THE ECONOMIC-CONSIDERATIONS IN LAPAROSCOPIC SURGERY

There has been increasing concern in the medical, business, and insura nce communities and government agencies about the rising cost of healt h care. Since 1980 the cost of medical care has increased from $280 bi llion dollars per year to $670 billion dollars in 1990, and was estima ted at $900 billion in 1993. Several factors have contributed to this increase, including the high cost of hospitalization and new expensive technology, such as laparoscopic cholecystectomy. This present cost a nalysis was undertaken to determine the cost variables in laparoscopic cholecystectomy to see if changes in physician, nursing, and administ ration work activities could decrease the cost of hospitalization. Fif ty-four patients who had an uncomplicated elective cholecystectomy dur ing a five-month period in 1993 were assessed in terms of cost compone nts of hospitalization, including nursing unit labor costs, surgery pe rsonnel labor costs, supply/instrument cost, and ancillary costs. Nine general surgeons participated in this study, four of whom accounted f or 71% of the annual volume of cases. This analysis was performed with the help of Baxter Corporate Consulting, a Division of Baxter Healthc are Corporation. From this study, it was found that the average cost f or uncomplicated laparoscopic cholecystectomy patients was $1589 +/- $ 223. The operating room and supply/instrument component costs were the two largest expenses, accounting for 42% of the total cost. Reimburse ment from various insurance agencies were also evaluated, and it was d etermined that a contract made with a local HMO caused the hospital to lose an average of $443.00 per patient. Instrument cost was evaluated , showing that the surgeons who used disposable instruments had an ave rage instrument cost of $806 +/- $63 per case, whereas those using reu sable products had an average cost of $303 per case. (A reprocessing c ost of $200 was also added when reusable instruments were used. This i ncluded the cost of cleaning, repairs, and labor costs for this equipm ent.) The cost of disposable and reusable products was evaluated in te rms of the initial purchase price, replacement charges, equipment main tenance charges, and labor costs for cleaning, repackaging and inspect ion, sterilization, and quality control. A second factor identified wa s that patients directed to an inpatient nursing unit incurred an aver age direct nursing labor cost of $124, whereas the cost was only $54 w hen the patient went to an out-patient unit. A third observation demon strated that the operating room time averaged 203 min +/- 31 min, and the length of the operative procedure accounted for only 96 min +/- 20 min of the total operating room time. From this data it appears that, in hospitals with more than 300 laparoscopic cholecystectomy cases pe r year, the costs of using reusable and disposable instruments is simi lar. Time/motion studies in the operating room have also been institut ed, along with changes in postoperative physician orders, to decrease the cost of the hospitalization.