“Trimming the VAT(S)”: maximizing value delivery in thoracoscopic lobectomy—a narrative review

Introduction

Background

Rapidly rising health care costs have challenged governments and health policy makers around the world to deliver care that prioritizes value. Value-based health care is defined as health outcomes per dollar spent (1). While considerable attention and resources have focused on maximizing quality care in surgery (2), relatively less priority has been placed on cost containment. In the current post-pandemic era of ongoing economic uncertainty, all aspects of society will continue to face pressure to rein in spending. In Canada, hospital spending represents the largest component of health care costs (3). Operating room (OR) expenditures represent a considerable proportion of the total cost of inpatient surgical care, second only to room and board according to a US study linking American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to Medicare inpatient claims (4).

For thoracic surgeons, video-assisted thoracic surgery (VATS) lobectomy has been firmly established as the standard treatment for early-stage non-small cell lung cancer (NSCLC) (5). However, the rapid adoption of VATS over the past decade has led to surging operative costs, mainly due to increased disposable instrument utilization (6-10). Single-use linear endostaplers are routinely used for virtually all VATS lung resections. Therefore, a significant baseline disposable instrument cost exists for essentially all VATS lobectomies. As surgeons are usually the primary decision makers regarding instrument choice, we inadvertently become significant drivers of operative costs. Escalation in operative costs from disposable instrument usage has resulted in regulatory instrument limitations in some countries. In Korea, for example, a maximum of six cartridges per VATS lobectomy is covered under their health insurance system (11).

Rationale and knowledge gap

While systematic reviews of intraoperative cost reduction strategies studies among various surgical specialties have been performed (12), to our knowledge, a review of cost saving interventions specific to thoracic surgery has not been performed. Thoracic surgery—specifically VATS—is associated with high use of expensive, disposable instruments and presents a unique opportunity to explore potential cost saving strategies.

Merely presenting salient information to surgeons on resource costs may be insufficient to promote practice change (13). Behavioral economics, the study of human motivation, has become a focus of recent interest within health care in the past few years (14-16). A review of VATS cost reduction studies viewed through behavioral economics principles has not been performed previously but could help to better understand how to implement lasting change.

Objective

The aim of this study is to review specific cost-saving interventions in general thoracic surgery specific to VATS pulmonary resections and compare the extent of cost savings among interventions. Cost containment strategies in thoracic surgery will be further analyzed through a behavioral economics framework to identify program characteristics that optimize surgeon engagement. I present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-22-59/rc).

Methods

A literature review was carried out using MEDLINE, PubMed, Scopus, Google Scholar, and Cochrane databases between January 1990 and November 2022 to identify all studies on cost reduction in VATS lobectomy, using major search terms “VATS”, “VATS lobectomy”, “thoracoscopy” or “thoracoscopic lobectomy” and “cost”. Additional papers, abstracts, book chapters, letters and editorials were retrieved from bibliographies by manual research (see Table 1).

As the focus for this review was cost reduction interventions for VATS lobectomy cases only, excluded from analysis were cost studies involving benign disease. Also removed were comparison studies of VATS vs. other surgical approaches, i.e., uniportal, open thoracotomy or robotic surgery.

Results

Using the outlined search strategy, 63 articles were initially identified. After excluding works based on the above criteria and including only studies evaluating specific cost reduction interventions for VATS lobectomy, a total of 6 studies were identified (see Table 2). All studies were non-randomized, observational cohort design with historical control groups. From review of the available literature, the following principles of value delivery in VATS lobectomy are presented for consideration.

