A device category economic model of electrosurgery technologies across procedure types: a U.S. hospital budget impact analysis

Figures & data

Figure 1. Model schematic. Abbreviations. ABP, Advanced Bipolar Devices; EES, Ethicon Energy Solutions; MED, Medical Energy Devices; NMA, Network Meta-Analysis; OR, Operating Room; RBC, Red Blood Cell. ^†Refers to MEGA SOFT Reusable Patient-Return Electrodes (Reusable Dispersive Electrodes) (Blue Ash, OH, Ethicon Inc.). ^‡Refers to conventional (e.g. masks, ventilation) (i.e., 0% smoke evacuator use). ^§Current utilization assumes that smoke evacuators are not used among disaggregated MED, while future utilization assumes 80% use of EES smoke evacuation system in base-case analysis.

Table 1. Summary characteristics for studies informing model inputs for advanced energy devices.

First Author (Year)	Study design	Specialty (Procedure)	EES device	MED device (manufacturer)	Procedures (N)
					N (EES)	N (MED)
Hubner (2008)	RCT	Colorectal (Laparoscopic Left Colectomy)	HARMONIC ACE	LigaSure^vi 5 mm (Medtronic)^a	20	21
Tsamis (2015)	RCT	Bariatric (Laparoscopic Sleeve Gastrectomy)	HARMONIC ACE	LigaSure 7 mm (Medtronic)^a	51	43
Ferko (2020)	NMA	Gynecology	ENSEAL Product Family	Various	18-26 studies^b
Roy (2018)	RCT	Gynecology (Total Laparoscopic Hysterectomy)	HARMONIC Product Family	Thunderbeat^vii (Olympus)^a & LigaSure V (Medtronic)^a	20	40
Ferko (2020)	NMA	Thoracic	HARMONIC Product Family	Various	2-5 studies^b
Koga (2014)	Retrospective Cohort	Thoracic (Thoracoscopic pulmonary lobectomy)	ENSEAL Product Family	LigaSure (Medtronic)^a	15	11
Badawy (2017)	Retrospective Cohort	General (Parenchymal transection laparoscopic liver resection)	HARMONIC Product Family	Thunderbeat (7 mm) (Olympus)^a	32	16
Ferko (2020)	NMA	General surgery	ENSEAL Product Family	Various	26-29 studies^b

Abbreviations. EES, Ethicon Electrosurgery Devices; MED, medical energy devices (from multiple manufacturers); NMA, network meta-analysis; RCT, randomized control trial.

^aMedtronic refers to products of Medtronic LLP, including Covidien and Valleylab, manufactured in Boulder CO, USA. Olympus refers to products of Olympus Medical Systems Corp., manufactured in Tokyo, Japan.

^bPlease see Supplementary Appendix B for details regarding NMA methods and results.

Table 2. Model inputs for differences between EES vs. MED advanced energy devices.

Specialty	Outcomes differences
	OR time (Mins)	Hospital stay (Days)	Intraoperative transfusion (%)
Ultrasonic devices
Colorectal	−15.0[9]^c −15.0[9]^c	0.0[9]	0.0%[9]^,a
Bariatric	−5.0[19]	ICE	ICE
Gynecology	0.8[20]^c	−0.11[20]^c	ICE
Thoracic	−8.2^b	−0.43^b	2.2%^ab
General	−38.0[8]	0.0[8]	−1.0%[8]
ABP devices
Colorectal	ICE	ICE	ICE
Bariatric	ICE	ICE	ICE
Gynecology	5.7^b	0.15 ^b	−2.0%^a,b
Thoracic	−5.7[7]	ICE	2.0%[7]^a
General	−34.2^*,b	−0.27^b	−2.1%^a,b
Unit Costs	OR Cost (per Min)	Hospital Cost (per Day)	Transfusion (cost per RBC unit)
Colorectal	$24.26[48]	$972.47[48]	$222.65[49]
Bariatric	$30.81[48]	$1,115.53[48]
Gynecology	$24.27[48]	$503.49[48]
Thoracic	$29.46[48]	$869.13[48]
General	$20.63[48]	$659.28[48]
Device Cost	Assumes price parity ($400 per procedure)

Negative values represent savings in resources with using EES vs. MED.

Abbreviations. ABP, Advanced Bipolar; ICE, Inadequate Comparative Evidence; OR, Operating Room; RBC, Red Blood Cell.

Note: Measures of error were typically not available for hospital resource outcomes. Where available, results provided in Supplementary Appendix B.

^aInput was informed by meta-regression. ^bInput was informed by NMA ^cIndicates significance not reported. *p < 0.05 for differences.

