C. P. Childers1,4, B. Zhao2, J. Tseng3, R. D. Hays4, G. Kominski4, S. L. Ettner4, R. F. Alban3, B. M. Clary2, M. Maggard-Gibbons1 1University Of California – Los Angeles,Surgery,Los Angeles, CA, USA 2University Of California – San Diego,Surgery,San Diego, CA, USA 3Cedars-Sinai Medical Center,Surgery,Los Angeles, CA, USA 4University Of California – Los Angeles,Fielding School Of Public Health, Department Of Health Policy & Management,Los Angeles, CA, USA
Introduction:
The choice of surgical instruments is often left to the surgeon. But there is a paucity of data to help surgeons balance effectiveness and cost. Medical devices are a multi-billion dollar industry, yet little is known about how surgeons perceive the effectiveness and cost of the surgical instruments they use.
Methods:
A web-based survey was distributed to 100 attending general and subspecialty (eg, colorectal) surgeons at 3 academic health systems. Surgeons were provided a clinical vignette for a routine elective laparoscopic cholecystectomy and asked to choose their preferred instrument (comparison 1: 5mm (A) vs. 10mm (B) Endoclip applier; comparison 2: Clearify visualization system (A) vs. anti-fog (B) solution) and to state the relative effectiveness and cost of these items (Figure). Descriptive and multivariable analyses were performed to assess the impact of cost and effectiveness on choice of instruments.
Results:
Eighty-two (82%) surgeons provided complete data. Surgeons’ preferences varied, with 29 (36%) choosing the 10mm endoclip (comparison 1) and 35 (43%) choosing Clearify (comparison 2). Virtually all (98%) surgeons knew Clearify was more expensive than anti-fog solution but fewer (63%) knew the 5mm endoclip was more expensive than the 10mm. Surgeons were divided with respect to perceived effectiveness for both comparisons (comparison 1: A>B 24%, A=B 64%, A B 59%, A = B 40%, A < B 1%).
C-statistics for the endoclip choice were 0.75, 0.65, and 0.82 using effectiveness only, cost only, and effectiveness + cost as covariates. Surgeons who knew the 5mm endoclip was more expensive were one-third (RR 0.67, CI 0.48-0.87) less likely to choose the 5mm endoclip, but over half (54%) still chose it as their preferred item. C-statistics for the Clearify/anti-fog choice were 0.5, 0.83, and 0.82. Surgeons who viewed the anti-fog as similar or only slightly worse in effectiveness than Clearify were 2.7 times more likely to choose anti-fog (RR 2.66, CI 1.4-6.5).
Conclusion:
In this multi-institutional study, surgeons were divided in their preference of instruments with effectiveness as the dominant motivator. Cost appears to have only a small impact on instrument choice. Given the variability in surgeons’ perceived effectiveness, randomized trial evidence may be needed to help guide surgeons in choosing surgical instruments.
