Abstract
Surgical case costing is critical for health leaders to make decisions about resource utilization. Synoptic reporting offers the potential for surgeons to capture these costs and work with other leaders to make evidence-based decisions. The purpose of this study was to determine whether surgeons documented intra-operative cost drivers as part of their operative report. This article outlines a synoptic reporting system at a quaternary spine care centre. Data were captured from 2015 to 2020. Surgeon rates of documentation for specific devices, bone graft, and surgical adjuncts were evaluated. It is hoped that the results of this survey will help to guide programs to capture costs in other settings.
Introduction
The costs of spine surgical care have risen exponentially both in North America and internationally. 1 A significant amount of this cost is related to new techniques and instrumentation as well as expensive adjuncts enabling better/robust fusion of the spine. Pedicle screw instrumentation, lateral mass screws, interbody implants, and more recently computed tomography scan or fluoroscopically navigated systems have increased the costs of spine surgery substantially when compared with older non-instrumented techniques for fusion. 2,3
Case costing estimations can use either bottom-up or top-down methods. Bottom-up case costing estimates costs as they are consumed or used in care of patients along the care pathway. Efforts are made to calculate every contributor to the overall cost of the patient from the payer perspective. 4 Top-down methods use the end of quarter or year budgetary values and subsequently assign approximate values to areas or divisions of care and then subsequently down to the surgical procedural level. 5 Bottom-up case costing, when performed appropriately, confers significant advantages since major cost drivers can be identified with more sensitive costing reports. 6,7 Case costing strategies are costly themselves to implement since many aspects of care must be considered to generate truly representative estimates of the overall costs of care. 8
Although surgeons may be very aware of the prices for certain implants in various healthcare environments, there is a paucity of literature evaluating whether surgeons themselves may play a role in collecting or documenting implants and other expensive adjuncts that they use as part of a surgical procedure. Synoptic operative reports are replacing traditional oral narrative operative reports in many jurisdictions given the higher completion rate leading to more complete and safe surgical documentation. 9 Surgeons are required to record certain aspects of the surgical procedure utilizing a templated, uniform nomenclature, while other sections are optional. The synoptic developer has the ability to determine which fields are mandatory. Users, including trainees, of a spine surgery synoptic report have demonstrated the ease of use with faster and more complete required data elements compared to traditional dictated reports. 10 The purpose of the current study was to determine whether surgeons will reliably record the instrumentation systems and any other expensive adjuncts used in order to help generate a cost estimate for the surgical procedure. A secondary objective was to evaluate variation between participating surgeons and evaluate strategies used by individual surgeons who have higher compliance rates with respect to information capture for instrumentation.
Methods
Study setting and surgical procedures
This study took place at a quaternary care hospital associated with a medium-sized university with five full-time spine surgeons at various phases of their careers servicing a population of approximately 1.2 million people. The range in time spent in independent practice for the participating surgeons ranges from 5 to 17 years and range in age from 38 to 52 years. All surgeons have advanced fellowship training in spine surgery, with some having further advanced training in subspecialty areas of spine surgery including minimally invasive techniques and/or deformity spine surgery.
Inclusion criteria were as follows: cervical, thoracic, and lumbar surgical procedures where a device, bone graft, or surgical adjunct was used and a full synoptic report where essential information was recorded. These procedures were chosen given that they had optional menus where information could be recorded and they also represent higher cost aspects of the spine procedure. Exclusion criteria were as follows: reports with incomplete mandatory data, irrigation and debridement procedures, and procedures where both narrative and operating procedure (OP) notes were recorded. 11
Development of the synoptic report
A synoptic reporting system was adopted by the divisions of neurosurgery and orthopaedic surgery of a combined spine service as part of a quality improvement project through the health authority. The synoptic report was developed by two of the participating spine surgeons, in conjunction with the health authority, and then subsequently rolled out for revisions by other participating surgeons, and ultimately, the synoptic report (OP note) was live in August 2015. Surgeons had the option of completing narrative reports or transitioning into the new system. A collective decision among all surgeons was made about which pieces of clinical information were mandatory for reporting purposes. Key administrative coding personnel were also included in this decision-making process. Adverse events, procedure performed, diagnosis (pre- and post-operatively), traumatic versus non-traumatic categories, among others, were mandatory, while other aspects such as radiographic measurements, instrumentation used, antibiotics, and medical co-morbidity data were optional. Each mandatory and optional information then populated further fields for more detail and this was additional optional data that could be entered.
