WikiJournal Preprints/Specialty-Specific Gynecology Operative Units Promote Cost-Effectiveness

Introduction
Healthcare in the United States is the most expensive in the world (1). In 2013, annual healthcare spending increased to almost 3 trillion dollars, accounting for 17.4 % of the Gross Domestic Product (2). By 2020, this is anticipated to increase to almost 5 trillion dollars (3). As 32.1% of this cost is attributed to hospital care, surgical professionals and hospitals must deliver more cost-effective care while maintaining patient safety (4).

The contribution of gynecologic surgery to this cost is not small. With approximately 500,000 procedures performed annually in the United States, hysterectomy is one of the most common gynecologic procedures (5). It accounts for approximately 5 billion dollars annually (6). The American College of Obstetrician and Gynecologists (ACOG) recommends a minimally invasive approach to hysterectomy when possible (7). A minimally invasive approach, whether vaginal or laparoscopic, may decrease overall cost when hospital stay, postoperative pain, risk of complications, and time off work are considered (7).

The Institute of Healthcare Improvement’s Triple Aim Initiate is tasked at not only improving patient outcomes and health of populations, but also reducing per capita healthcare cost through a systems approach (8). One area of interest has been designated surgical teams and the effect this may have on optimizing performance within the operating room (OR). The operating room is expensive, with most charges accrued within the first 30 minutes. The total cost is multifactorial but the majority arises from length of surgery and the costs of instrumentation. An OR team familiar with specific operative procedures has been found to decrease turnover times, OR preparation times, and overall procedural times (9, 10, 11).

We hypothesize that a streamlined, dedicated gynecology OR team at our institution would yield faster, more efficient surgeries and overall lower cost. To this end, we examined a single procedure, total laparoscopic hysterectomy, and its related costs, comparing OR teams and location.

Materials and Methods
This is a retrospective cohort study of all patients who underwent total laparoscopic hysterectomy (TLH) with one of three high-volume minimally invasive gynecologic surgeons at Vanderbilt University Medical Center between July 1, 2011 and December 31, 2014. The patients were identified via the specific Current Procedural Terminology (CPT) Codes: 58570 (TLH ≤ 250gm), 58571 (TLH with tubes and/or ovaries, ≤ 250gm), 58572 (TLH > 250gm), 58573 (TLH with tubes and/or ovaries >250gm). A total of 343 patients were identified with these criteria.

The patient cohort was then divided by the exposure—the OR location where the surgery took place. At our institution, there are two distinct surgical areas in which cases are performed. There is a dedicated gynecology operative suite consisting of 3 ORs, staffed consistently with experienced gynecologic anesthesia providers, nurses, scrub assistants, preoperative and post-anesthesia care unit (PACU) providers. This provides a team in which practice patterns and preferences are well known to all team members. The alternate location is the general ORs, staffed by off-service teams of anesthesia providers, nurses, scrub assistants, preoperative and PACU providers. The measured outcomes included differences in cost, time, and complications. Complications data (as an outcome measure) are not included in the scope of this paper, but it was included in statistical analysis as a confounder, where appropriate. Surgery information and basic patient demographic information (BMI, ASA Class, and age) were abstracted using the Vanderbilt Operating Room Management Information System (ORMIS) database for this analysis.

Our primary objective was to determine differences in operative time (defined as incision to case stop time), room time (defined as room-in to room-out time), and recovery area time (defined as total PACU time).

Our secondary objective was to evaluate cost differences, including total case cost, cost of disposable supplies and instrumentation, OR room charges, anesthesia room charges, and PACU charges. For this information, the Vanderbilt billing department supplied a list of itemized charges incurred by each case.

Statistical analysis was performed using the Fisher exact and student t-tests for bivariate analysis, and ANCOVA for multivariate analysis, where appropriate. Variables with p<0.05 were considered to be statistically significant. Statistical analyses were performed using commercially available software (STATA version 11; StatCorp, College Station, TX.)

This study was approved by the Vanderbilt University Medical Center Institutional Review Board.

Results
A total of 343 total laparoscopic hysterectomy cases meeting study criteria were identified—19 (6%) in the general OR group and 324 (94%) in the gynecology OR group. Age, BMI, and ASA class data from these patients are recorded in Table 1 and are noted to be similar at each operative location. Table 2 describes location, surgeon, CPT code and fiscal year of the procedures. There is a significant difference in the hysterectomy code and location.