Preoperative

Cost awareness

Price ignorance is a prevalent problem among surgeons that contributes to unrestrained instrument-related expenditure (23-26). Undoubtedly this lack of instrument cost awareness is not accidental, as bulk pricing contracts between instrument vendors and institutions are almost always confidential. Price transparency is often absent when pertaining to surgeons’ decisions of surgical instrument use. Without knowledge of instrument costs, surgeons are at a distinct disadvantage when it comes to making value-based choices. Cost awareness can be delivered “passively”, where instrument pricing information is simply conferred to the user. We published the results of a cost awareness strategy using a price list of commonly used disposable instruments displayed prominently in our thoracic OR. Following price display, overall median disposable instrument VATS lobectomy costs decreased by 13.8% (17). Dayan and colleagues utilized a unique, proprietary software program that displayed real-time instrument usage and associated cost to the surgical team during VATS lobectomy cases through barcode scanning of utilized products and showed a 22.7% cost reduction following implementation (18) (see Table 2). In both studies, stapler costs significantly decreased following cost awareness interventions. Interestingly, while the two studies were similar in design, VATS instrument-related expenditure was reduced through different means. Whereas Dayan et al. demonstrated cost reduction via decrease in the mean number of cartridges per case (18), our group showed that cost reduction was specifically achieved by less frequent usage of “high cost” cartridges (curved tip and thick tissue “black” reloads) (17). While stapler utilization change was the most significant factor in reducing operative costs in the aforementioned studies, routine use of other disposable products may also significantly inflate operative costs. Disposable adjuncts such as ports, clip appliers and endoscissors contributed 54% difference in intraoperative supply costs between thoracic surgeons in a study by Richardson and colleagues (27). Omitting these components or switching to reusable alternatives may significantly reduce VATS expenditure. Similar price awareness initiatives have been implemented among other surgical specialties with reported success in cost reduction (28,29).

Value stream analysis and standardization

Variation of surgeon-specific health care expenditure is costly, and accounts for 30% of US Medicare spending (30,31). Furthermore, a significant proportion of routine care, when analyzed on a value-added lens, provides little benefit and therefore an unnecessary cost. Lean and Six Sigma methodologies were originally developed in the automotive industry (32) but have now been applied to a variety of industries, including health care (33). The central principle of Lean Six Sigma is to increase operational efficiency by identifying and eliminating interventions of minimal value. One focus for potential operative cost savings in VATS resections is surgical instrument tray standardization. The cumulative costs of sterilization, packing and transport of multiple unused instruments are considerable. Often individual surgeon preference cards are quite variable and contain multiple instruments that are rarely if ever used. While it may be comforting for the surgeon (and scrub nurse) to have every possible instrument available for a case, excess choice may paradoxically be deleterious. In behavioral economics this is known as choice overload, where too many choice options may induce a lack of action (16). A relatively simple means of operative cost savings would be reducing choice overload for the surgeon. Cichos et al. reported results of reducing unnecessary instruments in standard surgical trays for index thoracic surgery cases (20). Removal of non-essential instruments on thoracic surgical trays resulted in an estimated total cost savings (related to instrument replacement/sterilization) of $21,890 USD (United States dollars) for VATS procedures (see Table 2). Multiple other surgical subspecialties have noted similar cost savings from instrument tray standardization (34-36). Aside from the direct cost savings related to reduced sterilization and replacement, a reduction in the number of tray instruments may also lessen OR instrument count time, reduce potential of incorrect counts and improve room turnover.

Yeo et al. described a comprehensive value stream mapping process of perioperative care in VATS lobectomies at their institution and eliminated significant cost drivers such as routine chest X-rays, bloodwork, pain consults as well as instrument standardization and noted a 40% overall cost reduction (21). A similar work by Schwarzbach and colleagues showed that introduction of a VATS-specific enhanced recovery clinical pathway (with standardized analgesia, early ambulation, early removal Foley catheters, etc.) was associated with a decrease in median hospital stay by 5 days, representing a €1,150 cost savings per patient (22). The degree of cost savings that may result from value stream analysis may vary by institution. For example, some routine but costly specialist referrals eliminated in the study by Yeo et al. included mandatory pain consults for patient-controlled analgesia and respiratory consults for incentive spirometry (21) which may not be standard practice elsewhere. Therefore, it would be prudent for surgeons to implement value stream analysis within their own organizations to identify specific areas where the greatest cost savings may be realized.

