UCLA

The rising cost of healthcare in the United States is arguably one of the largest challenges of the next generation. In surgery, the operating room is the most resource dense component of a patient’s care, estimated to cost $37 per minute. While much of this cost is not easily modifiable – such as wages and indirect costs - the supplies used by surgeons are tangible and potentially mutable. Preliminary research suggests significant variation in supply use and associated costs between surgeons, but little is known about surgeons’ knowledge of the cost of instruments, how this knowledge affects instrument preferences, and how use of different instruments impacts patient outcomes. In this dissertation, we first conducted a multi-institutional survey of 83 attending surgeons at 3 academic medical centers in Southern California. We then linked survey data from one medical center to a comprehensive medical record-based administrative dataset that included over 1800 laparoscopic cholecystectomies performed between 2013 and 2018. Our analysis found that there was significant variation in disposable supply costs between surgeons and facilities, even after adjustment for patient case mix. Together, the surgeon and facility explained 34% of the variation in supply costs. Our analysis further suggested that the cornerstone of intraoperative supply costs appears to be the surgeon’s preference card , with every 1 dollar increase in preference card cost associated with a 78 cents increase in actual case cost. Upstream, surgeons who were able to accurately discriminate the cost of common general surgery items may choose cheaper preference cards, but interestingly, passive exposure to instrument costs, such as through cost report cards, does not appear to increase cost knowledge and therefore may have little downstream effect. Finally, surgeons with more expensive preference cards do not appear to improve their patients’ short-term outcomes. Taken together, the results suggest that the most successful efforts to reduce intraoperative supply cost variation will involve an active approach to reducing preference card cost, perhaps through standardization, and that cost reducing efforts may not adversely affect patient outcomes.