Surgeon education can reduce unnecessary spinal hardware wastage

An educational program for surgeons can reduce unnecessary hardware "explantations" during spinal surgery, reports a study in the March 1 issue of Spine. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

At the study hospital, surgeon education reduced the rate of spinal hardware wastage by nearly one-third, leading to cost savings of more than $20,000 per year. "It is an obligation that spine providers are part of identifying and addressing any process or event that does not add value to the care of the patient," according to an editorial comment by Dr Kevin McGuire of Beth Israel Deaconess Hospital, Boston.

Educational Program Decreases Waste and Costs
Led by Dr Nancy E. Epstein of The Albert Einstein College of Medicine, Bronx, N.Y., the researchers evaluated an educational program designed to reduce the frequency and costs of hardware explanation during spinal surgery. The program focused on one specific procedure—single-level anterior diskectomy and fusion, or "1-ADF"—commonly performed in patients with disk disorders in the upper (cervical) spine.

"Explantation" simply means the placement and removal of hardware (instrumentation) during the same operation. "For example, an implanted plate may not fit, or implanted screws may be too loose/too short," Dr Epstein and coauthors explain. In a previous study, they identified explanted hardware as a significant contributor to the cost of surgery.

Toward reducing the rates and costs of explantation, the researchers conducted educational sessions for all surgeons performing 1-ADF at their hospital. At those sessions, the surgeons were educated about the definition and costs of explanation of instrumentation used for 1-ADF.

The surgeons were also told that future rates and costs of hardware explantation would be tracked. The tracking data were used to evaluate how the educational program affected explantation rates.

Before the educational sessions, hardware was explanted in 45.5 percent of 1-ADF procedures. After the education sessions, this rate decreased to 16 percent. Explantation rates decreased for most types of hardware, including screws, plates, and spacers.

The decrease in explantation helped to lower costs of ADF-1 surgery. As a percentage of all hardware implanted, the cost of explanted devices decreased from 20 percent to 5.8 percent. On an annualized basis, avoiding explanted hardware resulted in estimated savings of $21,000.

For one type of hardware—"cages" used in placing bone graft material—there was no decrease in explantation rates. The tracking data showed that this problem was linked to individual surgeons, who may benefit from further education or tutoring to reduce waste.

Spinal surgery is likely to be a focus of efforts to control escalating surgical costs. Instrumentation is an important contributor to the high cost of spinal surgery—average costs for the hardware used in the study were $1,450 per plate and $1,200 per set of screws.

Dr Epstein and colleagues believe that the explantation rates and costs identified in their study may be just the "tip of the iceberg"—similar studies of more complex spinal procedures might identify further opportunities for reducing waste. They conclude, "Our findings should encourage the development and institution of surgeon-education practices to reduce the costs/frequency associated with explantation."