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Physician preference items: what factors matter to surgeons? Does the vendor matter?


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Background The USA devotes roughly $200 billion (6%) of annual national health expenditures to medical devices. A substantial proportion of this spending occurs during orthopedic (eg, hip and knee) arthroplasties – two high-volume hospital procedures. The implants used in these procedures are commonly known as physician preference items (PPIs), reflecting the physician’s choice of implant and vendor used. The foundations for this preference are not entirely clear. This study examines what implant and vendor characteristics, as evaluated by orthopedic surgeons, are associated with their preference. It also examines other factors (eg, financial relationships and vendor tenure) that may contribute to implant preference. Methods We surveyed all practicing orthopedic surgeons performing 12 or more implant procedures annually in the Commonwealth of Pennsylvania. The survey identified each surgeon’s preferred hip/knee vendor as well as the factors that surgeons state they use in selecting that primary vendor. We compared the surgeons’ evaluation of multiple characteristics of implants and vendors using analysis of variance techniques, controlling for surgeon characteristics, hospital characteristics, and surgeon–vendor ties that might influence these evaluations. Results Physician’s preference is heavily influenced by technology/implant factors and sales/service factors. Other considerations such as vendor reputation, financial relationships with the vendor, and implant cost seem less important. These findings hold regardless of implant type (hip vs knee) and specific vendor. Conclusion Our results suggest that there is a great deal of consistency in the factors that surgeons state they use to evaluate PPIs such as hip and knee implants. The findings offer an empirically derived definition of PPIs that is consistent with the product and nonproduct strategies pursued by medical device companies. PPIs are products that surgeons rate favorably on the twin dimensions of technology and sales/service.
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Physician preference items: what factors matter
to surgeons? Does the vendor matter?
Lawton R Burns1
Michael G Housman2
Robert E Booth3
Aaron M Koenig4
1Department of Health Care
Management, The Wharton
School, University of Pennsylvania,
Philadelphia, PA, 2Singularity
University, Moffett Field, CA,
33B Orthopaedics, Langhorne,
PA, 4Harvard Medical School,
Massachusetts General Hospital, Wang
Ambulatory Care Center, Boston, MA,
Background: The USA devotes roughly $200 billion (6%) of annual national health expendi-
tures to medical devices. A substantial proportion of this spending occurs during orthopedic (eg,
hip and knee) arthroplasties – two high-volume hospital procedures. The implants used in these
procedures are commonly known as physician preference items (PPIs), reflecting the physician’s
choice of implant and vendor used. The foundations for this preference are not entirely clear. This
study examines what implant and vendor characteristics, as evaluated by orthopedic surgeons,
are associated with their preference. It also examines other factors (eg, financial relationships
and vendor tenure) that may contribute to implant preference.
Methods: We surveyed all practicing orthopedic surgeons performing 12 or more implant pro-
cedures annually in the Commonwealth of Pennsylvania. The survey identified each surgeon’s
preferred hip/knee vendor as well as the factors that surgeons state they use in selecting that
primary vendor. We compared the surgeons’ evaluation of multiple characteristics of implants and
vendors using analysis of variance techniques, controlling for surgeon characteristics, hospital
characteristics, and surgeon–vendor ties that might influence these evaluations.
Results: Physician’s preference is heavily influenced by technology/implant factors and sales/
service factors. Other considerations such as vendor reputation, financial relationships with the
vendor, and implant cost seem less important. These findings hold regardless of implant type
(hip vs knee) and specific vendor.
Conclusion: Our results suggest that there is a great deal of consistency in the factors that
surgeons state they use to evaluate PPIs such as hip and knee implants. The findings offer an
empirically derived definition of PPIs that is consistent with the product and nonproduct strate-
gies pursued by medical device companies. PPIs are products that surgeons rate favorably on
the twin dimensions of technology and sales/service.
Keywords: physician’s preference, surgeons, orthopedics, hip implants, PPIs
Physicians are the primary decision makers regarding which technologies to use in
patient treatment. The growing sophistication of these technologies and the intensity
with which they are used are commonly identified as a major portion of hospital
expenses and a major driver of rising health care costs. Thus, physician-level decisions
on products and product vendors represent “ground-zero” in efforts to contain costs.
For a nontrivial portion of medical-surgical supplies used in patient treatment,
physicians have traditionally exerted some preference for (and some active control
over) the product to buy and the vendor to purchase it from. This control is exerted
through the hospital’s purchasing process and the materials manager. Such supplies
Correspondence: Lawton R Burns
Department of Health Care Management,
The Wharton School, University
of Pennsylvania, 3641 Locust Walk,
Philadelphia, PA 19104, USA
Tel +1 215 898 3711
Fax +1 215 573 2157
Journal name: Medical Devices: Evidence and Research
Article Designation: ORIGINAL RESEARCH
Year: 2018
Volume: 11
Running head verso: Burns et al
Running head recto: Physician preference items
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are labeled as physician preference items (PPIs). In recent
years, hospitals have begun to exercise some influence here
as well by imposing caps on vendor payments, restricting
access to vendors using formularies, and collaborating with
physicians in gainsharing programs.
Aside from a handful of industry-sponsored surveys,
little is known about the factors associated with physician’s
preference (ie, what it is that physicians prefer in a product
and its vendor). Part of the problem is that there has been little
conceptual or empirical effort to define PPIs. Moreover, little
is known whether vendors with higher market shares outper-
form their competitors on these product/vendor dimensions
or whether market share is based on other considerations.
This research begins with a conceptual model of the fac-
tors associated with the physician’s choice that may define
physician’s preference. It then presents survey data from
orthopedic surgeons in one state to assess this conceptual
model and identify the factors that surgeons say they use in
selecting a given product or vendor. Finally, it compares the
surgeon’s evaluations of the major implant vendors to detect
any possible differentiation along the factors that drive the
surgeon’s choice.
Twin pillars of medical device sector
The medical device sector, like the other technological sectors
in the health care industry, rests on the following two pillars:
the invention of new technology and assuring its adoption
by clinician customers.1 The twin pillars can be more simply
labeled as product innovation and commercialization or prod-
uct development and market development. The former entails
the development of new technology, innovative technologi-
cal features that increase its functionality and ease of use,
the ability of these technologies and features to meet unmet
clinical needs, research and development activities, clinical
trials of new products and data that convey their technological
advantage, development of intellectual property, and manage-
ment of the regulatory and reimbursement processes. The
latter entails product launch, sales force efforts to support the
launch and promote subsequent adoption (eg, by informing
physicians about new device products to treat new patients
indicated for such products by the clinical trials), product
training and feedback, and cultivation of relationships with
key opinion leaders and physician customers.
The medical device trade literature commonly acknowl-
edges the importance of these two capabilities in the success
of new devices across many product categories.2,3 Vendor cor-
porate documents and analyst reports similarly acknowledge
the twin pillars by their frequent reference to their company’s
dual focus on “product” and “nonproduct” strategies.4 The
different products marketed by multiproduct vendors (eg,
vascular intervention and cardiac rhythm management) share
similarities in their key success factors (identified earlier).
These two strategies target physicians (rather than
patients) as the core customer. Surveys indicate that the vast
majority of patients do not have a brand preference and leave
the decision on implant choice to their physician. Vendors
pursue the twin strategies to attract physician customers, and
physicians respond to those strategies in the form of product/
vendor preference.
In general, physicians treating patients in need of such
products gravitate toward companies that 1) continually
develop a pipeline of new technologies that 2) contain new
product components and features (eg, ease of implantation,
functionality, reliability, and product life) that 3) meet the
unmet clinical needs of their patients with 4) demonstrated
therapeutic efficacy and that (5) receive prompt regulatory
clearance and payer reimbursement and 6) are supported by
sales and service offerings that (7) target the physician as the
key customer and thus 8) maintain the physician’s loyalty to
the company’s representatives and broad line of differenti-
ated products, which is enhanced by 9) the manufacturer’s
reputation and brand image which 10) thereby help to sup-
port premium pricing. The top vendors compete on these
Physician’s preference
The product and nonproduct strategies of medical device
firms suggest that physician’s preference may similarly rest
on the dimensions of product innovation and sales/service.
