Jaime Landman: Hi, this is Jaime Landman, and thank you for tuning into another episode of Endourology Today, which is a collaboration between the fine folks at UroToday, The Endourology Society, and Mary Ann Liebert, and the Journal of Endourology. And today, I feel very blessed to have the Senior Author on the manuscript, Dr. Duane Baldwin, whose name you will recognize as a world-renowned endourologist, but who also, more importantly, I think is my friend, and spends a lot of time, since we're here in Southern California together, coming to our courses and teaching us all the time. Duane is currently a Professor of Urology at Loma Linda University. He directs their minimally invasive urology program. He went to Pacific Union College. He did his medical degree at Loma Linda, as did he do his residency. And then he worked with Elspeth McDougal in his minimally invasive fellowship over at Vanderbilt. And Duane, thank you so much for joining us today.

Duane Baldwin: Thank you so much, Jaime, for having me. It's a pleasure to be here.

Jaime Landman: So, it's really our honor. So Duane, you've published over a hundred articles, and this month in the Journal of Endourology, your article is entitled "The Impact of Patient, Procedural, and Staffing Factors Upon Ureteroscopic Costs". And the truth is this article struck me as very important. I am on our own Value Analysis Committee, and more and more, particularly in the era of COVID where finances seem particularly tight, we're getting pressed every day. And what I find is many administrators often look at the cost side, forgetting the revenue side and efficiency side. And as physicians, I think it's our responsibility to help them understand that, and that's why I love this manuscript, which by the way, I've already shared with the head of our OR, and I'm hoping will stimulate some conversations that will become very obvious as we go through your manuscript.

So in the introduction, Duane, you share really obvious data, which this was a couple of years ago, in 2014, we were spending $3.4 billion on stone disease. As we all know in urology, ureteroscopy is probably the number one mechanism by which we treat stones, as well has let us down a little bit, and fewer people are terribly comfortable with PCNL. So can I just start off by asking you to give me a brief summary of maybe why you did this, and what you did?

Duane Baldwin: Yeah. Well, I think in that introduction, you've really laid out exactly why we did it, which is, it is the most common procedure we do to treat stones. Stones are just a huge cost. I think I was looking at some data and stones are more costly than any other urologic diagnosis. So, it certainly is a problem. It's a problem at the healthcare level for the US. It's a problem at the hospital level and being such a common procedure, it's really a low hanging fruit to study to try and understand how we could be more cost-effective. And that's really everyone's goal is delivering a cost-effective surgical procedure at a very good price without compromising care. So, that was the impetus behind this study.

Jaime Landman: Very good reason. And specifically, what did you do? It was a prospective data collection, correct?

Duane Baldwin: So prospectively, we collected all this cost data, all the factors that go into cost, including operative room time, which is something that some studies don't include, disposables, staffing costs, everything is put in there. So, it's the total cost to the hospital of doing those cases. And so, we looked at that data. We cut it into those above the 50th percentile, and those below the 50th percentile. And then we went back and we tried to get a little bit granular and sort of tease out what were the factors that were spinning it, making one case cost more and one case costs less? And the thing that kind of came out, which it's easily understandable in some ways, but it's not completely obvious, is that the number one factor, and really the only factor that correlated with the total cost was how long the case took, the operative time.

Jaime Landman: Right. So, just to give our audience a quick summary, it was a robust study. He had 129 cases. Ultimately, 108 of those were included. And the nice thing was you found four things. Large stones, as you said, long cases was the one that really stood out, the presence of a resident, and a dedicated scrub tech, but not a dedicated circulator, which I thought was fascinating. So a large stone, I can't control that, because I'd love to say I only do easy cases, but quite frankly, we get some easy ones, and we get a lot of hard ones, too. So, that one's uncontrollable. Long cases, so let's talk about that, because operative length was one of the key metrics.