There was not a significant difference in total OR room time, length of case time, or PACU time, although there was a non-significant trend toward longer times in each category for cases performed in general operating rooms (Table 3). This was most pronounced in the OR room times.

Table 4 demonstrates the breakdown of the individual charges. All charges/costs are greater in the General OR surgeries, and most of these are statistically significant. The total adjusted mean case cost for TLHs performed in gynecologic ORs was $41,483 compared to $47,090 in the general ORs (p .003) (Figure 1). There was a significant increase in the cost of all disposable instruments and devices used in a case when performed in a general OR, $1205 versus $1836 (p <.0001) (Table 4). Additionally, PACU and anesthesia costs were noted to be significantly less for gynecologic ORs (Figure 2).

Discussion
In this retrospective cohort study, there was no statistically significant difference in operative time, room time, or PACU time for total laparoscopic hysterectomies performed in dedicated gynecologic ORs versus general ORs. However, there was a significant difference in total cost, disposable instrument cost, anesthesia cost and PACU costs between the locations. In our institution, performing a laparoscopic hysterectomy in the general OR (with a non-GYN staff in an unfamiliar location) instead of the dedicated gynecology OR resulted in an additional $5,607 in cost.

In our experience, use of teams familiar with operative procedures allows for cost containment. Often, in unfamiliar ORs with an inexperienced staff, efficiency and cost containment become less of a priority as the staff is focused on “being ready for anything,” so unnecessary disposable devices, instrument trays, and supplies are opened. Additionally, anesthesia staff and PACU staff familiar with post-operative routines of minimally invasive gynecologic patients allow a rapid recovery and discharge.

Although our study did not directly demonstrate it, we suspect that time and cost are directly related. While a difference in time was not observed, the difference in cost observed might still be at least partly attributed to time differences that trended toward, but did not achieve, a statistically significant difference.

The strengths of our study include analysis of three high-volume, minimally invasive-trained gynecologic surgeons, chosen to minimize variation in surgical technique and operative time. This study provides evidence, as seen in other operative specialties, that procedure specific teams can reduce costs of surgery. To our knowledge (supported by PubMed searches for terms such as operating room efficiency, turnover time operating room, dedicated operating room, gynecology), this is the first evaluation of specialty specific teams in the gynecologic literature, though other cost-savings papers do exist. This study describes the benefit of supporting the practice of high volume surgeons with dedicated operative suites and staff for cost containment in the era of value driven healthcare.

Another strength is the homogeneity of the cohort within the different OR locations. In many institutions, patients with significant co-morbidities are scheduled in large, general operative suites. However, in our institution, operating location is most often determined by case volume and staff allocation rather than patient-specific factors. In our dataset, there was no difference in BMI or ASA Class between the two locations. In fact, all of the ASA Class 4 patients were operated on in gynecologic ORs. Thus, the impact of patient selection bias on our findings is negligible.

Our data is limited to a retrospective chart and billing data review, which introduces possible data processing error and may not identify other confounding factors. Representation in the general operative suites cohort is small, and does affect our ability to identify greater differences in time variables. Additionally, this is data from a single private academic institution and may not be generalizable to all institutions. However, this study does provide an opportunity for further prospective studies to demonstrate cost containment in this manner.

Conclusion
This is a unique look at specialty specific ORs in Gynecology. To date, similar data is not available in this discipline. Attempting to curtail healthcare costs requires a multifaceted approach executed on multiple levels, including systems-based practices. A more cost effective approach to patient care is not mutually exclusive to optimizing patient outcomes and potentially improving safety measures. Institutions will be tasked with implementing cost-reduction protocols. Based on our data, this may include choice of surgery location and the creation of specialty-specific operative units.

Tables
*   Data are given as percent or mean (SD) * CPT = Current procedural terminology. Data are given as N (%) * Data are given in minutes as mean (95% CI), adjusted for age, BMI, case type, ASA class, and surgeon * Data are given in dollars as mean (95% CI), adjusted for age, BMI, case type, ASA class, and surgeon

Acknowledgements
Marc Robinson, MS

Competing interests
No conflicts of interest to disclose.

Funding

No funding to disclose.