Researchers have noted that physicians not only have specific
brand preferences for device product lines, instrumenta-
tion, and supplies but also desire high levels of service.5,6
Similarly, a recent government report describes PPIs as
products that physicians “have high confidence in terms of
their value to patient care and reliability, after promotion by
device makers.7
The existence of physician’s preference should not be
surprising. Workers in many skilled occupations, as well as
athletes in many professional sports (golf and baseball), are
known to have favorite tools (and vendors who supply them).
Some observers claim that clinical input has probably been the
most important influence over product choice for decades.8
When hospitals recruit specialists to their medical staffs, they
are also recruiting the vendors who make the products those
specialists favor and utilize, as well as the sales representatives
who may assist the surgeon with the procedure in the operating
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Physician preference items
room (OR). Often these preferences are formed early on in
the surgeon’s career following medical school training, such
as in residency and fellowship programs.9
Importance of PPIs
USA expenditures on medical devices represent 6% of
national health expenditures, or roughly $200 billion in
2015.10,11 Musculoskeletal procedures (eg, knee and hip
arthroplasties) that utilize implants constitute a large share
(24%) of OR procedures and have exhibited extremely high
growth rates (93 and 40%, respectively, between 2001 and
2011).12 Total joint arthroplasties are considered one of the
most successful surgical interventions of the past century,
reaching over 800,000 patients by 2013.13 There is thus
great interest in understanding (and perhaps influencing)
physician’s preference among implants and other PPIs, which
comprise anywhere from 40 to 60% of a hospital’s total
expenditures on supplies.14 Moreover, the physician’s choice
of a given PPI may not be closely tied to the product’s cost,
which can thwart hospital cost containment efforts.
Physician’s preference and influence over product choice
affect the prices that hospitals pay, in part by reducing the
latter’s ability to standardize on a small number of vendors
and obtain bulk pricing (exchange high volume for lower
unit cost). Rising health care costs, technological innova-
tions introduced during the 1990s and early 2000s (eg, bare
metal and drug-eluting stents, pacemakers, and implantable
cardioverter defibrillators), the emergence of nationally
organized group purchasing organizations (GPOs), the advent
of bundled payment, and growing attention to the hospital
supply chain have highlighted these issues regarding PPIs.
Denition of PPIs
Surprisingly, despite the attention paid to PPIs, there is little
empirical research on what physician’s preference actually
rests on. There are a host of definitions, however:
Montgomery and Schneller14 defined PPIs as those for
which physicians have strong preferences and make the
choice in hospital purchasing – typically not based on cost
but rather on personal experience with the device and rela-
tionships with the vendor’s sales representative.
Wilson et al15 defined them as products with which physi-
cians have familiarity and loyalty, often built on relationships
based on product development, training, continuing medical
education, and service.
Premier, a national purchasing group, suggests that
working relationships between physicians and vendors in
developing and testing new products help to turn clinicians
into vendor advocates.29
Lerner et al16 defined PPIs as implantable medical devices
that “surgeons choose, hospitals purchase, patients receive,
and the public pays for”.
Robinson17 and DeJohn8 defined them as “high-cost and
high-quality devices to distinguish them from more humble
supplies purchased via bulk discounts”.8,17
McIlhargey,18 finally, defined PPIs more broadly as prod-
ucts that physicians believe will ultimately produce a higher
quality of life for their patients, require specialized training on
the part of the surgeon, and frequently represent some kind of
liability risk associated with their use and expected outcomes.
As is evident from the review of the literature, the definition
of PPIs may be “as broad as the number of physicians in this
country”.18 It may also be broadly characteristic of supplies in
many clinical areas beyond musculoskeletal (eg, orthopedics)
and circulatory (cardiovascular) to encompass general surgical
instruments and even more mundane items such as needles
and syringes.9,19
PPIs are further defined by the physician’s role in product
choice. Several industry studies have confirmed the central
role of physicians (vis-à-vis materials managers, OR man-
agers, and hospital administrators) in product selection.20–23
The choice among technologically advanced and evolving
products is made by the surgeon, in consultation with the
patient, but the order is placed by the materials manager and
the purchase is made by the hospital or ambulatory surgery
center. The complex nature of these PPIs, the division of labor
in medical device selection vs ordering vs purchase, and the
close relationship between the vendor and the physician may
help to explain the large variation in medical device costs that
is not explained by case volume or hospital characteristics.24
This explains the recent policy and research interest in PPI
price transparency, physician–hospital collaboration in new
product selection and vendor bargaining, implant formular-
ies, case-based pricing, technology assessment committees,
and other efforts to control implant costs.25–27
Which factors are more important than others in physi-
cian’s preference? A prior survey of hip and knee surgeons
reported quality (clinical results), cost, and improved material
technology as the three main reasons for changing implant
brands, followed by ease of use as a distant fourth.28 Premier
reported the following top five factors influencing the hos-
pital’s purchasing behavior of PPIs: clinical outcomes, cost,
physician’s past experience and familiarity, the hospital’s
value analysis process, and the physician’s preference.29,30
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Burns et al
By contrast, industry studies suggest that the decision is
not driven by the PPI’s cost but rather by product technology
and service considerations.21–24 The former include longev-
ity, instrumentation, ease of use, product innovation, and
manufacturer reputation; the latter include the sales repre-
sentatives, training programs, and existing relationships with
other surgeons in the practice.31 Industry surveys reveal that
more than two-thirds of orthopedic surgeons have worked
with their sales representative for >5 years.31 These factors
are not necessarily tied to product cost but rather to personal
experience with the product, assessment of a patient’s inter-
ests, and relationships with the sales representative. Surveys
suggest that physicians believe the consulting and proctoring
contracts with vendors are important for the development
and delivery of safe and effective products and surgical
techniques, even though only a small minority of surveyed
orthopedic surgeons (6%) had such contracts.31
Dimensions of physician’s preference
This study identifies factors that surgeons state they use in
their choice of orthopedic implant and vendor. They cover
the product’s technological features (eg, scientific evidence,
length of follow-up in scientific studies, patient outcomes,
longevity, design and ease of implantation, and design and
ease of instrumentation), sales and service features (eg,
implant training program, willingness to listen to sugges-
tions about product improvement, the sales representative’s
availability and follow-up, the sales representative’s tenure,
and continuing education), and other features such as vendor
and product reputation, product cost, and consulting arrange-
ments. Some factors may apply across implants, while others
may be implant specific. The article then analyzes 1) which
factors are more or less important to physicians, 2) whether
the factors vary in importance across two types of implants
(hip versus knee), 3) whether the factors important to physi-
cians vary across implant vendors, and 4) whether physician
ratings differ across vendors.
More generally, the article seeks to help hospitals with
medical device decision making by comparing five major
vendors of hip and knee implants on multiple dimensions
of product performance, service, and quality. We rely on
evaluations from practicing orthopedic surgeons in one state.
Surgeon evaluations reported here are based on long-term
clinical experience but are not meant to represent clinical
studies. Our data also reflect what surgeons state they use
in implant and vendor selections and not the actual implant
choices for particular patients.
Materials and methods
Questionnaire design
The data presented here are taken from a survey of orthopedic
surgeons in the Commonwealth of Pennsylvania. We devel-
oped the survey in consultation with high-volume orthope-
dists, executives of several orthopedic implant vendors, and
materials managers at several hospitals. An earlier version of
the survey was pilot tested with 25 orthopedic surgeons at a
hospital in another state specializing in orthopedic implants.
Results from this survey were used to refine the survey instru-
ment prior to the state-wide survey implementation.
The survey first solicited background information from
the surgeons regarding their primary vendor for hip and knee
implants, the other implant vendors they used, the proportion
of their practice devoted to arthroplasty vs spine vs trauma,
the number of years in practice, whether they completed an
arthroplasty fellowship, whether they used the primary vendor
during their residency/fellowship, their involvement in teach-
ing and research functions, and their economic relationships
with the vendor (consulting fees and honoraria for talks). The
second part of the survey asked surgeons to rate the factors that
influenced their decision to use an implant product or vendor
using Likert-type scales (ranging from 1 “strongly disagree”
to 5 “strongly agree”). Some items asked surgeons to sepa-
rately evaluate the knee from the hip implant they used most
frequently. These survey items mapped onto our conceptual
model of product preference across the following four domains.