And by the way, as always, we got special permission from the Journal of Endourology, so that your article will be right here on the UroToday website. If anyone's interested to look at what we're talking about right now, figure five is an incredibly impressive summary that shows in a bar graph, so you can see how relevant each of these factors was. So going back to the long cases, what can I do to shorten my case? Obviously there's certain work time, particularly with the big stones it's going to make things longer, but what kind of things are you going to suggest to the people listening to this? How can I make my case shorter and thus more efficient?

Duane Baldwin: So, that's the million-dollar question. And obviously, being efficient not only saves money, but it also decreases the risk for the patient, it gets you home in time to spend time with your family. So, it's good all around, and it is actually also the hardest question to answer because there are so many factors that go into it. So on our univariate analysis, there were many that correlated, as you pointed out, the size of the stone, whether or not a resident was present. Obviously, something that we didn't have controlled in this study was the amount of time that the resident is operating. But clearly, the longer you let someone who's less experienced operate, the longer the case time is going to go. And there it gets complicated because certainly, training is very important. You want the residents to be well-trained when they finish their residencies. And so, you want them to get as much experience as possible, but you also don't want it to make the case take an unnecessarily large amount of time. So, a few things that you can consider, and that we've been trying to do.

We talk about parallel processing in turnover times in the operating room all the time, but I think we can also do parallel processing during the case. And if everyone is engaged, and you brought up the point that having a dedicated tech was extremely important in reducing costs. And I think one of the reasons for that is, recently I went on a mission trip and I was operating in the Galapagos Islands, and I had a great team. They were experienced, good, very experienced. But the only problem was they spoke Spanish and I spoke English. And so when I would ask for things, my translator would have to convert what I had said. My translator, by the way, was not a medical person to the other team, and I realized it was quite inefficient.

And yet, hospital administrators frequently will put in your room with you a tech from orthopedics or some other person's tech, who doesn't speak the language of urology. And it's really not all that different than operating with someone who doesn't speak English. Urology has very specific guide wires. There's a very big difference between an angle-tipped guidewire, and a double floppy, super stiff wire. And if you're an orthopedic tech, you don't know that, and you don't know which is which. And so you have to go down to, "Hand me the one that has the red with the round. It's about this big," and that takes a lot of time. So that's very inefficient. So clearly, having designated urology-specific staff makes a big difference.

Having things pulled ahead of time, we used to try and limit our disposables, because we thought disposable costs were very important. And what our study showed, and what we're doing much less of now is we're realizing that the time trumps the cost of the disposables. For example, in our center, the nurse has to step out of the room, go down the hallway, get a catheter. If we ask for a 16 French Foley catheter, at the end of the case, she has to walk out of the room, down the hallway, open up the door, go in, pull out the catheter, walk back down the hallway. And that whole process, which takes probably three minutes, maybe four minutes, if you multiply that by $37 a minute, you lose a lot of money while she's doing that. It'd be much cheaper to have the catheter open. Maybe you don't use it, but you'll save money in the long run.

Jaime Landman: I hate to interrupt, but I'll be honest. I don't know how many other urologists are going to be feeling great to hear what you just said, but that happens to us all the time. And I'm just like, "Wow, it's a Foley catheter, and we're urology. You think that would be available to us." So, thank you. You have no idea how much frustration ... just misery loves company. So thank you for being great company. And I think your point is that the circulator and that time trumps everything else, it is really a good point. But in the end, while in every study, and this is not a criticism of the study, you have to pick individual metrics to measure. What I really thought about as I mulled through your study and read it a couple of times, was that really everything is about like a gestalt. And what I find is delay begets delay, begets delay, and efficiency begets efficiency. And even to the point where you ended up building a culture of efficiency, where people are shocked when there's a delay, and will take that extra step to hustle.

