When it comes to upgrading or adopting new technology for your OR, it can be difficult to decide what is worth investing in, when and why. Whereas refractive surgery technology can add lines of revenue for an ophthalmic surgery center, the revenue from retina surgical cases is capped by insurance contracts. New expenditures have to be justified by increased efficiency in time or costs or by an increase in safety or improved outcomes. New machines and devices are introduced to the market frequently, and researching all the options can feel overwhelming and perhaps unnecessary, particularly when you feel satisfied with what you have. However, making the right investments could benefit your clinical practice and surgery center in ways you might not have considered.

Retina surgeons have the duality of being attracted to new technologies and simultaneously surgically averse to changes. In the operating room, this can translate to staying within the confines of one or two company suppliers or platforms and only trying the new technologies associated to their chosen platform. To achieve better return on our surgical investments, it may be best to utilize a standardized process for evaluating new retina surgery technology.

EXPAND YOUR HORIZONS, EXPLORE YOUR OPTIONS

The most obvious barriers to adopting new technology are financial. The most important, on the other hand, are logistical. Learning about new technologies should begin years before time of purchase, by constantly following the trends and exposing the surgical team to new devices and platforms. The last important hurdle is the natural resistance to change by both the surgeon and the supporting nursing and technical team. Other common barriers include:

• Being comfortable with your current equipment. A great procedure is defined by great outcomes, but also efficiency, cost and patient happiness. You can do a great procedure that lasts 4 hours, but if the patient is in pain (or has some other discomfort) it’s not a success. Get out of your comfort zone and try something new. Some surgeons are satisfied with their outcomes using 20-gauge instruments, then they try 25- or 23-gauge and they are amazed at the difference.
• Not knowing what’s available. Don’t automatically choose the newest version of your current machine. Consider the alternatives. Reach out to local reps and find out what’s available. They often let you try out new equipment before buying. Also, ask them to refer you to other surgeons who use the equipment to find out about their experience.
• Cost concerns. Consider opportunities to save money. When starting a deal with a new company, they are often willing to negotiate. You can also negotiate depending on what and how much you are buying.

EVALUATE YOUR ASSETS

Before proceeding with large expenditures, evaluate the equipment at your facility. Where is it in its life cycle? Approach the vendor and sales representatives to analyze future issues with technical support, as older equipment may soon be unsupported. Are there any available upgrades that can extend its life span or increase capacity without requiring major capital investments?

In the process of understanding your current and potential future situations, it is important to discuss with all the stakeholders their opinions, problems and needs. Stakeholders range from the surgeons, nurses and technicians to the staff members responsible for ordering supplies. When multiple vendors provide clinically equivalent equipment, other non-clinical factors become more important, like ease of ordering and payment flexibility.

When discussing equipment preferences with surgeons, some may resist any changes in their operating room. In my experience, these surgeons are usually early in their careers and are uncomfortable with any modifications in the midst of their learning curve, or they are at the tail end of their surgical careers. The best approach usually requires an open discussion of advantages and drawbacks, constantly demonstrating the benefit to patients and the surgery space. Colleague mentorship through these transitions can alleviate many difficulties.

Equipment types and considerations

From a general perspective, retina surgical equipment can be divided into three groups: large platforms, smaller consumables and peripherals. The two larger platform categories are microscopes (top right) and vitrectomy machines (bottom right). These usually require significant capital expenditures and have a life cycle of more than 7 years. Smaller equipment ranges from metal reusable instruments and disposable forceps, cannulas and laser probes. Peripherals are equipment used outside of the operating field that support efficiency, documentation and education; this category includes tools such as cameras, video screens, digital video recorders and EMR technology.

Vitrectomy machine platform selection is perhaps the most significant decision to be made. Not only does it determine the basic capacity for vitrectomy surgery, but also disposable packs and equipment purchasing depend on the machine chosen. This is a decision with large clinical and financial consequences. It is also the decision with the largest psychological component for surgeons, since many have not performed surgeries with more than a single platform. This decision is best approached with an objective and critical lens: Are you using your current equipment at its highest capacity? Trying out the different platforms to objectively compare them in surgery can help highlight their similarities and differences.

