Surgeons and Biologics are Key Cost Drivers in Arthroscopic Rotator Cuff Repair
Key findings
- This retrospective analysis was the first to apply time-driven, activity-based costing to assess the total cost of arthroscopic rotator cuff repair (aRCR) while accounting for patient, procedure, rotator cuff tear, and surgeon characteristics
- In a cohort of 625 patients (24 orthopedic surgeons), intraoperative care accounted for 92% of costs and total aRCR cost varied nearly six-fold (5.9x) between individuals
- Factors tied to high-cost aRCR were mostly as expected (e.g., longer operating room time, larger or more chronic tears, use of multiple suture anchors, biologic/augment use, and revision surgery) but did not include fellowship training or surgeon volume
- In multivariable analysis, use of biologic adjuvants and surgeon idiosyncrasy were the most important drivers of total aRCR cost
- As orthopedic surgeons seek to optimize value for patients, they may be able to control a great deal of the cost themselves once future research determines what exactly is being captured within the surgeon variable
The utilization of arthroscopic rotator cuff repair (aRCR) in the U.S. is estimated to increase exponentially. Researchers at Massachusetts General Hospital recently completed the first study to apply a time-driven, activity-based costing methodology to assess the cost of aRCR in a highly granular manner, considering patient, procedure, rotator cuff tear, and surgeon characteristics.
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In the Journal of Shoulder and Elbow Surgery, they conclude the major cost drivers in aRCR are the use of biologic adjuncts and surgeon idiosyncrasy. The latter is defined broadly as things surgeons do (or don't do) that affect total cost, and, for aRCR, those things still need to be determined.
The authors are David N. Bernstein, MD, PhD, MBA, MEI, a resident in the Harvard Combined Orthopaedic Residency Program, Jon J.P. Warner, MD, co-chief of the Shoulder Service in the Department of Orthopaedic Surgery at Mass General, Evan A. O'Donnell, MD, a sports medicine and shoulder orthopedic surgeon in the Department, and colleagues.
Methods
The researchers reviewed data on patients who underwent aRCR between January 2019 and September 2021 at Mass General or one of two affiliated ambulatory surgery centers. They developed process maps for each of the three phases of care: preoperative, intraoperative, and same-day postoperative.
Time-driven activity-based costing considers only the quantity of time and cost per unit of time for each resource used during a care episode, which in this study was equated with a care phase. The cost for each care phase was determined and the total cost was the sum of the costs of the three care phases.
625 patients (24 orthopedic surgeons) were included in bivariate analyses to compare patient, procedure, rotator cuff tear, and surgeon characteristics between high-cost patients (those in the top decile of cost) and all others. 572 patients (13 surgeons) were included in a multivariable linear regression analysis to determine the major cost drivers of aRCR.
Total Cost and Cost by Phase of Care
Intraoperative care accounted for 92% of costs in the overall cohort, mostly attributable to personnel and implants. Total aRCR cost varied nearly six-fold (5.9x) between individuals.
Distinguishing Characteristics of High-Cost aRCR
Many of the factors significantly associated with high-cost aRCR were as expected:
- Male sex
- Higher body mass index
- Procedure done at Mass General rather than at a freestanding surgery center
- Longer operative time
- Larger average number of anchors used
- More frequent incorporation of a bioinductive implant
- Multiple tendons involved
- Higher Goutallier classification average across all tendons
- Higher Goutallier maximum severity
- Greater maximum tendon retraction
- Revision surgery
Interestingly, subspecialty fellowship training and case volume were not associated with high-cost aRCR.
Cost Drivers
In multivariable analysis, the use of biologic adjuvants and surgeon idiosyncrasy were by far the most important drivers of total cost:
- Use of bioinductive implant—Regression coefficient (RC), 0.54 (P<0.001)
- Surgeon 3 vs. reference surgeon—RC, 0.50 (P<0.001)
- Surgeon 12—RC, 0.36 (P=0.001)
- Surgeon 11—RC, 0.29 (P=0.01)
- Surgeon 10—RC, 0.24 (P=0.03)
- Surgeon 8—RC, 0.20 (P<0.001)
- Surgeon 13—RC, 0.17 (P<0.001)
- Surgeon 9—RC, 0.12 (P=0.002)
- Surgeon 6—RC, 0.10 (P=0.02)
- Number of anchors—RC, 0.039 (P<0.001)
- Goutallier average—RC, 0.029 (P=0.005)
Interpreting the Findings
Even when provided with the same patient and pathology, some surgeons have significantly more costly preferences when performing aRCR. This study could not determine what exactly is being captured within the surgeon variable.
Future work might show that surgeon idiosyncrasies represent differences in techniques learned during training, treatment inertia (taking a one-size-fits-all approach), availability of low-cost versus high-cost implants, and/or differences in adoption of newer and/or costlier technology.
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