Domains of physician’s preference
Scientific evidence of better outcomes
Length of follow-up in scientific studies
Outcomes in surgeon’s patients
Device design and ease of implantation
Instrument design and ease of use
Implant longevity in patient
Product reputation
Ease of switching to another vendor’s product
Sales and service
Vendor’s implant training program
Availability and likeability of the sales representative
Follow-up, thoroughness, and knowledge of the sales
Stability and tenure of the sales representative
Ability of sales representative to augment OR staffing
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Physician preference items
Ability of sales representative to improve case quality or
OR efficiency
Education-focused seminars/events funded by vendor
Information available to patients on the Internet
Experience with senior surgeon mentors during orthope-
dics training
Product/vendor used during orthopedics training
Implant vendor
Vendor’s willingness to listen to surgeon’s suggestions
for improving existing products
Product innovations introduced by vendor
Vendor reputation
Vendor’s willingness to create specialized products to
meet surgeon’s needs
Another vendor makes a similar implant that performs
the same function
Cost/financial considerations
Cost of implant
Willingness of insurers to adequately reimburse surgeon
and hospital
Consulting arrangements with vendor
The study also measured the surgeon’s hip and knee
implant volumes at each hospital where they performed
arthroplasty procedures. These data were taken from the
discharge database maintained by (and available for purchase
from) the Pennsylvania Health Care Cost Containment Coun-
cil ( This database has previously been uti-
lized by researchers to study volume–outcome relationships
in arthroplasty procedures.32 Commonwealth of Pennsylvania
publications of these same data reveal that the vast majority
of surgeons (301/316 or 95%) performing 30 or more hip or
knee replacements a year perform both procedures.33 These
data also allowed us to identify the surgeon’s primary hospital
and its characteristics (bed size, surgical volume, teaching
status, ownership, and hospital system membership), as well
as measure the number of hospitals at which the surgeon
performed implant procedures and the percentage of implants
performed at the primary facility.
Questionnaire administration
The PHC4 discharge database yielded a large, initial popula-
tion of surgeons (N=2,421) linked to a hip or knee implant
procedure in Pennsylvania hospitals. This number dwarfs
the number of surgeons performing 30 or more procedures
reported in the PCH4’s own publications, suggesting that
there is some “noise” in the database’s surgeon identifier.
The vast majority of surgeons in the state database (N=1,869)
performed less than one procedure per month on average;
of these, the vast majority performed only one (N=1,188) or
two (N=349) per year. We excluded the low-volume surgeons
(defined as <12 annual total procedures) from our sample and
the survey administration because they were less likely to be
active orthopedic surgeons and to have sufficient familiarity
with the implant vendor and its products. This yielded a total
of 552 surgeons, a number that seems reasonable given that
it lies between the total number of orthopedists identified by
the Commonwealth of Pennsylvania who performed knee and
hip replacements in 2002 (N=488) and 2013 (N=619), thereby
further justifying our exclusion decision.33,34 We excluded an
additional 60 surgeons for whom we did not have full names
or could not locate mailing addresses. Following these exclu-
sions, we had a final sample of 492 orthopedists to whom we
sent the survey. After two mailings, we received responses
from 201 surgeons, representing a response rate of 40.85%.
Analysis of survey nonresponse
We used the PHC4 discharge database to compare responders
and nonresponders on a number of practice characteristics
that might affect their evaluations of vendors. These included
the number of hospitals that surgeons utilized, their implant
procedure volumes for hips and knees, the share of their total
hip and knee implant volume at the primary hospital, and the
share of the hospital’s total implant volume accounted for by
that surgeon. Student’s t-test (appropriate for continuous vari-
ables) revealed that most of these differences were significant
or marginally significant. Compared to the nonresponders, the
responders utilized significantly fewer hospitals (1.6 vs 1.8,
P<0.07) and had higher hip implant volumes (34.7 vs 27.5
procedures, P<0.10), significantly higher knee volumes (66.4
vs 53.2 procedures, P<0.05), higher shares of their implant
volume at the primary hospital (20.7 vs 18.7%, P<0.25), and
significantly higher shares of the hospital’s total implant vol-
ume (17.2 vs 14.1%, P<0.02). Since these variables are likely
to influence the results, we statistically controlled the differ-
ential response. We estimated a logistic regression model to
predict survey response using the surgeon’s utilization and
volume characteristics, computed the inverse mills ratio to
measure the odds of survey nonresponse, and then used it as
an additional covariate in the results. We also weighted the
data to conform to known population distributions to estimate
population means.35,36
As an additional test of nonresponse bias, we conducted
a wave analysis to compare the responders to the first and
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Burns et al
second administrations of the survey.37,38 There were no sig-
nificant differences across all survey items.
Statistical analysis
Our analysis first sought to identify the factors that surgeons
rate most highly in their choice of implant or vendor. For this
portion of the analysis, we present the univariate statistics
from the survey for items pertaining to each of the factors.
We then sought to determine whether there was any dif-
ferentiation across two implant types (hip vs knee) and five
implant vendors on these factors. For this latter analysis, we
used bivariate statistics displaying the means for each factor
across the five major vendors and, then, tested for significant
differences by vendor using analysis of variance (ANOVA).
Surgeon respondents who used another vendor for their hip
and knee implants were excluded due to small sample sizes.
Because performance evaluations are likely to be influenced
by a variety of factors, we computed the least-square means
across vendors controlling the following: the surgeon’s hip/
knee implant volume; the proportion of practice devoted to
spine/arthroplasty/trauma; the number of years in practice;
completion of an arthroplasty fellowship (1= yes); use of the
same vendor during residency/fellowship (1= yes); number
of hospitals used; proportion of implant procedures at pri-
mary hospital; engagement in three extracurricular activities
including teaching fellows/residents, writing journal publica-
tions, and speaking at extramural meetings (1= yes); presence
of two different economic ties with implant manufacturers
including consulting fees and honoraria for talks (1= yes);
and the survey nonresponse correction term. We also included
characteristics of the surgeon’s primary hospital, including
academic medical center (yes =1), ownership (for profit =1
and public =1; nonprofit is excluded contrast), size (factor
scale combining bed size and surgical volume), and member-
ship in hospital system (1= yes).
We conducted two additional analyses to summarize dif-
ferences in factors promoting vendor choice. We calculated
the Tukey–Kramer pair-wise differences-of-means that con-
trast each vendor with every other vendor on each factor. We
also used the least-square means to rank order the vendors
on each performance measure to determine whether there
were any clearly preferred implant vendors or any association
with vendor market shares. The large number of respondents
afforded a sizeable number of orthopedists using three of
the five vendors (and a reasonably large number using the
other two) to assure the vendor-specific means are reasonably
normal. In all of the bivariate analyses, we were more con-
cerned with vendor rankings on the performance measures
than the effects of the background variables; hence, we did
not rely here on more sophisticated modeling approaches to
untangle their effects.
This study was reviewed by the University of Pennsylvania
Office of Regulatory Affairs and exempted from IRB Review
(category 2, minimal risk). Informed consent was obtained
via a cover letter requesting participation and voluntary
survey completion.
Univariate statistics
Table 1 presents the univariate statistics from all of the
measures. The average orthopedist performed 101 implant
procedures, devoted ~41% of their practice to arthroplasty,
had been in practice over 17 years, and concentrated ~90%
of their implant procedures at one hospital. Orthopedists typi-
cally used more than one hip implant vendor (mean =1.48)
and one knee implant vendor (mean =1.35) but concentrated
well over 90% of their implant purchases with one vendor.
Only 12% had economic ties with implant vendors, and only
13% used the vendor during their residency/fellowship.
With regard to the factors that, according to surgeons,
influenced their choice of vendor, those that pertain to the
technology appear more important. These included (in
order) better outcomes for patients (mean of 4.49 out of
5.00), longevity of implant (4.34), design and ease of both
implant (4.32) and instrumentation (4.32), scientific evidence
of better outcomes (4.29), length of follow-up in scientific
studies (4.25), and to a lesser extent, product reputation
(3.64). The other set of factors that appeared quite important
included one vendor characteristic – the absence of another
vendor making a similar implant (4.11) – and the following
three sales/service characteristics: the sales representative’s
follow-up and thoroughness (4.39), knowledge (4.36), and
availability (4.16). However, the important role played by the
sales representative in fostering physician’s preference was
not global. The sales representative’s role in the OR was of
intermediate importance – in terms of improving case quality
(3.80), increasing OR efficiency and turnaround (3.31), and
augmenting OR staffing (3.16) – as was their stability (3.87)
and likeability (3.53).
