At the health system level, and potentially overriding physician, patient and device factors, contractual obligations may restrict physicians from using devices with which they are proficient, or considered best suited for patients’ needs, which was thought to increase costs due to complications and revisions. If this phenomenon is widespread, it challenges whether decisions about medical devices can be considered preference sensitive, which hinges on patients having legitimate treatment options . First, research should establish whether device restrictions imposed by purchasing groups are associated with poor outcomes, perhaps by comparing outcomes at hospitals with and without such arrangements.