Intraoperative cost reduction strategies in VATS technical considerations

Once a case is underway, the thoracic surgeon can control costs through a variety of intraoperative techniques. Apart from judicious use of higher priced cartridges as noted previously, another potential strategy to minimize costs in VATS lobectomy is simultaneous multi-vessel division using a single cartridge. Often, adjacent vascular branches align in parallel and may allow a single cartridge to pass around both simultaneously. Simultaneous artery and vein staple ligation has been described specifically for right upper lobectomy as a safe and effective maneuver (37,38). However, multi-vessel division may be applied for other lobes where vessels lie in the same parallel plane (see Figures 1,2). Obviously, this should be performed with caution and only if vessel position allows safe passage of the stapler without tension. Performing multi-vessel division when feasible during VATS lobectomy may significantly reduce the number of staplers used per case and reduce intraoperative costs. In our experience, if there is sufficient space to allow easy passage of a blunt tip instrument such as a thoracoscopic DeBakey or right-angle dissector, multi-vessel ligation is a safe maneuver. If there is any concern of excessive tension, individual vessel division using multiple staplers should be performed. Thoracic surgeons should diligently assess the need for liberal cartridge consumption and seek less expensive alternatives if feasible. Energy devices (e.g., Harmonic Scalpel^TM) have been reported safe in pulmonary artery division in VATS anatomic resection. However, its application is limited to vessels less than 7 millimetres diameter (39,40). The additional cost of energy sealant must then factor into the overall calculation to determine if any cost saving is realized. In some circumstances, completion of fissure division may be safely done using electrocautery instead of staplers. Xu et al. in a comparison of stapled fissure division vs. electrocautery for VATS right upper lobectomy, showed no difference in overall hospital stay, and reduced hospitalization costs using electrocautery fissure division (41). When only a small bridge of parenchymal tissue remains between the specimen and remaining lung, metal clip(s) may be substituted for staplers.

Figure 1 Simultaneous stapling of superior pulmonary vein branch and truncus anterior pulmonary artery branch during thoracoscopic right upper lobectomy.

Figure 2 Simultaneous stapling of three separate posterior pulmonary artery branches during thoracoscopic left upper lobectomy.

Postoperative period

Avoiding complications—maintaining quality while reducing costs

While not a true intervention, navigating a patient successfully through a major pulmonary resection without postoperative morbidity is perhaps the single most important factor to maximize value, both in terms of efficient resource use and quality care provision. In addition to the obvious detrimental consequences of major perioperative complications for the patient, the resultant resource demands from these adverse events significantly increase overall costs of care. Jawitz et al. analyzed the influence of complications on cost following lobectomy in a large US dataset cohort of over 24,000 patients and noted a 25% incidence of postoperative complications, with total complication-related costs of nearly $40 million USD (42). In a similar review, Geller et al. showed that major complications following lobectomy for NSCLC increased costs by 57% (43). In their analysis of VATS lobectomies from the Society of Thoracic Surgeons (STS) database, Khullar and colleagues noted that the development of a single postoperative complication increased mean costs by $6,438 USD, while two complications increased costs by $10,108 USD (8). Clearly, avoidance of major complications following VATS lobectomy is a fundamental aspect of value-based care.

Review of different cost reduction initiatives suggests that intraoperative expenses may be reduced without compromising clinical outcomes. Cost awareness interventions successfully reduced VATS instrument-related expenses with no differences in OR time, conversions to open procedures, pulmonary artery injury, blood loss/transfusion and hospital (17-19). Value streamlining analysis and process redesign of VATS lobectomy standard practices led to an overall 40% cost reduction while reducing postoperative complications and readmission rates (21). Costly instruments (ports, clip appliers, tissue sealants) may be safely omitted from routine VATS lobectomies without compromising perioperative outcomes (27).

Evidence-based value delivery—new, but improved?

When a new version of an existing product is released, the discerning consumer should demand evidence of superiority over the prior model it intends to replace, thus justifying its inevitable price premium. However, often relatively minor technological advantages are purported by the vendor to achieve improved performance in the absence of independent quality evidence to support these claims. Furthermore, the corresponding price premium is often disproportionate to its proposed advantages. When considering new costly technology, if surgeons intend to maximize value-based care, it is important to see evidence of improved quality metrics to justify higher costs. Specific to VATS procedures, design changes in linear stapler technology have been introduced with industry claims of improved performance. For example, vendors have developed new cartridge interfaces with specially designed stepped faces and graduated height staple rows, claimed to minimize tissue trauma and improved tissue sealing over their older cartridge designs with flat faces and equal height staples. However, a randomized trial comparing the two cartridge designs (graduated vs. same height staple rows) demonstrated no significant differences in air leak or bleeding events (44). Despite the absence of any significant clinical advantage, the graduated height cartridges are up to 3 times the price of the equivalent same-sized legacy cartridges from the same vendor. Another technological advance in stapler technology has been the addition of a curved anvil tip to facilitate passage of the stapler around dissected structures. The curved tip feature adds a cost premium approximately double that of a non-curved, same sized cartridge. A clinical study comparing stapler passage time around hilar structures demonstrated a modest reduction of 54 seconds using the more expensive curved tip anvil compared to conventional staplers (45). In terms of value-added benefits, the discerning surgeon must decide if this degree of clinical improvement warrants its routine use and incremental additive costs. Certainly, there are situations where a tapered anvil tip may facilitate passing around tight spaces behind structures. However, in our experience, if sufficient dissection has been performed, the less expensive, non-curved, same sized cartridge can usually be safely substituted. Similarly, the extra thick black cartridge reload is priced up to 1.3 times higher than the next largest sized cartridge which can often be substituted. In our cost study, the most significant contributor to VATS disposable instrument cost reduction was related to decreased use of these higher cost stapler cartridges (19).