Similarly, according to surgeon respondents, most factors
tied to the implant vendor were of intermediate importance:
vendor reputation (3.55), product innovations introduced by
vendor (3.53), vendor-funded educational seminars (3.53),
vendor willingness to listen to surgeon’s suggestions for
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Physician preference items
Table 1 Univariate statistics (N=201)
Surgeon background characteristics Mean SD
Hip implant volume 34.72 49.78
Knee implant volume 66.42 75.05
Number of years in practice 17.38 8.60
Number of hip vendors used 1.48 0.81
Number of knee vendors used 1.35 0.71
Number of hospitals utilized 1.61 0.77
Proportion completing arthroplasty fellowship 21%
Proportion using same vendor from residency/fellowship 13%
Proportion of hip implant cases performed using primary vendor 93%
Proportion of knee implant cases performed using primary vendor 96%
Proportion of surgeon implant volume at primary hospital 88%
Proportion of practice devoted to arthroplasty 41%
Proportion of practice devoted to spine 4%
Proportion of practice devoted to trauma 18%
Proportion with extracurricular activities:
Teach residents/fellows 46%
Write journal publications 18%
Speak at extramural meetings 43%
Proportion with economic relationships with vendors:
Consulting fees 12%
Honoraria for talks 12%
Proportion aflated with each vendor
Vendor 1 8%
Vendor 2 25%
Vendor 3 10%
Vendor 4 19%
Vendor 5 32%
Others 5%
Factors inuencing surgeon decision to use given product or vendoraMean SD
Scientic evidence of better outcomes 4.29 0.69
The length of follow-up in scientic studies 4.25 0.66
Better outcomes in my patient population 4.49 0.57
The design and ease of use of the implant 4.32 0.61
The design and ease of use of the instrumentation 4.32 0.62
The longevity of the implant in the patient 4.34 0.64
Reputation of a specic productb3.64 0.96
Ease of switching to another vendor’s productb3.38 1.26
Implant vendor
Vendor willingness to listen to my suggestions for improving existing products 3.44 1.00
The product innovations introduced by the vendor 3.53 0.86
Reputation of the vendorb3.55 0.94
Vendor’s willingness to customize product for surgeonb3.31 1.11
Another vendor makes similar implantb4.11 0.88
Information available to patients on the Internet and/or patient requests 2.12 0.88
The vendor’s implant training program 2.79 1.11
Availability of the sales representativeb4.16 0.96
Likeability of the sales representativeb3.53 1.01
Follow-up and thoroughness of the sales representativeb4.39 0.71
Knowledge of the sales representativeb4.36 0.78
Stability and tenure of the sales representativeb3.87 0.99
Ability of the sales representative to augment OR stafngb3.16 1.25
Ability of the sales representative to improve case qualityb3.80 1.07
Ability of the sales representative to increase OR turnaroundb3.31 1.21
Seminars/events funded by vendor and focused on educationb3.53 0.96
Particular product/vendor used during orthopedics trainingb3.05 1.33
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Burns et al
product improvements (3.44), and vendor willingness to cre-
ate specialized products to meet the surgeon’s needs (3.31).
Compared to these items, other factors were much less
important, including experience with surgeon mentors during
residency training (3.23), exposure to the implant/vendor dur-
ing training (3.05), implant cost (3.21), the vendor’s implant
training program (2.79), hospital reimbursement (2.54),
surgeon reimbursement (2.22), patient information (2.12),
and consulting arrangements (2.10). The low importance of
consulting arrangements may reflect the low percentage of
surgeons (12%) with such arrangements among our sample.
This percentage may be slightly higher than the national
average. Data reveal that only 4% of orthopedists received
industry payments in 2007;39,40 data from the Open Payments
Program database revealed that only 402 orthopedists per-
forming adult reconstructive procedures received industry
payments during the latter part of 2013.41
Bivariate results: factors driving implant/
vendor choice, by implant type
Surgeons ranked the importance of several factors across
the four domains of product preference (technology/implant,
vendor, sales/service, and cost/financial considerations) sepa-
rately for hip and knee implants. The ratings were virtually
identical. There were no significant differences for any item.
For the sake of parsimony, these results are not presented here
(available from lead author).
Bivariate results: factors driving implant/
vendor choice, by vendor
Table 2 presents the unadjusted means for the factors associ-
ated with the surgeon’s choice of vendor for hip implants,
broken out by specific vendor (identity masked). There are
few significant differences across vendors (P<0.05); thus,
we present data on only a subset of the items across the
four domains. Table 3 compares the means across vendors,
adjusted for all of the background variables included in a
least-squares regression. There are no significant differences
across vendors. Moreover, the ranks are not associated with
vendor market shares.
Key ndings
Our results suggest that orthopedic implants represent PPIs
on several dimensions. Consistent with vendor strategy,
these dimensions encompass both the technology/implant
and sales/service. Factors relating to the technology are rated
most important; some factors relating to sales/service are
also highly rated but not uniformly so. Factors that relate to
the vendor and the implant’s cost/financial considerations are
rated lower in importance. This is not to say that these other
factors are not important but only that they are relatively less
important as evaluated by surgeons.
Specifically, the most important technological consid-
erations associated with physician’s preference encompass
patient outcomes and implant longevity, scientific evidence,
and the design and ease of both the implant and its instru-
mentation. The most important sales/service considerations
encompass the sales representative’s follow-up, thoroughness,
knowledge, and availability. These findings thus suggest that
PPIs are products that help the surgeon with his/her profes-
sional role as the patient’s agent.
The importance of these factors does not seem to vary
by type of implant (hip versus knee). This finding is not that
surprising, given that the orthopedic surgeons studied here
perform both hip and knee procedures, utilize both types of
implants, and procure them from the same vendor. It is also
possible that our questionnaire design which asked orthope-
dic surgeons to rate both implants introduced some response
set bias in the ratings.
There is not a great deal of variation in the importance
assigned to these factors across vendors, as reported by
orthopedic surgeons. This finding is consistent across the
four domains of technology, vendor, sales/service, and
cost/financial considerations. There are also no significant
differences in how the vendors were rated on these factors.
Surgeon background characteristics Mean SD
Experience with senior physician mentors during training23.23 1.32
The cost of the prostheticb3.21 1.10
Willingness of insurers to adequately reimburse physicianb2.22 1.19
Willingness of insurers to adequately reimburse hospitalb2.54 1.24
Consulting arrangements with vendorb2.10 1.16
Notes: aLikert items: 5= strongly agree that factor inuences decision and 1= strongly disagree that factor inuences decision. bRatings of importance for hip implant.
Table 1 (Continued)
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Physician preference items
One or two vendors appeared to have higher average ratings
than the others, but the differences separating them are not
statistically significant. Vendor implants are thus viewed
more as similar than differentiated products by surgeons.
This suggests that “quality” may not be the decisive issue
in defining PPIs; all vendors seem to make quality prod-
ucts. Surgeons nevertheless have decided preferences for
a particular vendor, expressed in terms of primacy of use
and long-term loyalty. This is also what makes hip and knee
implants PPIs. Our findings suggest that such preferences
may not be based solely on perceived differences between
vendors’ products and services, but perhaps on habit,
familiarity, and accumulation of user (practice) efficien-
cies over time.