So what I find is, and you didn't mention it and hopefully, this doesn't happen to you, but I suspect it doesn't, not only when I have that ortho circulator, who's terrific, I'm sure they're the best ortho circulator ever, in urology do they slow me down? But how many times have you asked for a specific wire or a basket and you get something else, and you're like, "Wow, that's a $250 basket". You can, I guess, put it on the side. Maybe I can take it down to the lab and use it during an experiment, or something now. But it's just totally wasted, right? By your nodding, I hope that's happened to you because now misery loves company some more.

Duane Baldwin: I remember the most egregious example of a case like that was, I was doing a laparoscopic donor nephrectomy with the nurse who had never done a donor nephrectomy before. And we use the ligature in that case, which is a $600, I don't know, extremely expensive tool. And she dropped two of them on the floor, dropped the first one, they got a second one, and she dropped that one on the floor before we got the third one. And clearly, that was because she was not prepared, and not used to it, and nervous, and whatever. So ...

Jaime Landman: I presume you didn't give her the kidney to take to the next room, right?

Duane Baldwin: No.

Jaime Landman: You dropped that, right? That worked out okay. So, the other thing that, and I want to make this quick because we want to be efficient with people's time who are listening, but tell me about the resident issue. Because for those of us who are training residents, like yourself, is there something we can do about it? Because I think some people have made suggestions in laparoscopic manuscripts. Do you have any thoughts about that? I know you do because it's in the inclusion section.

Duane Baldwin: Yeah. So, it is a really important question. And so, we said that on the multi-varied analysis, time was the only factor that predicted cost. But then we went back, and we did a posthoc analysis looking at what were the factors that determine the time? And one of the things that came out was having a resident in the case. Having a resident in the case increases the cost of the case. So clearly, we need to be better at training residents without taking obsessive amounts of time. And so, I think the things that we've talked about in laparoscopic surgery like you say, is giving the resident defined goals. "Okay, in this case, I want you to do this. I want you to do this part of the stone from here to here. I want you to be focused and efficient, and when you get through that, then I'll take over."

So, I think getting the residents on simulators. I know you, at Irvine, have been doing a lot of work with simulators, and the benefits that those have. So you could probably speak to that even much better than I could, but I think simulator training ahead of time, getting them on cases, getting them to do all parts of the case, but maybe they don't have to do the entire case from start to finish, just to keep the case moving forward. I think those are all probably pretty good suggestions, and just setting expectations appropriately.

Jaime Landman: Wonderful. The only last question I'll ask you before we say adieu is I think a lot of people are going to be very interested in this. Cost-reduction is a hot topic. Do you have any pitfalls that you want to help people avoid? Do you have any suggestions? What things could go wrong, and what do we not want to do?

Duane Baldwin: So, what we don't want to do, that's an extremely important question, is we don't want to compromise the quality of the care that we're delivering. And so if we get done really fast, and at the end of the day, the patient is not stone-free, they drop a fragment into the ureter, and come back into the ER with pain and get readmitted, we have not saved a penny, and we've actually spent a lot more money.

So we need to not sacrifice at all the quality of care. We need to not rush trying to leave larger chunks in the kidney. I think that would be my advice, is do a good job, do it well, but do it efficiently. And don't cut corners on things like, if you think it needs a stent, don't try to save the $50 by not putting the stent in, and then have the patient come back with colic or whatever. So I think, don't compromise the principles, provide good care, but just do it in an expeditious manner. And so, I think the main pitfall is don't compromise the quality of the operation.

Jaime Landman: Well Duane, it has been a true pleasure and honor. It's always great seeing you, and this has been extraordinarily helpful and informative for those who are listening. If you're interested, the article is here. For those who are interested in this type of topic, please join the Endourology Society. You will automatically be signed up for the Journal of Endourology. And again, thanks to UroToday, Mary Anne Liebert, who publishes the Journal of Endourology, Endourology Today, the Endourology Society for making this possible.

Duane Baldwin: Thank you, Jaime, for inviting me. Thank you UroToday and Endourology Today for inviting me for this segment, and have a great day.