Behaviorial economics and the surgeon

Resistance to change

It is estimated that physician decision accounts for over 80% of overall health care costs (46). Surgeons are the primary decision makers regarding individual instrument choice, and subsequently the central drivers in expenditure variations for specific cases (12). While most would agree that efforts should be made to reduce the financial burden on the health care system, adoption of such efforts by surgeons can present challenges. A central theme of behavioral economics is that human behavior is often irrational and may be influenced by certain cognitive biases. Individuals, particularly surgeons, may resist change when faced with the prospect of altering established routines that have become familiar over time. This core principle of behavioral economics is aptly named inertia, or status quo bias (16). In a survey of orthopedic surgeons, the most important factors influencing treatment decisions with inconclusive evidence were “works in my hands”, “familiarity with the treatment”, and “what my mentor taught me”, while factors related to quality, safety, and efficiency such as “cheapest/most resourceful”, “shorter procedure”, and “what others are doing” (in the sense of diminished unwarranted variation) were rated relatively unimportant (47). Another survey of gynecologists’ opinions regarding instrument demonstrated low priority to device cost compared to clinical variables such as effectiveness, safety and personal experience, even after participating in cost awareness campaigns (13). It can therefore become difficult to overcome the inertia of surgeon familiarity and comfort to change practice for the sake of cost reduction, particularly in the absence of any perceived reciprocal benefit. Another well described bias that may be applicable is cognitive dissonance, defined as an individual’s rejection of new information that conflicts with their prevailing beliefs (48). A related and relevant cognitive bias is the sunk-cost fallacy, where individuals are reluctant to give up something they have invested money, time or effort into, even if costs outweigh benefits (49). Collectively, these innate tendencies may contribute to the immutability of surgeons’ longstanding practice patterns, particularly regarding surgical instrument choices. Being aware of our natural cognitive biases and open to consider alternatives that maximize value may help to make rational evidence-based decisions.

Extrinsic vs. intrinsic motivation

Some efforts to influence surgeon behavior change have included compensatory rewards. A study by Zygourakis and colleagues demonstrated a total operative cost saving of $836,147 one year after surgical departments were offered a financial incentive of $50,000 if they met a 5% cost reduction goal (50). Conversely, policy makers have implemented penalties for failing to meet certain benchmarks. However, punitive measures may be ineffective and even result in worse outcomes. In a 2018 study, Wadhera et al. examined implementation of the US Hospital Readmissions Reduction Program (HRRP)—a program that imposes financial penalties for hospitals with higher than expected 30-day readmission rates—and noted that HRRP implementation was associated with significantly increased 30-day post discharge mortality after hospitalization for heart failure and pneumonia (51). External “carrot and stick” drivers may elicit temporary behavior change but could fail to foster long-term engagement. Thus, to facilitate lasting change, interventions need to instead foster intrinsic motivations. A specific focus for intrinsic drive, particularly among surgeons, is our innate sense of competition among our peers. In behavioral economics this principle is known as relative social ranking (16). An analysis of the relative impact of surgeon report cards on risk-adjusted coronary bypass mortality rates estimated that intrinsic motivation resulted in mortality rate improvement 4 times larger than external financial incentives (52). Other reports have documented success in cost reduction following implementation of some form of surgeon feedback through report cards (53), EMR dashboard display (54), or real-time OR cost display and surgeon/peer group reports (18). This highlights another behavioral economics principle of immediacy, where people tend to respond more strongly to frequent performance feedback than delayed information (16,54). When compared to other passive cost awareness initiatives (price list, educational presentation), we observed that the highest cost savings were associated with more active surgeon engagement i.e., performance self-assessment, peer comparison, and positive deviance seminar discussion led by the lowest cost surgeon (19). The positive deviance framework identifies cost reduction solutions that are currently feasible because the low-cost surgeon has already successfully employed them. In contrast to resource heavy cost reduction strategies that have relied on financial incentives (50) or providing full day skills labs (55), positive deviance seminars require minimal resource use and are internally governed among surgical colleagues. Furthermore, when cost reduction initiatives are driven by surgeons (as opposed to mandated directives from external policy makers), the resulting culture change may become durable and more effective long term.