Limitations of the ndings
This study suffers from several limitations. First, we rely
on survey responses rather than empirical analyses of sur-
Table 2 Unadjusted means
Physician preference item
Pr > FaSignicancebVendor Signicant
#1 #2 #3 #4 #5
Scientic evidence 0.16 0.76 4.35 4.25 4.31 4.37 4.23
Patient outcomes 0.06 0.94 4.45 4.46 4.56 4.52 4.46
Design/ease of use 0.38 0.35 4.47 4.20 4.38 4.40 4.25
Implant longevity 0.53 0.26 4.57 4.32 4.11 4.41 4.33
Ease of switching 0.38 0.87 3.33 3.21 3.42 3.42 3.23
Vendor listens 1.14 0.32 3.83 3.39 3.18 3.55 3.36
Product innovation 2.44 0.01 *** 3.56 3.17 3.85 3.73 3.52 2–3, 2–4
Reputation 1.42 0.12 3.97 3.34 3.68 3.57 3.66
Specialized products 1.22 0.42 2.16 1.89 1.99 2.02 2.30
Alternative implant 0.85 0.71 3.51 3.26 3.46 3.66 3.39
Patient information 0.86 0.36 1.68 2.16 2.19 2.16 2.16
Training programs 2.23 0.12 2.30 2.71 3.04 2.67 3.02
Sales representative service level 0.11 0.92 4.12 4.01 4.12 4.04 4.12
Sales representative impact 2.01 0.08 * 3.78 3.08 3.60 3.42 3.47
Seminars 0.37 0.81 3.56 3.40 3.47 3.54 3.62
Prior training/exposure 1.49 0.19 3.44 2.98 2.81 3.27 2.97
Adequately reimbursed 1.54 0.14 2.30 2.46 2.68 2.91 2.67
Consulting 4.13 0.03 ** 3.46 2.94 2.40 3.33 3.26 3–4, 3–5
Notes: aTest of null hypothesis of no differences among vendors on physician preference item. bTukey–Kramer pair-wise comparison signicance: *P<0.10; **P<0.05;
Table 3 Adjusted least-square means
Physician preference item
Pr > FaVendor Signicant
#1 #2 #3 #4 #5
Scientic evidence 0.17 0.68 4.34 4.21 4.38 4.40 4.22
Patient outcomes 0.48 0.26 4.25 4.41 4.80 4.53 4.45
Design/ease of use 0.26 0.60 4.54 4.23 4.42 4.40 4.28
Implant longevity 0.14 0.79 4.43 4.28 4.24 4.34 4.42
Ease of switching 0.99 0.59 3.50 3.36 3.59 3.69 3.16
Vendor listens 1.81 0.11 4.03 3.32 3.40 3.71 3.21
Product innovation 1.01 0.28 3.61 3.23 3.81 3.56 3.54
Reputation 1.27 0.18 3.96 3.27 3.48 3.65 3.63
Specialized products 1.12 0.41 3.38 3.13 3.47 3.66 3.15
Alternative implant 1.01 0.30 4.09 3.86 3.95 4.35 4.21
Patient information 0.55 0.56 1.80 2.27 2.09 2.02 2.07
Training program 1.03 0.53 2.35 2.77 2.80 2.66 3.02
Sales representative service level 0.12 0.92 4.19 4.01 4.18 4.12 4.10
Sales representative impact 1.60 0.14 3.67 3.22 3.98 3.34 3.25
Seminars 0.39 0.79 3.85 3.47 3.57 3.64 3.46
Prior training/exposure 1.45 0.27 3.23 2.92 2.69 3.41 3.25
Adequately reimbursed 1.20 0.23 2.41 2.51 2.62 3.05 2.72
Consulting 0.32 0.89 2.42 2.04 2.10 2.08 2.14
Notes: aTest among vendors on physician preference item. bTukey–Kramer pair-wise comparison signicance: P<0.10; P<0.05; P<0.01.
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Burns et al
geon product selection for particular patients. Thus, we do
not measure actual implant performance or longevity, but
rather surgeon perceptions of why they use that implant.
Second, we do not analyze specific types of implants or
components or make comparisons between similar implant
types. Thus, we do not control for the surgeon’s choice of
specific product lines and lack information on the number
of surgeons using specific lines. We also do not know
whether the implant products evaluated here by surgeons
were approved by the US Food and Drug Administration
through the premarket approval or 510(k) route,42 or had
clinical data available. Third, we do not conduct head-to-
head comparisons of the ratings of different implants or
vendors by the same surgeon.
Fourth, the study relies heavily on responses to one
survey, from which we glean many of the variables. Thus,
there is the possibility of common methods bias, which
can inflate the association among variables.43 Fifth, there is
the possibility of social desirability bias, which might lead
surgeons to underreport the prevalence and impact of their
financial ties with vendors. However, both national data and
other studies reveal that relatively few surgeons have such
economic ties with vendors, which is consistent with the
low levels reported here. Social desirability bias might lead
surgeons to rank insurer willingness to adequately reimburse
them low; however, surgeons rate both physician and hospital
reimbursement low. Social desirability bias might also lead
surgeons to rank clinical outcomes more highly relative to
relationships with sales representatives; however, several
measures of the sales representative are indeed just as highly
ranked here.
Sixth, the data are taken from surgeons in only one state
and may not be generalizable to the rest of the country. We
make no claim here that Pennsylvania orthopedists resemble
their counterparts elsewhere, although we know of no reason
why Commonwealth of Pennsylvania physicians would have
different views on implant/vendor preference. Seventh, we
lack data on several important variables that might influence
the surgeons’ evaluations reported here: implant/vendor
prices, the possible existence of hospital contracts with the
vendor, and the surgeon’s involvement in hospital negotiations
(and pricing decisions) with the vendor. Eighth, surgeons’
ratings of implants and vendors across the four domains may
change over time, depending on vendor and hospital strategies
or changes in surgeons’ practices (eg, employment). Finally,
our results are based on survey data from 201 surgeons, which
may limit our ability to discern differences in evaluations
across vendors.
There are also several strengths of the study. The investi-
gators followed a rigorous process to develop the question-
naire based on the academic literature on medical products
companies and input from several orthopedists regarding the
domains that might be salient in product choice: technology/
implant, vendor, sales/service, and cost/financial consid-
erations. The survey was first pilot tested in an orthopedic
specialty hospital and then administered to the population of
active orthopedic surgeons in one state who had significant
experience performing hip and knee implants. The data
reported here reflect what surgeons state is important in
their selection of an implant or vendor and not what hospi-
tal managers believe is important. The research controlled
nonresponse bias and utilized supplemental data to control
surgeon volume. Finally, the study encompassed both hip and
knee implants, finding similar patterns for each.
PPIs may not be totally idiosyncratic across surgeons. There is
a great deal of commonality in surgeons’ ratings of orthopedic
products across implant types and vendors. Such consistency
suggests that physician’s preference may have some underly-
ing dimensions related to the technology’s patient benefits and
features and the sales/service effort associated with marketing
it; that is, the twin pillars in vendor strategy are reflected in
two primary domains of physician’s preference for the ven-
dor’s products. Future research should investigate whether
the findings reported here hold over time and other products.
REB is a consultant for Zimmer Biomet for which he receives
royalties and speaking honoraria. The authors report no other
conflicts of interest in this work.
1. Burns LR, Lawrence D, Sammut S. Healthcare innovation across sec-
tors: convergences and divergences. In: Burns LR, editor. The Business
of Healthcare Innovation. (Chap. 8). Cambridge, UK: Cambridge
University Press; 2012:515–563.
2. Cassak D. Abbott Vascular: the now-ready-for-prime time player. In
Vivo. 2004;22(5):25–29.
3. Cassak D. Building billion-dollar businesses: an interview with Robert
Croce. In Vivo. 2005;23:27–36.
4. Keusch L, Lin K. Healthcare: Medical Devices – Annual Cardiac Rhythm
Management Survey. New York, NY: Goldman Sachs; 2001.
5. Schneller E, Smeltzer L. Strategic Management of the Health Care
Supply Chain. San Francisco: Jossey-Bass; 2006.
6. Burns LR. The Health Care Value Chain. San Francisco: Jossey-Bass;
7. Government Accountability Office. Medicare: Lack of Price Trans-
parency May Hamper Hospitals’ Ability to Be Prudent Purchasers of
Implantable Medical Devices. GAO-12-126. Washington, DC: GAO;
2012. Available from:
Accessed December 10, 2017.
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and includes a quick and fair peer-review system. Visit http://www. to read real quotes from authors.
Physician preference items
8. DeJohn P. The last frontier: saving on M.D. preference items. Hosp
Mater Manag. 2005;30(1):9–11.
9. ECRI Institute. Wasting Millions By Making Purchases Based Solely
on Physician Preference? Not in My Hospital!. Plymouth Meeting, PA:
ECRI Institute; 2009.
10. Donahoe G, King G. Estimates of Medical Device Spending in the
United States. Washington, DC: Advamed; 2012. Available from: https://
medical-device-spending.pdf. Accessed December 20, 2017.
11. Statista [webpage on the Internet]. Medical devices expenditure as
a share of total U.S. health expenditures from 1989 to 2013. The
Statistics Portal. 2017. Available from:
Accessed on August 24, 2017.
