain patients may present with complex pathology that merits individual approaches, yet routine LA procedures can be performed with less-expensive techniques that provide the same quality of care.

Session: Podium Presentation

Program Number: S083

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