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

In a study by Lawton R. Burns, Michael G. Housman, Robert E. Booth, and Aaron M. Koenig, the authors examine why orthopedic surgeons prefer certain hip and knee implants—commonly referred to as physician preference items (PPIs). Given that the United States spends roughly $200 billion annually on medical devices, with a substantial share tied to orthopedic procedures, understanding the drivers of surgeon preference has major financial and policy implications.

PPIs are named for the physician’s discretion in selecting both the implant and the vendor, yet the foundations of this discretion have remained unclear. This study seeks to clarify which implant and vendor characteristics matter most to surgeons, and whether other factors—such as financial relationships or vendor tenure—play a meaningful role.

The authors conducted a comprehensive survey of all practicing orthopedic surgeons in the Commonwealth of Pennsylvania who performed at least 12 implant procedures per year. Surgeons were asked to identify their preferred hip or knee implant vendor and to evaluate the factors that influenced that choice.

Using analysis of variance techniques, the researchers compared how surgeons rated multiple implant and vendor characteristics. Importantly, the analysis controlled for surgeon demographics, hospital characteristics, and existing surgeon–vendor relationships that could bias evaluations.

The results show that physician preference is driven primarily by two factors: technology/implant characteristics and sales and service support. Surgeons consistently rated these dimensions as the most important determinants of vendor choice.

In contrast, other commonly cited considerations—such as vendor reputation, financial relationships with manufacturers, and implant cost—were found to be far less influential. These findings held true across both hip and knee implants and across different vendors.

The consistency of these results suggests that surgeons apply a relatively uniform evaluative framework when choosing PPIs. Regardless of procedure type, they prioritize implants that perform well technologically and vendors that provide strong, responsive sales and service support.

The authors conclude by offering an empirically grounded definition of PPIs. Physician preference items are not simply expensive or branded products; rather, they are implants that surgeons rate highly on the dual dimensions of technology and sales/service. This definition aligns closely with the strategies pursued by medical device companies seeking to influence surgeon choice.

Overall, the study provides clarity into how surgeon preferences are formed and highlights why efforts to control device costs must account for the technical and service-oriented factors that physicians value most.