12. Weiss A, Elixhauser A. Trends in Operating Room Procedures in U.S.
Hospitals, 2001-2011. Statistical Brief #171. Washington, DC: Agency
for Healthcare Research and Quality; 2014.
13. Belatti D, Pugely A, Phisitkul P, Amendola A, Callaghan J. Total joint
arthroplasty: trends in Medicare reimbursement and implant prices.
J Arthroplasty. 2014;29:1539–1544.
14. Montgomery K, Schneller E. Hospitals’ strategies for orchestrating selec-
tion of physician preference items. Milbank Q. 2007;85(2):307–335.
15. Wilson N, Schneller E, Montgomery K, Bozic K. Hip and knee implants:
current trends and policy considerations. Health Aff (Millwood).
16. Lerner J, Fox D, Nelson T, Reiss J. The consequence of secret prices:
the politics of physician preference items. Health Aff (Millwood).
17. Robinson JC. Value-based purchasing for medical devices. Health Aff
(Millwood). 2008;27(6):1523–1531.
18. McIlhargey B [webpage on the Internet]. Contracting for physician-
preference items. J Healthc Contract. 2017. Available from: http://
Accessed August 31, 2017.
19. Burns LR, Lee A, Bradlow E, Antonacci A. Surgeon evaluation of suture
and endo-mechanical products. J Surg Res. 2007;141:220–233.
20. Hsu M, Wise F. Orthopedics: Unique Market Dynamics Drive Steady
Growth. New York: Bear Stearns; 2004.
21. Scannell J, Bedell L. Orthopaedics: Company Pricing Power Rests with
Sticky Surgeons. Summary of Quantitative Switching Survey. New York,
NY: Sanford Bernstein & Co; 2008.
22. Scannell J, Bedell L. Orthopaedics: Surgeon Switching, Loyalty, and
Patterns of Product Use. Part 1of Detailed Survey Results. New York,
NY: Sanford Bernstein & Co; 2008.
23. Scannell J, Bedell L. Orthopaedics: Future of Surgeon Switching and
Ortho Pricing Power. Part 2 of Detailed Survey Results. New York, NY:
Sanford Bernstein & Co; 2008.
24. Nudell BM. BMET, SYK and ZMH: Price Transparency is a Major
Threat. Downgrading BMET; Lower ZMH Target to $62 and SYK to
$44. New York: Sanford Bernstein and Co; 2006.
25. Pauly MV, Burns LR. Price transparency for medical devices. Health
Aff (Millwood). 2008;27(6):1544–1553.
26. Olson S, Obremskey W, Bozic K. Healthcare technology: physician col-
laboration in reducing the surgical cost. Clin Orthop Relat Res. 2013;471:
27. Grennan M, Swanson A. Transparency and Negotiated Prices: The
Value of Information in Hospital-Supplier Bargaining. Working Paper.
Philadelphia: Wharton School; 2016.
28. Sharkey P, Sethuraman V, Hozack W, Rothman R, Stiehl J. Factors
influencing choice of implants in total hip arthroplasty and total knee
arthroplasty. J Arthroplasty. 1999;14(3):281–287.
29. Premier [webpage on the Internet]. Physician preference: balancing cost
and quality. Economic Outlook. 2001. Available from:
premiercs/docs/public_eo_sept_2011_final_web. Accessed August 24,
30. Siddel K. Hospitals losing on physician preference items. OR Manager.
31. Miksic M, Reicin G, Yik A, Roman D. Hospital Supplies & Medical
Technology: 2005 Orthopaedic Survey. New York: Morgan Stanley; 2005.
32. Singh J, Kwoh CK, Boudreau R, Lee G-C, Ibrahim S. Hospital volume and
surgical outcomes after elective hip/knee arthroplasty: a risk-adjusted anal-
ysis of a large regional database. Arthritis Rheum. 2011;63(8):2531–2539.
33. Pennsylvania Health Care Cost Containment Commission. Total Hip
and Knee Replacements. Harrisburg, PA: PHC4; 2005.
34. Pennsylvania Health Care Cost Containment Commission. Knee and
Hip Replacements: 2013 Data. Harrisburg, PA: PHC4; 2015.
35. Kalton G. Compensating for Missing Data. Ann Arbor, MI: Institute
for Social Research; 1983.
36. Tomaskovic-Devey D, Leiter J, Thompson S. Organizational survey
nonresponse. Adm Sci Q. 1994;39(4):439–457.
37. Hikmet N, Chen SK. An investigation into low mail survey responses
of information technology users in health care organizations. Intl J Med
Inform. 2003;72:29–34.
38. Rogelberg SG, Stanton JM. Understanding and dealing with organiza-
tional survey nonresponse. Organ Res Methods. 2007;10(2):195–209.
39. Hockenberry J, Weigel P, Auerbach A, Cram P. Financial payments by
orthopedic device makers to orthopedic surgeons. Arch Intern Med.
40. Steinbrook R. Industry payments to physicians: lessons from orthopedic
surgery. Arch Intern Med. 2011;171(19):1765–1766.
41. Lopez J, Ahmed R, Bae S, et al. A new culture of transparency: industry
payments to orthopedic surgeons. Orthopedics. 2016;39(6):1058–1062.
42. FDA. 510(k) Clearances. Silver Spring, MD: US Food and Drug
Administration. Available from:
Clearances/. Accessed December 10, 2017.
43. Meade AW, Watson AM, Kroustalis CM. Assessing common methods
bias in organizational research. Paper presented at: 22nd Annual Meet-
ing of the Society for Industrial and Organizational Psychology. New
York: 2007.
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... For the past 15 years this topic has being researched mostly on professional press (Conway, 2019;DeJohn, 2005;Flick and Schulz, 2016;McGinnity, 2003;Serb, 2004). More recently, Burns et al. (2018) has pointed out that this issue has been under researched in academia. In fact, there are few studies on the topic, and research on PPIs is mostly reported in health care journals. ...
... Physicians are the main decision makers regarding expensive medical devices purchases. Since physicians are directly involved in acquiring and using those items, they have developed strong preferences over certain suppliers (Burns et al., 2018). Physicians have strong preference over certain brands due to the characteristics of the product, (such as durability, individual patient necessities, familiarity with the product, resitence to change, consulting arrangements made by suppliers and relationship with suppliers) and they are reluctant to switch brands. ...
... Strong preference for certain items can be enhanced by suppliers salesperson (Atilla et al., 2018). A recent research pointed out that physicians are higly influence by technology and the medical device characteristics, and also by sales or service factors provided by suppliers (Burns et al., 2018). ...
... Also, little is known about the factors associated with physician preferences in a product and its vendor. 3 Moreover, there are no theories or conceptual frameworks that were specifically designed to explain the influence of physicians' motivation on medical devices adoption in a healthcare context. 4 ...
... 5 Also, physicians are the primary decision-makers when it comes to medical device purchases and patient treatment. 3 Their control is emphasized through the healthcare institutions purchasing process and the decision-makers in the procurement and materials departments. 3 Another study argued regarding the challenges that healthcare sector policymakers have in curbing the costs of purchases and at the same time ensuring high-quality service. ...
... 3 Their control is emphasized through the healthcare institutions purchasing process and the decision-makers in the procurement and materials departments. 3 Another study argued regarding the challenges that healthcare sector policymakers have in curbing the costs of purchases and at the same time ensuring high-quality service. 6 The objective of the study is to assess the factors and their values that influence orthopedic physicians in purchasing medical devices and equipment. ...
Full-text available
Purpose: It is explanatory and descriptive research to explain the relationship among factors influencing the orthopedic physician's decision of purchasing medical devices and equipment. Methods: Quantitative method will be used in this study as all heads of departments in MOH hospitals refused to make one-to-one interviews and suggested only questionnaires that will be high in confidentiality. Results: For the first question: What is the ranking of factors that influence orthopedic physician decision in purchasing medical devices and equipment in MOH hospitals in Kuwait? According to HB analysis, the most preferred attribute is implant review in a journal and the lowest preferred factor is product training. Moreover, Brand was the second preferred attribute followed by leader influence. Surprisingly, price came after all these attributes. Physicians ranked technical support and sponsorship in the fifth and sixth places. For the second question: How can marketing and sales management predict orthopedic physicians' decisions before designing product proposals? This will assist M&S department in creating proposals that satisfy orthopedic physicians through expecting their decisions on various alternatives. Conclusion: There is a good opportunity for all medical devices companies, after discussion with SMEs, either for growth or leaving stagnation phase. However, SMEs have no real understanding of what factors matter to the orthopedic physicians' decision in purchasing medical devices and equipment. Thus, one of the goals of this research is to give M&S departments in medical devices companies with recommendations that will help them in forming attractive product offers to orthopedic physicians in MOH hospitals in Kuwait. Moreover, predicting the response from them in the future. In addition, four simulation scenarios have been conducted in this research to reach the best economic offer that maintains physicians attracted.