Device, bone graft, and adjunct data
Annual device supply was ensured between the various vendors and the procurement department through the sterile processing division. All of the instrumentation systems used, regardless of vendor, were listed as part of the synoptic reporting system. Menus, or “drop-down” options, were available depending on which procedure was being performed. For example, surgeons were required to select the initial diagnosis and the procedure that was performed, but the available fields for instrumentation system would appear but were not necessary to fill in as part of the synoptic report. The decision not to include the instrumentation details was made at the initial introduction of the synoptic reporting system so that there would be adequate uptake of the system without overbearing surgeons with numerous fields and duplicating details of the systems already documented elsewhere in the patient chart.
Additionally, specific bone graft substitutes or bone growth stimulants such as bone morphogenic proteins (rhBMP-2, Infuse; Medtronic Inc.) were included in drop-down menus. These were included in the analysis because they can also generate very large costs for the procedure (upwards of $4,000).
Additional adjunct use was also captured, which included usage details about transexamic acid, antibiotics, anti-embolic stockings, Foley catheter, hemovac drains, intravenous Decadron, topical Depo-Medrol, Surgifoam, bone wax, and Tisseel (Baxter) or DuraSeal (Integra) application. Although not all of these adjuncts lead to significant increases in cost, they were included to generate a better idea about how micro-costs of a procedure may be recorded by participating surgeons. (Note that Tisseel is a fibrin-based sealant and DuraSeal is a hydrogel sealant both used as adjuncts for dura closure both adding considerable costs to procedures).
Strategies for data capture
Within the synoptic reporting system, there are options where fields may be pre-populated if the surgeon is fairly repetitive in the instrumentation system used for certain procedures or with respect to the typical bone graft used for fusion surgeries. For example, a surgeon may perform an L4/5 spinal fusion surgery with the exact same pedicle screws, rods, interbody implant, antibiotics, bone graft, and antibiotics each time. If a dural tear or leak were to occur, then the surgeon would simply only need to add this additional piece of information with respect to Tisseel usage rather than add all of the data for instrumentation and bone graft since it was pre-populated.
Statistical analysis
Inter- and intra-surgeon comparisons by year were analysed using Analysis of Variance (ANOVA) statistics. Average monthly reports completed by surgeons 1-5 per year were also evaluated and compared with ANOVA statistics. Significance was set at P = .05. STATA software was used to perform the analysis.
Results
Overall operative report utilization
There were 2,915 surgical reports available for evaluation from January 2016 to March 2020. There was significant variation between surgeons annually. Upon implementation of the OP note platform, surgeons 1-3 reported the majority of their operative procedures over the study period where instrumentation was used. Surgeon 4 and 5 gradually increased the usage of OP note over the study period.
There was significant variation among surgeons in terms of what additional, optional information that could be used to formulate case costing estimates for the procedures. Surgeon 3 had the highest incidence of recording specific device, adjunct, and bone graft materials. Surgeon 1 reported adjuncts used on more than 90% of cases but reported bone graft and device information less commonly. This likely reflects fewer procedures where devices or bone graft were used. Surgeon 2 rarely reported bone graft or adjunct use, whereas they provided device details 25% of the time. Surgeon 4 initially provided very few details about device, bone graft, or adjunct usage for the initial 2-year phase of the project but subsequently reported more than 95% of the time from the years 2018 to 2020. Surgeon 5 gradually increased the number of OP note procedure forms and less commonly reported on bone graft, instrumentation details, or adjuncts used. See Figure 1 for full details of surgeon OP note utilization.
Device, bone graft, and adjuncts section completion in spine (OP-note) reports.
Operating room (OR) report utilization by month per year
Operating room (OR) reports completed by month did not vary substantially throughout the years since the project was implemented (P = .45) (see Table 1). The number of cases recorded on average per year by surgeon did vary however since the outset of the program. Although all ANOVA results per year demonstrated a statistically significant difference, the results became less significant by the year 2019 (P = .026) versus when the program was initially introduced where the results were highly significantly different (P < .001). On average, surgeons 1-3 reported similar numbers of cases per year, whereas surgeons 4 and 5 reported lower numbers at the outset of the OP note introduction but were reporting significantly higher numbers of procedural reports by the year 2019.
