Systematic review of reusable versus disposable ...

Background: The quality of instruments and surgical expertise in minimally invasive surgery has developed markedly in the last two decades. Attention is now being turned to ways to allow surgeons to adopt more cost-effective and environmental-friendly approaches. This review explores current evidence on the cost and environmental impact of reusable versus single-use instruments. In addition, we aim to compare their quality, functionality and associated clinical outcomes.

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Method: The Medline and EMBASE databases were searched for relevant literature from January 2000 to May 2015. Subject headings were Equipment Reuse/, Disposable Equipment/, Cholecystectomy/, Laparoscopic/, Laparoscopy/, Surgical Instruments/, Medical Waste Disposal/, Waste Management/, Medical Waste/, Environmental Sustainability/ and Sterilization/.

Results: There are few objective comparative analyses between single-use versus reusable instruments. Current evidence suggests that limiting use of disposal instruments to necessity may hold both economical and environmental advantages. Theoretical advantages of single-use instruments in quality, safety, sterility, ease of use and importantly patient outcomes have rarely been examined. Cost-saving methods, environmental-friendly methods, global operative costs, hidden costs, sterilization methods and quality assurance systems vary greatly between studies making it difficult to gain an overview of the comparison between single-use and reusable instruments.

Conclusions: Further examination of cost comparisons between disposable and reusable instruments is necessary while externalized environmental costs, instrument function and safety are also important to consider in future studies.

This article highlights the cost–benefit analysis of disposable surgical instruments over reusable devices from an end-user perspective

 

The economics of using reusable surgical instruments have been analysed in detail by taking appropriate cost indicators for comparison purposes. Hospital expenditure on the reusable devices during its life cycle in the system has been analysed using data from various clinical studies and economic analysis projects published in leading journals and by associations such as the World Health Organization, European Commission and Eurostat.

 

Why cost benefit comparisons are an important determinant of product choice 

The population in Europe is likely to increase from 495.4 million in 2008 to 505.7 million in 2060, with the population aged above 65 years rising from 17.1% of the total population in 2010 to 30.0% in 2060.(1) Healthcare expenditure, however, is likely to increase only marginally from 6.7% of GDP in 2007 to 8.6% in 2060.(1) The expenditure growth is not in line with the population needs from a healthcare provision point of view, resulting in massive efforts to reduce inefficient spending. We expect larger emphasis on improving efficiency in care provision and choice of products and solutions in the future.

 

Avoidable instances of expenditure during care provision

Cost of infection in surgical cases

There are currently approximately 234 million surgical procedures conducted worldwide. Approximately 10% of the surgeries have a risk of acquiring surgical site infection. Surgical site infections increase the average length of stay of every patient by around 9.7 days and the costs by €15,950 per patient.(2) Around 28% of the surgical site infections caused were attributed to equipment cleaning and sterilisation.(3)

 

Surgical environment – cost increases due to inefficiencies

In the surgical environment, the OR costs range between €11.5 and €19.2 per minute to run and maintain.(4) Interestingly, around 28% of planned surgeries tend to be cancelled and approximately 24% of these cancellations are due to insufficient theatre time available.(5) The average increase in theatre time per procedure, due to equipment/instrument failure, is 5.6 minutes.(6) Human error accounts for 85% of the instrument failures or contamination. Nursing is an expensive resource. Investment on training for novice perioperative nurses range from €23,000 to €38,000 per nurse, whereas it ranges from €7600 to €11,500 for perioperative nurses.(7)

 

In today’s scenario, more than 30% of the surgical procedures performed in Europe are day surgeries. More than 60% of the day surgeries are performed outside the hospital environment.(4,8) Non-hospital settings lack sufficient in-house sterilisation facilities. More than 55% of the local decontamination units do not have dedicated areas for decontamination.(9) With a high volume of procedures, the demand for instrument stock tends to be higher in the day surgery units. The resource needed to sterilise reusable instruments in these care settings is not seen to be financially viable in the long term. 

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Surgical inventory costs

The average hospital in a developed country has surgical instrumentation inventory worth anywhere between €1.5 million to €3.0 million.10 The cost of sterilisation per item ranges from €0.18 to €1.28.(11) Sterilisation failures are very common and in most cases it stems from operator errors. Human error accounts for 85% of failures. There are additional maintenance costs to the tune of 9% of the procurement costs of reusable devices.(12) The repair costs associated with the reusable devices accounts for an additional 7.4% on the price of the individual device annually.(13)

 

Conclusions and recommendations

In the last decade, healthcare expenditure on hospitals has reduced globally. Hospitals have been faced with challenges such as increasing administrative costs, procurement costs, resource crunch, and increasing patient flow. 

 

In term of procurement costs, the use of disposables is preferred because it reduces overall costs and also the hassles related with inventory management, infection control etc.

 

In terms of cost efficiency, the use of disposable devices is preferred over the use of reusable devices. The major reasons supporting the use of the disposable devices are given below.

 

Costs

Hospital expenditure related to procurement of surgical instruments and inventory management could be reduced. Disposables provide better financial returns than reusable instruments.

 

Efficiency

There is need to improve functional efficiency of hospitals, more importantly operating rooms. Operating room and staff utilisation levels can be enhanced by use of disposable instrumentation that is less susceptible to failures and have a negligible exposure to decontamination processes.

 

References

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1. Giannakouris K. Eurostat, Statistics in Focus, 72/2008. Ageing characterizes the demographic perspectives of the European societies.
2. de Lissovoy G, Fraeman K. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control.2009;37(5):387–97.
3. Schaefer M. Infection control assessment of ambulatory surgical centers. JAMA 2010;303(22):2273–9.
4. Ministry of Health and Consumer Affairs. Estadística de establecimientos sanitarios con Régimen de Internado. 
5. Ebirim LN, Buowari DY, Ezike HA. Causes of cancellation of elective surgical operations at a University Teaching Hospital. J Med Med Sci 2012;3(5):297–301.
6. Courdier S, Garbin O. Equipment failure: causes and consequences in endoscopic gynecologic surgery. J Minim Invasive Gynecol 2009;16(1):28–33.
7. Association of Perioperative Registered Nurses; Perioperative Orientation Resources – Your guide to orientation, recruitment and retention. www.aorn.org/Education/Curriculum/Periop101/Perioperative_Orientation_Re….
8. Toftgaard C. World Wide Day Surgery Activity 2003. The IAAS Survey on Ambulatory Surgery. www.iaas-med.com/files/Journal/13.1/13.1TOFTGAARD.pdf.
9. Scottish Executive Health Department Working Group. The decontamination of surgical instruments and other medical devices. www.scotland.gov.uk/Resource/Doc/158669/0043050.pdf.
10. Frost & Sullivan analysis.
11. National Health Service Scotland; Sterile Services Provision Review Group: 1st Report – The Glennie Framework. www.sehd.scot.nhs.uk/publications/GlennieFramework.pdf.
12. National Health Service, Wales. Hywel Dda HB Financial Returns 2011–12.
13. Cohen T. The cost of biomedical equipment repair and maintenance: results of a survey. Med Instrum 1982;16(5):269–71.
14. National Expenditures for Health Services and Supplies by Category. Centers for Medicare & Medicaid Services, Office of the Actuary.