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The Use Of A Vascular Surgery Operative Cost Sheet To Increase Surgeon Financial Awareness And Decrease Operative Cost
Drew Goldberg, BA1, Scott Damrauer, MD2, Grace Wang, MD2, Venkat Kalapatapu, MD3, Paul Foley, MD2, Benjamin Jackson, MD2, Ronald Fairman, MD2, Julia Glaser, MD3.
1Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA, 2Hospital of the University of Pennsylvania, Philadelphia, PA, USA, 3Penn Presbyterian Medical Center, Philadelphia, PA, USA.

Objective: Surgical expenses compose one-third of the rising healthcare costs in the United States. Therefore, novel strategies for mitigating cost in the vascular surgery space are warranted. Our institution implemented a cost reduction strategy in 2017 by simply showing surgeons the costs of their implants and disposable supplies at the end of each case in order to increase surgeon financial awareness and potentially reduce cost.
Methods: We performed a retrospective analysis of recorded supply and implant costs for vascular procedures from 2015-2019 at a single institution. Total operative cost was defined as the accumulated implant and supply cost during a procedure. We assessed total implant and disposable supply cost, supply cost alone, and cost per time. Cost was analyzed over 2 periods: the 24 months prior (PRE) to the tool implementation and 24 months following (POST) with a 1-month washout. Median and IQR were calculated for each parameter and compared using the Mann-Whitney U test.
Results: We analyzed a total of 1372 procedures within several categories performed over the time period studied. Total supply and implant cost (-17.5%; p<0.01), supply cost (-1.99%; p=0.049) and cost/minute (-28.24%; p=0.02) all saw significant reductions across the composite of open procedures from the PRE to POST time point (Table 1). Largest supply cost reductions were seen in CFEA (-42%; p<0.01). The total operative cost/time was most significantly reduced for carotid endarterectomy (-8.89%; p<0.01), AAA repair (-16.21%; p=0.02), and carotid-subclavian bypass (-9.94%; p=0.032), with non-significant cost reductions in AV grafting, common femoral endarterectomy, and rib resection. Relative price increases of 31%, 8% and 3% were calculated for temporal artery biopsy, upper extremity AV fistula, and distal bypass, respectively. The composite of all EVAR and TEVAR procedures saw large implant cost increases with minimal change in supply cost.
Conclusion: A low-cost, highly implementable cost sheet is effective at reducing cost in vascular surgery. Further investigations should assess how and why surgeons choose supplies and implants to target further intraoperative cost savings.

ProcedureTotal Supply and Implant Cost [$]Supply Cost [$]Total Cost/Time (Supply + Implant) [$/min]
PREPOST% ∆ p-valuePREPOST% ∆ p-valuePREPOST% ∆ p-value
Carotid Endarterectomy504.3 (411.5-664)452.6 (409.5-525.7)-10.250.01250.3 (238.5-277)249.1 (235-276.1)-0.450.354.86 (4.05-6.09)4.43 (3.77-5.25)-8.89<0.01
AAA Repair1686 (1268-2041)1399 (1257-1717)-17.010.04542.5 (432-602.5)536.8 (456.6-621.8)-1.0520.827.59 (5.67-9.49)6.36 (1.65-8.13)-16.210.02
Carotid-Subclavian Bypass681 (609.1-805.4)682.6 (641-771.6)0.230.95272.3 (245.8-385.7)259.9 (245.1-290)-4.540.365.49 (4.52-6.36)4.85 (1.39-5.76)-9.940.03
Common Femoral Endarterectomy3102 (1107-5232)971.3 (532.5-4309)-68.690.01662.4 (441.3-886.1)382.8 (237.8-566.8)-42.21<0.0114.35 (6.32-14.35)8.45 (3.81-8.45)-41.160.06
AV Graft181.8 (130.8-189.2)183.3 (123.8-223.1)0.8220.54113.8 (108.3-132.4)112.5 (106.7-125.9)1.08650.542.07 (1.39-10.57)1.70 (1.48-2.67)-17.650.14
Rib Resection119.7 (115.8-124.6)116.6 (112.2-149.2)-2.5770.87120.3 (117.8-123)114.6 (109.7-138.3)-4.7380.061.46 (1.25-2.06)1.39 (1.02-2.11)-4.460.56
Temporal Artery Biopsy45.25 (34.4-73.4)90.26 (47.84-121.4)99.49<0.0145.25 (34.41-73.4)90.55 (48.17-121.4)100.01<0.011.38 (0.79-1.79)1.81 (1.25-3.05)30.92<0.01
Upper AV Fistula181.9 (125.1-249)187.7 (132.2-269.2)3.160.51127.2 (113-145.7)114.9 (101.3-121.1)-9.669<0.011.89 (1.02-2.84)2.05 (1.39-2.56)8.680.53
Distal Bypass831.7 (491.8-2315)767.6 (480-2987)-7.690.84308.8 (244.9-382.6)377.9 (242.4-572)22.360.082.64 (1.87-7.98)2.72 (1.59-8.29)3.260.94
All Endovascular (EVAR + TEVAR)17,653 (12,890-24,376)22,524 (15,366-29,092)27.59<0.012031 (1581-2588)2022 (1559-2597)0.4370.81180.3 (11.4-262.1)163.2 (97.84-271.4)-9.480.64
All Open549 (275.1-1115)452.7 (209.3-782.4)-17.54<0.01250.3 (141.1-411.1)245.3 (121.5-343.2)1.990.0495.237 (2.039-11.03)3.758 (1.86-7.241)-28.240.02

Table 1: Cost trends before and after implementation of a cost sheet across multiple vascular surgery procedures. Values demonstrated as median (IQR)

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