Procedures documented per month by surgeon
Abbreviation: N/A, due to the COVID-19 pandemic reporting was delayed and the number of cases per month were very small.
Strategies for data capture
Only surgeon 3 had a pre-defined template for common procedures performed. Surgeon 3 had the highest rate of compliance over the study period of all surgeons. Surgeon 5 had developed a pre-defined template by 2019, but this did not affect the overall reporting of specific device information, bone graft usage, or additional adjunct information.
Discussion
Surgeon utilization of the OP note synoptic reporting system was highly variable among surgeons; however, by the end of the study period, there was considerable uptake for all surgeons for raw usage of the system. Analysing specific report details, however, only surgeon 3 reliably recorded most aspects of device details, bone graft, and adjunct usage. Surgeon 4 had improved their recording of all three realms by the end of the study period, but surgeons 1, 2, and 5 had not increased their utilization or reporting of the three categories of interest by the end of the term. The results of this 4-year study period would suggest that the majority of surgeons are unlikely to assist in generating accurate case costing details in order to generate value-based assessments of different instrumented spine cases within the healthcare system.
Prior studies evaluating synoptic reporting have outlined significant advantages from a quality improvement prerogative. Park et al. reported greater completeness of necessary information within a significantly shorter period of time in addition and ease of use for the surgeon where the time to complete the entire report and sign off being less than 5 minutes. 12 The purpose of our current study did not evaluate the quality improvement advantages of the system but rather which cost driving aspects of the operation were recorded by the surgeon within the report. Our findings would suggest that although user uptake improved and the critical, required safety information was recorded in all reports, other significant cost data were missing from the majority of surgeons.
One critical shortcoming of the current effort to generate accurate cost details from the synoptic report was that the instrumentation, adjunct, and bone graft details were all optional information and this was clearly highlighted on the report itself. It is less likely that surgeons with significant demands for their time will always document in areas where the information is optional or may be found in other areas of the chart. In future iterations, by making these data essential or mandatory for documentation purposes, better estimations of cost could be made in the future from these reports. Estimating costs is always very difficult in healthcare given the complexity of direct and indirect costs. However, when costs are documented in multiple places, comparisons between estimates can help formulate better sensitivity analyses. In essence, if more estimates are obtained by different methods and they are similar, then administratively, this creates confidence that the results represent true estimates of the cost of a procedure. In this particular setting where micro-case costing data are not traditionally captured, the synoptic report represents tremendous potential in this regard especially if one focuses only on the results of surgeons 3 and 4 over the last 2 years of the study period.
Eryigit et al. evaluated completion rates in a systematic review when comparing narrative and synoptic reports and found that for certain more specific details of the procedure that they were more commonly captured within the narrative, but when fields within the synoptic were mandatory, then completion rates approached 100%. 13 With more mandatory fields for the current surgical group, there is a strong likelihood that completion rates for device, adjunct, and bone graft would all improve.
One unique finding of this work illustrates the importance of procedure templates where the majority of information is pre-populated if the surgeon predictably uses similar devices, bone grafts, and adjuncts with certain specific procedures. Even though the device data may not be pre-populated, if other information is pre-populated, then this allows more time for detailing other aspects of the procedure. Future work will not only focus on making certain fields mandatory but also encouraging surgeons to share or create templates to improve data capture.
Limitations
Although the purpose of this study was to evaluate the micro-case costing abilities of the report, there are other important potential cost drivers that were not evaluated as part of this study. The additional quality improvements and better communication between providers leading to fewer medical errors could be a future focus of this work rather than micro-case costing strategies. Further, the cost savings from quality improvements could significantly outweigh any subtle opportunities for better resource utilization within micro-case cost reports or trends. There is also a counter cost of OP note development and maintenance that must be taken into account with any future work evaluating cost savings.
Conclusion
Synoptic reporting in this setting did not reliably allow for accurate micro-case costing based on the utilization/documentation patterns illustrated by the majority of surgeons. Prefabricated templates for common procedures and changing fields from optional to mandatory may facilitate some case cost estimates in the future. The overall quality improvement costs of synoptic reporting should be considered in any future formal analysis. Health care decision makers should be aware of the limitations of cost estimates with synoptic reporting while entertaining future efforts in improving reporting by surgeons.