Figure 2. PRISMA diagram for systematic searches to inform model inputs for advanced energy devices. *Final number analyzed includes studies that are found by multiple searches. Abbreviations. ABP, advanced bipolar; BIM, Budget Impact model; MED, Medical Electrosurgery Device; NMA, Network Meta-Analysis; S1, Search 1 HARMONIC Product Family; S2, Search 2 ENSEAL Product Family; S3, Search 3. Advanced bipolar devices from several non-Ethicon manufacturers.

Table 3. Cost inputs for smoke evacuation and reusable dispersive electrodes [2,51,52].

Smoke evacuators		Reusable and disposable dispersive electrodes
Parameter	Value	Parameter	Value
Disposable smoke evacuation pencil (1 per procedure, used in 50% of procedures)^a	$26	Reusable dispersive electrode cost Device lifecycle (years) Device weight (lbs)	$2,482 2 5.4
Disposable laparoscopic tubing (1 per procedure, used in 50% of procedures)^a	$11	Cost per disposable pad	$3.18
Smoke Evacuator filters (4 per year per system)	$346	Number of disposable pads per procedure	1
Fluid Traps (1 per procedure)	$9	Weight of disposable pad (lbs)	0.2
Use of Smoke Evacuator (Current vs. Future)	0% vs. 80%	Cost of waste disposable per pound	$0.22

Abbreviations. lbs, pounds.

^aModel assumes that 50% of procedures use the open approach (requires disposable smoke evacuation pencil) while the other 50% uses laparoscopic surgical approach (requires disposable laparoscopic tubing).

Figure 3. (a) Model-predicted annual cost differences with complete (Base-Case) and partial (secondary analyses) uptake of EES device-category vs. MED. *Negative values indicate cost savings with EES vs. MED. *Results do not include potential savings due to differences in Advanced Energy device prices. ^†Other devices refer to smoke evacuators and reusable dispersive electrodes. (b) Model-predicted annual cost differences by device type and surgical specialty. Negative values indicate cost savings with EES vs. MED. Abbreviations. ABP, Advanced Bipolar Devices; EES, Ethicon Electrosurgery; MED, Medical Energy Devices. *Results do not include potential savings due to differences in Advanced Energy device prices. ^†Other devices refer to smoke evacuators and reusable-dispersive electrodes.

Table 4a. Model-predicted annual cost differences with adoption of EES vs. MED: results by specialty, resource, and device type.

	OR time	Hospital stay	Intraoperative transfusion	Device and waste cost	Ultrasonic	ABP	Sub-totals
Colorectal	−$218,340	$0	$0	$0	−$218,340	$0	−$218,340
Bariatric	−$92,430	$0	$0	$0	−$92,430	$0	−$92,430
Gynecology	$47,327	$6,042	−$1,386	$0	−$10,790	$62,773	$51,983
Thoracic	−$125,500	−$112,118	$2,762	$0	−$183,145	−$51,710	−$234,855
General	−$446,846	−$53,402	−$2,083	$0	−$235,850	−$266,480	−$502,330
Ultrasonic	−$612,599	−$128,733	$776	$0	−$740,555	–	−$740,555
ABP	−$223,190	−$30,745	−$1,482	$0	–	-$255,417	−$255,417
Sub-Totals	−$835,781	−$159,478	$706	$171,213	−$740,555	-$255,417	Total: −$995,973

A negative value indicates cost savings with EES.

Abbreviations. ABP, Advanced Bipolar Device; EES, Ethicon Energy Solutions; MED, Medical Energy Device; OR, Operating Room.

Table 4b. Model-predicted annual cost differences with adoption of EES vs. MED: device type and total.

Reusable dispersive electrodes	Smoke evacuators	Reusable dispersive electrode and smoke evacuator total
−$15,859	$187,072	−$171,213
		Advanced Energy Total
		−$995,973
		Device Category Total
		−$824,760

A negative value indicates cost savings with EES.

Figure 4. (a) One-way sensitivity analyses assuming uptake of the complete EES device-category.

Table

Scenario	EES utilization (%)							Smoke evacuation uptake (%)
Current	0%	20%	40%	50%	60%	80%	100%	0%	0%	0%	0%	0%	0%
Future	100%	80%	60%	50%	40%	20%	0%	100%	80%	60%	40%	20%	0%
Result ($, Thousands)	−$825	−$414	−$227	$171	$570	$782	$1,167	−$781	−$825	−$859	−$913	−$957	−$1,012

Savings indicate cost-savings from overall economic model. Abbreviations. ABP, Advanced Bipolar; AE, Advanced Energy; EES, Ethicon Electrosurgery; LOS, Length of Stay; MED, Medical Energy Devices; OR, Operating Room; US, Ultrasonic. Savings indicate cost-savings from overall economic model. (b) Sensitivity analyses of inputs involving adjusted utilization of EES advanced energy and smoke evacuator uptake.

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Data availability statement

All data were included in the tables, figures, and Supplementary information.