... To claim one AMA PRA Category 1 Credit TM for the CME activity associated with this article, you must do the following: (1) read this article in its entirety, (2) answer at least 80 percent of the quiz questions correctly, and (3) complete an evaluation. The quiz, evaluation, and form for claiming AMA PRA Category 1 Credit TM are available through the AMA Ed Hub TM . ...
... Benefit-Risk Analysis A 2018 study found that physicians rated the following factors most highly when choosing whether to use implantable devices: better outcomes for patients, the longevity of the implant, design and ease of both implant and instrumentation, scientific evidence of better outcomes, length of follow-up in scientific studies, and product reputation. 2 When new implantable devices are cleared by the FDA via the 510(k) pathway, it therefore raises a particular challenge to physicians and hospital purchasing committees, since many of these factors might be unknown. ...
The number of new medical devices cleared by the US Food and Drug Administration (FDA) through the 510(k) pathway that has subsequently been associated with safety risks has led to discussion of approaches to regulation and communication of device risks. As debate continues over whether the pathway needs to be altered, features of ethical use of 510(k)-cleared devices can include (1) heightened caution with respect to newly cleared 510(k) products until adequate data are gathered through postmarket surveillance, (2) facilitating informed consent by improving physician and patient knowledge of the 510(k) pathway, and (3) basing distribution of these devices on individual risk assessments while ensuring equitable access.
... This process must be delicately balanced with surgeon autonomy and comfort-level using various instrumentation. 44 ...
Full-text available
Study design: Review article. Objectives: There have been substantial increases in the utilization of complex spinal surgery in the last 20 years. Spinal instrumented surgery is associated with high costs as well as significant variation in approach and care. The objective of this manuscript is to identify and review drivers of instrumented spine surgery cost and explain how surgeons can reduce costs without compromising outcome. Methods: A literature search was conducted using PubMed. The literature review returned 217 citations. 27 publications were found to meet the inclusion criteria. The relevant literature on drivers of spine instrumented surgery cost is reviewed. Results: The drivers of cost in instrumented spine surgery are varied and include implant costs, complications, readmissions, facility-based costs, surgeon-driven preferences, and patient comorbidities. Each major cost driver represents an opportunity for potential reductions in cost. With high resource utilization and often uncertain outcomes, spinal surgery has been heavily scrutinized by payers and hospital systems, with efforts to reduce costs and standardize surgical approach and care pathways. Conclusions: Education about cost and commitment to standardization would be useful strategies to reduce cost without compromising patient-reported outcomes after instrumented spinal fusion.
... Operating room stocks are different from healthcare unit stocks in three ways. Firstly, they are very expensive (Robinson, 2008) as medical supplies for operating rooms represent 60% of purchases for this group of products (Burns et al., 2018). Next, several of these supplies are specific to a precise surgical procedure, and sometimes even to a particular physician. ...
The healthcare supply chain lags far behind supply chains in other industries in terms of performance and the deployment of best practices. Managers could bridge this gap and improve the performance of the healthcare supply chain by implementing digitalization initiatives. However, the erratic, disconnected digitalization of practices already deployed in the healthcare sector makes it difficult to maximize the potential of these initiatives. In order to generate the greatest benefits from digitalization while improving healthcare delivery, this article sets out a roadmap for implementing technologies. Unlike previous studies that focused on the entire supply chain or had been limited to patient flow, this study adopts the perspective of the hospital as a central launching point for digitalization initiatives. The roadmap, which involves both internal and external digitali-zation trajectories, is based on a research methodology that combines observations with an umbrella review of literature. This methodology enables us to capture the research challenges associated with the healthcare supply chain and show how digitalization initiatives can address them. The digitalization proposals put forward are structured in terms of priority and centered on hospitals. These proposals can help managers make improvements to the supply chain and also clinical flows.
... When deciding between these 2 operations, the decision has historically been based on the extent of the pathology and surgeon preference. 57 Given the paucity of systematic reviews or randomized controlled trials examining the 2 procedures, we sought to review the literature comprehensively to assess postoperative pain, function, and long-term success as measured by nonunion and patient outcomes. ...
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Purpose The aims of this systematic review were to examine the use of radiolunate (RL) or radioscapholunate (RSL) arthrodesis as surgical management for patients with advanced radiocarpal arthritis that failed conservative management and to assess postoperative outcomes. Methods We reviewed articles from PubMed, EMBASE, and Web of Science from inception through December 2019. We identified complete manuscripts written in English reporting on RL or RSL arthrodesis for treatment of wrist pathology that included the primary outcomes (pain or grip strength) and at least 2 secondary outcomes (range of motion, patient-reported outcomes, or nonunion). Data pooling was used to calculate weighted averages. Results We identified 2,252 articles and selected 13 for inclusion. Across all studies, RSL arthrodesis was performed for 180 patients (49% female; 45 years old) and RL for 94 (87% female; 50 years old). Both procedures exhibited improvements in pain score and grip strength. Both cohorts demonstrated postoperative changes in flexion-extension arc, flexion, extension, ulnar deviation, supination, and pronation after data pooling. The nonunion rate for RSL was 15% versus 2% for RL, whereas the rate of progression to total wrist arthrodesis for RSL and RL was 4% and 0%, respectively. Conclusions Both RL and RSL arthrodesis can be successfully used to manage debilitating radiocarpal arthritis by affording patients with pain reduction. Each has its own benefits, in which RSL arthrodesis provides a total arc of motion within the functional demands of most activities of daily living, and RL arthrodesis has low rates of nonunion and progression to total wrist arthrodesis. Further research is needed to compare the 2 surgeries directly and prospectively in comparable patient groups. Type of study/level of evidence Therapeutic III.
Operative repair of orbital fractures utilizes implants constructed of a plethora of materials that vary in cost. Surgeon preference as well as fracture complexity may dictate the implant chosen. In this study, we retrospectively compared the complication rates of the four most common types of implants utilized at our institution. We found no significant difference in complication rates in our sample of 88 patients. Additionally, the least expensive implant was as effective as the most expensive implant in addressing isolated orbital blowout fractures. This situation is not unique to the field of oculoplastics. As evidenced from published literature in other areas of surgery, from orthopaedics to orthodontics, cheaper alternatives often afford similar outcomes as more expensive options. We herein argue that a cost-effective approach should be considered while still allowing for high quality of care, in the face of rising health care costs and health disparities in America.
RÉSUMÉ Le contrôle des coûts des produits de spécialité (physician preference items) utilisés dans les blocs opératoires est une préoccupation majeure des gestionnaires d’établissement de santé. Ces articles sont très dispendieux : ils accaparent une majorité des coûts de la grande famille des fournitures médicales et ils génèrent des coûts administratifs importants. Cependant, il est difficile de restreindre leurs coûts. Le processus d’achat dans un centre hospitalier doit déjà composer avec de nombreuses parties prenantes, et l’une d’elles, les chirurgiens, constitue un groupe d’influence qui est normal ement peu réceptif à se faire dicter ses choix de produits. Cette réalité rejoint les défis de la gestion des achats dans les milieux professionnels. Dans la province de Québec (Canada), les responsables des achats d’établissements publics de santé souhaitent revoir leurs stratégies d’achat pour ces produits. Notre étude cherche à répondre à la question de recherche suivante : comment les acheteurs peuvent-ils contribuer à améliorer les décisions d’achat lors du cycle d’achats des produits de spécialité de bloc opératoire ? Notre étude débute par une revue de littérature afin d’identifier les facteurs qui influencent le processus d’achat de ces produits. Par la suite, nous précisons la méthodologie qui s’inscrit dans une démarche de recherche collaborative. Nous présentons les principaux résultats obtenus auprès de six organisations nord-américaines permettant d’apprécier l’équilibre entre la durée des contrats avec les fournisseurs, la durée du processus de mise à contrat et les économies réellement dégagées.
