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The Cost of Intra-Operative Craniofacial Education
Sarah Sasor, MD, Roberto L. Flores, MD, John J. Coleman, MD, William A. Wooden, MD, Sunil S. Tholpady, MD PhD.
Indiana University, Indianapolis, IN, USA.

PURPOSE:
Common surgical thinking states providing a surgical education in the operating room prolongs the length and thus costs of cases. As more academic physician groups are absorbed into hospitals, this academic time training surgeons while taking care of patients is unrecognized and unvalued. A cost analysis of the financial burden of increased surgical time in index craniofacial cases was performed to quantify this effect in the context of lost RVU in training residents.

METHODS:
A single senior surgeon's experience from 6/05-3/12 was retrospectively evaluated for CPT codes 40700 (repair of primary unilateral cleft lip) and 42200 (palatoplasty). Collected variables included operative time, total operative time, other procedures, age at surgery, sex, complications, and presence of a resident or fellow and PGY level. Statistical analysis was performed with the Kruskal-Wallis test using the S+ programming language. Further analysis was performed to quantify the effect of additional time to the amount of RVU lost. This effect per resident per case was then used to calculate cost per year for these two index cases.

RESULTS:
During the study period, a total of 45 patients had primary, unilateral cleft lip repair and 70 patients had cleft palate repair. For cleft lip repairs, there were 39 cases (87%) with a resident. For cleft palate repairs, there were 60 cases (86%). There was a statistically significant difference in the amount of time required to perform either surgery with a resident physician than without, with operative times being 160% (p=0.020) longer for cleft lip repair and 165% (p=0.0016) longer for cleft palate repairs. The 2011 RBRVS relative value units (RVU) designated for cleft lip and cleft palate surgery are 14.17 and 12.53, respectively. For a resident to participate operatively in 10 cleft lip and 10 cleft palate cases, this cost becomes substantial. Considering the added operative time, it was determined that no less than 85.4 and 82.0 RVUS are invested for intra-operative cleft lip and cleft palate repair training per resident., respectively. At $50/RVU, this effect is over $4000 per case type per resident.

CONCLUSION:
Resident involvement in OR procedures is crucial to the education and independent surgeons. This involvement comes at significant cost and the burden is being shifted disproportionately to the academic surgery attending. This current study was undertaken because it was realized that hospital administrators believe resident participation in the OR diminishes operative time. Because of this, no acknowledgement of teaching in the OR is planned because that allows 'double-dipping' - charging for cases as well as collecting reimbursement (financial or otherwise) for teaching efforts in the OR. This study is the first to demonstrate that operative times are significantly lengthened even with general surgery board eligible plastic surgery fellows. The result is per hour RVU return is diminished, and academic surgeons are discouraged from teaching in the OR. Realization and adjustment will allow for more optimal pre-operative teaching strategies to reduce operative times, as well as incentives to retain academic surgeons and allow them to be productive teachers in the OR.


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