Discussion

Narrative

In reviewing the limited studies available regarding cost reduction in VATS resections, value delivery has been successfully demonstrated through a variety of methods, including cost awareness (17-19), value stream mapping (21,22) and tray standardization (20). To our knowledge, this is the first literature review summarizing all reported VATS lobectomy-specific cost reduction initiatives. Furthermore, analysis of surgeon decision making was performed through a behavioral economics perspective, exploring potential cognitive barriers to cost effective choices, and strategies to engage surgeons through strategic peer-led education.

This review has several limitations. As seen from the small number of studies (Table 2) identified through this literature search, there is a relative paucity of literature specifically pertaining to VATS lobectomy-related cost reduction initiatives. While other reviews have summarized global surgical cost containment strategies (12), thoracic surgery—specifically VATS lobectomy—is uniquely dependent on regular use of multiple linear stapler applications. Therefore, application of widespread cost reduction strategies focused solely on disposable instrument use may not be as effective. The VATS-specific cost reduction interventions highlighted in the current review—cost awareness, peer group feedback, instrument standardization and value stream mapping—demonstrate short term success in reducing perioperative expenditure. It could be ascertained that a significant proportion of the observed cost savings was due to the Hawthorne Effect (i.e., the beneficial influence on performance due to subject awareness of being observed) (56) and overestimating the efficacy of a given intervention. Therefore, it would be prudent to assess long term durability of cost saving interventions following their initial implementation. All the studies identified in the present review were non-randomized cohort studies comparing the intervention group to historical control group. With any cohort study using historical controls, the confounding effect of changing practice over time highlights a significant limitation of ascribing positive outcomes solely to the intervention. One study did demonstrate baseline constancy of instrument costs over a one-year period prior to cost reduction intervention to assess for pre-existing cost trends (19). As the present review did not include robotic, uniportal lung resection, or non-pulmonary procedures (e.g., esophageal, mediastinal resections) further studies will be necessary to determine the most effective long-term strategies to constrain costs in thoracic surgery that include these and other surgical approaches, without sacrificing quality. Finally, the relative costs used to calculate expenditure changes were specific to the negotiated procurement contracts between health care institutions and the device manufacturer(s). Therefore, it is unknown if the relative savings observed would be replicable in other centers with different pricing agreements. As five of the six studies were from North America (three from Canada, two from the US—see Table 2), generalizability of cost reduction initiatives to sites outside North America may not be applicable, particularly in countries where government-mandated restrictions on disposable instrument use may limit further reductions on perioperative expenditure (9,11).

Thoracic surgeons bear an incredible burden of having to perform complex minimally invasive pulmonary resections on high-risk patients on a routine basis. Some may feel that quality care provision should be the surgeon’s sole concern, and that matters of cost are irrelevant to them and should be relegated to hospital administrators. Furthermore, one cannot deny that the evolution of modern stapler technology ushered in the era of minimally invasive lung resection. Nobody would suggest outright elimination of staplers and regression back to manual vessel suture ligation purely for the sake of cost reduction. However, thoracic surgeons cannot ignore the unsustainable growth of health care expenditure, and our collective responsibility to control costs. Health care delivery models have undergone seismic transformation over the past few years, with movement away from the traditional volume-based (fee-for-service) structure and emphasis towards value-based care and compensation. Within this new paradigm, health care systems are demanding from all providers that costs be minimized while maintaining excellence in patient care. Surgeons share a fiduciary duty to do the right thing, not only regarding provision of evidence-based quality care, but also ensuring that its associated costs are minimized. It is vital that surgeons assume leadership positions within health organizations to guide changes that optimize cost efficiency without compromising surgical care.

Conclusions

VATS pulmonary resection has revolutionized the field of thoracic surgery, but if left unchecked, its associated costs could excessively strain hospital budgets. Surgeon-led efforts to “trim the VAT(S)” will help ensure ongoing sustainability of our specialty and our increasingly fragile health care ecosystem.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The author has completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-22-59/rc

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-22-59/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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