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A Strategy for Cost Containment in Carotid Endarterectomy: Analysis of the Impact of Surgeon Preference on Operating Room Cost
Jason K. Wagner, MS, Samuel N. Steerman, MD, Sadaf S. Ahanchi, MD, Jonathan A. Higgins, MD, Babatunde M. Almaroof, MD, Carolyn Mosely, CPA, Jean M. Panneton, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.

The growing concern over healthcare cost and the implications of a transition towards bundled payments for surgical procedures has made cost analysis a necessity for health systems and providers alike. Identifying areas which improve the delivery of quality care and simultaneously limit cost are essential to maintaining a sustainable healthcare model.
Variability in operating room charges based solely on surgeon preference is an ideal target for cost containment measures. The goal was to identify the impact of preference-dependent utilization of surgical supplies on the intraoperative charges for carotid endarterectomy (CEA).
A retrospective chart review was undertaken for patients who underwent CEA between January 2009 and August 2010 at a high-volume academic center. Data was collected from the electronic medical record and billing system and then categorized. The three categories with the highest degree of cost variability were identified and analyzed.
The records of 140 patients (32% female, 68% male) with an average age of 68.5 years (range 45-86) were reviewed. Preoperative symptomatology was known for 127 patients, of whom 32% (41) were symptomatic and 15% (19) of procedures were performed urgently. The average length of stay was 3 days (mode 1, range 1-20) and the average charge incurred during a CEA hospitalization was $29,459 (range $14,723-$128,328). The three areas that comprised the highest percentage of total hospital charges were operating room services (28%), ICU stay (12%), and surgical supplies (11%). Operating room (OR) times averaged 173 minutes (range 89-315) and charges averaged $6,663.35 (range $4,176.50 - $10,843.50). After a base charge of $1,551.00, OR charges were $31.97/minute. Within surgical supplies, the three units with largest cost variability were surgical trays, hemostatic agents and shunts, comprising 48%, 15% and 11% of the total operative supply charges respectively. Within surgical packs, the mean charge was $834/patient; however, the range was $339 - $4853. Hemostatic agents were used in 83 of 140 cases, with a mean charge was $431 (range $107- $1531). Shunts were utilized in 60 of 140 cases mean charge $444, (range $96-$2493).

In addition to OR time, preference in the composition of surgical packs, shunt type and hemostatic agent used generate wide variability in the intra-operative charges of CEA. These categories with significant surgeon-dependent variability are potential targets for cost containment.

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