Is all ignorance bliss? Expenses for implants in surgery decrease when prices are known, study shows

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Costs were found to decrease for implants in surgery when prices were known, concludes a study presented by Andrew Glennie from Dalhousie University, Halifax, Canada, at the Eurospine 2018 annual meeting (19–21 September, Barcelona, Spain).

“Suffice to say there is quite a bit of opportunity for cost savings, as there is quite a dramatic difference in the costs of implants depending on what you choose to use in these CDF’ s [cervical discectomy and fusion] versus what you choose to use in single level lumbar spine fusion,” said Glennie. Given the variations in costs, Glennie and colleagues aimed to determine whether surgeons change their choice of implants or equipment once they are aware of the specific costs.

Surgeons were initially blinded for five months—in which they were unaware of costs—followed by another five months where detailed cost information was known, allowing the investigators to gain an insight into how this information would affect physician behaviour.

Glennie acknowledges that particularly in Canada, surgeons may remain somewhat naïve to the costs of particular devices or surgical equipment, including the impact on overall costs of care. Reasons for this, he reports, include rapid technological advancements and a single payer healthcare system.

The study set out to determine the costs of all implants used by a spine surgical service at a large tertiary care centre. Three procedures; anterior cervical discectomy and fusion (ACDF), posterior cervical fusion and single level lumbar interbody fusions, were included. To ensure quality-of-life outcomes were equal in patients, the investigators collected quality-of-life scores three months after the procedure. Statistical analysis was undertaken with STATA software.

Costs were found to have decreased by CA$478 for instrumentation once actual prices were known—but this result was not statistically significant (p=0.069). Interestingly, only ACDF procedures demonstrated statistically significant cost savings of CA$754 (p=0.009). Procedural costs were also less (CA$297; p=0.194) as well as the total overall costs of admission (C$401; p=0.228). Furthermore, there were no significant differences in surgeon costs or in health-related quality-of-life outcomes for patients.

No effect on overall healthcare costs

Glennie concluded his presentation by saying that although expenses decrease for implants in surgery when prices were known, this appears to have little or no effect on overall costs of care. However, he maintained that length of stay and operating room time appear to have equal or greater effects on global costs.

He further alluded to a couple of caveats in the study. For example, in addition to being limited by the five-month time period on each side, there were no long-term data available for follow-up beyond three months. Furthermore, generalisability comes into question, as the study was only carried out at a single site.

During the audience discussion, Glennie was questioned on whether he would expect the results to be different with longer follow-up data. He responded by saying, “I absolutely do, yes… [however] there are rigid post-operative protocols that drive costs up, and that is where you need to focus your attention… not necessarily on costs in the operating room”.

Moving forward with the current findings, Glennie notes that cost containment strategies focusing on savings with instrumental costs are likely very short sighted. Therefore, future efforts to encourage efficient cost savings should focus on practice variability for similar conditions, and better long-term collection of cost data—rather than limiting the use of certain implants.

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