Purchasing of disposable equipment, by virtue of its lower unit cost, requires less initial financial commitment. But, disposables require adequate inventory management, which is more complex from an administrative perspective. The supply of disposable devices needs to be constantly updated and verified. The amount of inventory at hand needs to be tracked. Nursing and technical staff need to be trained not to open all pieces of disposable equipment that may be needed in a surgery, which is typical in a hospital setting. Instead, it should be available yet unopened until the moment the surgeon specifically needs said equipment. In the retina operating room, each surgical vitrectomy gauge has its line of disposable and reusable equipment. That means a whole additional line of inventory management. This not only increases the administrative burden but also decreases the ability to predict utilization of each specific instrument or device, risking not having equipment available when necessary. I personally recommend that centers agree to predominantly use a single vitrectomy gauge. That allows a more predictable inventory and purchasing system. In addition to simplification of ordering, consolidating the volume into a single line of equipment may also allow negotiations for lower purchasing prices.

 

 

ASK THE RIGHT QUESTIONS

Once you’ve done your homework, it’s time to evaluate objectively. Ask yourself: “Could this technology allow improved surgical efficiency or patient outcomes? Improve the patient experience at my practice? Benefit my staff and/or me (eg, ergonomic design, reduced workload, increased revenue or money saved in the long run)?”

Cost of equipment can be significantly offset by time of surgery. The cost of every minute inside an operating room can be calculated without including equipment costs, anesthesiologist billing time and surgeon professional services cost. The factors that then drive the cost of each OR minute are: real estate expenses (lease or mortgage and amortization of leasehold improvements), non-physician payroll (nursing, technicians and clerical staff) and other fixed operating costs required to maintain compliance (administrative, equipment maintenance and sterilization, surgical gases and supplies). The cost varies between setting (hospitals being more costly than surgery centers), but it is not unusual for costs higher than $25 a minute. In other words, reducing 10 minutes of surgery time can save upwards of $250 per case. This is a reasonable way to evaluate the financial cost/benefit ratio of an instrument.

Consider efficiencies with consolidation. Certain vitrectomy platforms are also excellent cataract surgery platforms, for example. When there are separate rooms for anterior segment and posterior segment procedures, having distinct platforms for each room may be efficient. On the other hand, if the vitrectomy room is also utilized for cataract surgery procedures, it may be advisable to consider a combined platform. Use of a single platform may require less consumables, occupy less space in the room, provide a single point of contact for sales and support and, most importantly, allow techs to learn a single user interface instead of several.

MAKE YOUR DECISION — AND MAKE A PLAN

Once a specific piece of equipment has been chosen, the next steps are purchasing and implementation. Depending on the type of equipment, capital cost and vendor, there may be different options for purchase or lease. The correct decision is different for each individual center based on financial situation and volume projections.

Incorporation of equipment and maximization of utilization are common problems, particularly with complex electronic systems. It’s not unusual to have one surgeon utilize a piece of new equipment more than his or her peers. This discrepancy is both a sign of inefficiency as well as an opportunity for improvement. This can be improved with communication and training, to allow those more resistant to change to accept and adopt new technologies. I am a strong believer in standardization of procedures inside an operating room, since standardization improves efficiencies and quality. The more the staff trains in a single process, instead of distinct processes per surgeon, the more the output of their efforts is maximized.

CONCLUSION

Evaluating new technology can be time and resource intensive, but it’s a critical step in ensuring that you are delivering the best possible patient outcomes and optimizing your practice. Following these steps will help streamline the process and ensure that you make decisions that maximize your return on investment. OM

About the Author

Jorge I. Calzada, MD, FACS, is founder of the specialty clinic Deep Blue Retina in the Memphis, Tenn., metro region, and of Panamerican Vitreoretinal Consultants in the Republic of Panama. He serves as adjunct professor of ophthalmology and vision science at the University of Nebraska.