Background Surgical standardization has been shown to decrease costs without impacting quality; however, there is limited literature on this subject regarding ankle fracture fixation. Methods. Between October 5, 2015 and September 27, 2017, a total of 168 patients with isolated ankle fractures who underwent open reduction, internal fixation (ORIF) were analyzed. Financial data were analyzed across ankle fracture classification type, implant characteristics, and surgeons. Bivariate analyses were conducted. One-way analysis of variance was used to compare hardware costs across all 5 surgeons. Linear regression analysis was used to determine if hardware cost differed by surgeon when accounting for fracture type. Results The mean contribution margin was $4853 (SD $6446). There was a significant difference in implant costs by surgeon (range, lowest-cost surgeon: $471 [SD $283] to $1609 [SD $819]; P < .001). There was no difference in the use of a suture button or locking plate by fracture type (P = .13); however, the cost of the implant was significantly higher if a suture button or locking plate was used ($1014 [SD $666] vs $338 [SD $176]; P < .001). There was an association between surgeon 3 (β = 200.32 [95% CI 6.18-394.47]; P = .043) and surgeon 4 (β = 1131.07 [95% CI 906.84-1355.30]; P < .001) and higher hardware costs. Conclusions Even for the same ankle fracture type, a wide variation in implant costs exists. The lack of standardization among surgeons accounted for a nearly 3.5-fold difference, on average, between the lowest- and highest-cost surgeons, negatively affecting contribution margin. Levels of Evidence Level IV
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This paper advances a theoretical model that explains organizations' nonresponse to surveys as a predictable aspect of organizational behavior and structure. We argue that survey researchers must take into account the authority, capacity, and motive to respond of both the organizations sampled and the designated respondent within the organization. Our analysis identifies a series of organizational sources of nonresponse that have clear consequences for final sample bias. These include resource independence from the environment, subsidiary status, information dispersal in large establishments, and lack of staff dedicated to information processing. We provide suggestions for future organizational survey design and for analysis strategies to cope with sample selection bias.
Using data on hospitals’ purchases across a large number of important product categories, we find that access to information on purchasing by peer hospitals leads to reductions in the prices hospitals negotiate for supplies. These effects are concentrated among hospitals previously paying relatively high prices for brands purchased in large volumes. Evidence from coronary stents suggests that transparency allows hospitals to resolve asymmetric information problems, but savings are limited in part by the stickiness of contracts in business-to-business settings. Savings are largest for physician preference items, where high-price, high-quantity hospital-brand combinations average 3.9% savings, versus 1.6% for commodities.
Under the Physician Payments Sunshine Act, "payments or transfers of value" by biomedical companies to physicians must be disclosed through the Open Payments Program. Designed to provide transparency of financial transactions between medication and device manufacturers and health care providers, the Open Payments Program shows financial relationships between industry and health care providers. Awareness of this program is crucial because its interpretation or misinterpretation by patients, physicians, and the general public can affect patient care, clinical practice, and research. This study evaluated nonresearch payments by industry to orthopedic surgeons. A retrospective cross-sectional review of the first wave of Physician Payments Sunshine Act data (August through December 2013) was performed to characterize industry payments to orthopedic surgeons by subspecialty, amount, type, origin, and geographic distribution. During this 5-month period, orthopedic surgeons (n=14,828) received $107,666,826, which included 3% of those listed in the Open Payments Program and 23% of the total amount paid. Of orthopedic surgeons who received payment, 45% received less than $100 and 1% received $100,000 or more. Median payment (interquartile range) was $119 ($34-$636), and mean payment was $7261±95,887. The largest payment to an individual orthopedic surgeon was $7,849,711. The 2 largest payment categories were royalty or license fees (68%) and consulting fees (13%). During the study period, orthopedic surgeons had substantial financial ties to industry. Of orthopedic surgeons who received payments, the largest proportion (45%) received less than $100 and only 1% received large payments (≥$100,000). The Open Payments Program offers insight into industry payments to orthopedic surgeons. [Orthopedics. 201x; xx(x):exxx-exxx.].
The twin towers: invention and adoption All of the sectors analyzed in this volume face the same dual challenge: the invention of new technology and assuring its long-term clinical adoption by customers. These challenges are neither easy nor inexpensive. For many of the sectors, the technology and the underlying science have encountered the same phenomenon as technology development in other industrial fields – namely, convergence of many skills. Pharmaceutical and biotechnology firms – long accustomed to both random discovery and synthesis of bioactive chemicals or recombination of known active proteins – have added to their discovery strategies genomic and proteomic foundations for drug discovery. These new sciences are just the first steps in the long process of drug development wherein tools such as bioinformatics must be integrated. As companies in the sector pursue new avenues of discovery and development, and as the associated costs spiral ever upward, healthcare systems throughout the world seek to rationalize care and lower overall costs. The industry has two added burdens, therefore: (1) demonstrating the economic advantages of new drugs, thus giving rise to yet another new discipline, pharmacoeconomics; and (2) demonstrating the relative superiority of new drugs over rival products and therapies, thus giving rise to comparative clinical effectiveness.
To determine the factors influencing surgeons' choice of implants for total hip arthroplasty (THA) and total knee arthroplasty (TKA), 650 surveys were mailed to all active members of the American Association of Hip and Knee Surgeons practicing in the United States; 364 surveys (56%) were completed and returned. Analysis revealed that the average number of total hip and total knee replacements performed by the respondents in 1997 was 81 and 97; there was substantial regional variation. The average number of hip implant and knee implant brands used by these surgeons in 1997 was 2.4 and 1.8. Anticipated improvement in clinical results and cost of components were the most frequently listed reasons for changing brands. Surgeons were also queried about cost reduction programs at their particular institution. The most frequently listed strategies for cost reduction of implants included surgeon cost-awareness programs and volume discounting. More than half of the respondents (53.5%) anticipate manufacturers to decrease the cost of implants in the next 2 years. Most of the respondents (93.7%) currently have the ability to choose a particular implant. About half (46.7%) anticipate losing some or all control of this decision in the next 3 years. These respondents foresee their hospitals requiring the use of a discounted implant in the future. An additional survey was completed by 102 consecutive patients scheduled either for primary THA (64) or primary TKA (38) at our institution. When asked about implant selection, 93.1% responded that their orthopaedic surgeon should choose the prosthesis; 5.9% responded that their physician in consultation with the patient should choose the prosthesis. When asked what should be the primary determinant of implant choice, cost or quality, the overwhelming majority (97.1%) chose quality. A small percentage (2.9%) chose cost and quality. No patient chose cost alone. A large number of patients (84.8%) responded that they would pay additional costs if their insurance companies or health maintenance organizations refused to pay for a better but more expensive implant. Most patients realized how expensive components are, and 51% of the respondents correctly estimated the cost of an implant. Orthopaedic surgeons perceive that they are losing control of implant choice in THA and TKA. Cost of implants is one of the most significant factors influencing which implant is chosen. Patients (the true payors), however, overwhelmingly want their surgeons to choose the implant used at surgery, and they want quality, not cost, to be the primary determinant of this decision.
Background The increasing cost of providing health care is a national concern. Healthcare spending related to providing hospital care is one of the primary drivers of healthcare spending in the United States. Adoption of advanced medical technologies accounts for the largest percentage of growth in healthcare spending in the United States when compared with other developed countries. Within the specialty of orthopaedic surgery, a variety of implants can result in similar outcomes for patients in several areas of clinical care. However, surgeons often do not know the cost of implants used in a specific procedure or how the use of an implant or technology affects the overall cost of the episode of care. Questions/purposes The purposes of this study were (1) to describe physician-led processes for introduction of new surgical products and technologies; and (2) to inform physicians of potential cost savings of physician-led product contract negotiations and approval of new technology. Methods We performed a detailed review of the steps taken by two centers that have implemented surgeon-led programs to demonstrate responsibility in technology acquisition and product procurement decision-making. Results Each program has developed a physician peer review process in technology and new product acquisition that has resulted in a substantial reduction in spending for the respective hospitals in regard to surgical implants. Implant costs have decreased between 3% and 38% using different negotiating strategies. At the same time, new product requests by physicians have been approved in greater than 90% of instances. Conclusions Hospitals need physicians to be engaged and informed in discussions concerning current and new technology and products. Surgeons can provide leadership for these efforts to reduce the cost of high-quality care.