Value of Hip Arthroscopy for Femoroacetabular Impingement Varies by Procedure Type, Preoperative Function
Key findings
- “Value” in healthcare is defined as patient health outcomes achieved per dollar spent. Increases in value are achieved through improving outcomes, decreasing costs, or both simultaneously. Previous work to characterize the value of hip arthroscopy has focused exclusively on costs, but little work has been done on the relationship of costs and outcome measurements
- This study explored associations between the value of hip arthroscopy for femoroacetabular impingement and the pre- and intraoperative characteristics of 161 patients operated on by a single senior surgeon
- The normalized value of hip arthroscopy per patient ranged from 25.4 to 216.4 (mean, 100), with 3.0-fold variation between patients in the 10th and 90th percentiles
- Patient-reported preoperative function, preoperative Tönnis grade, osteoplasty type, method of labral management, and use of bone marrow aspirate concentrate augmentation or microfracture best explained the cost variation
- The findings emphasize the importance of specific indications of arthroscopy for femoroacetabular impingement (e.g., functional patients with lower Tönnis scores), but clinical care should always be guided by patient education and shared decision-making
“Value” in healthcare is defined as patient health outcomes achieved per dollar spent, so it can be improved by improving outcomes, reducing costs, or both. However, previous efforts to characterize the value of hip arthroscopy have focused exclusively on costs.
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Scott D. Martin, MD, director of the Joint Preservation Service in the Department of Orthopaedic Surgery at Massachusetts General Hospital, and colleagues performed a time-driven activity-based costing analysis of hip arthroscopy for femoroacetabular impingement (FAI) that integrated time, personnel costs, material costs, and clinical outcomes.
In Arthroscopy, Sports Medicine, and Rehabilitation, they report wide variation in healthcare value, most strongly explained by osteoplasty type, labral management technique, and preoperative patient-reported functional measures.
Methods
The research team retrospectively reviewed prospectively collected data on adults who underwent primary hip arthroscopy by Dr. Martin for treatment of a symptomatic labral tear due to FAI between June 2015 and September 2020. Patients were excluded if they did not have complete data from preoperative and 2-year postoperative patient-reported outcome measures, had previous ipsilateral hip surgery, or showed radiographic evidence of hip dysplasia or advanced hip osteoarthritis (Tönnis grade >1).
The researchers applied time-driven activity-based costing, now the gold-standard methodology for measuring costs within orthopedics, which synthesizes the quantity of resources expended with their per-unit costs. It entails mapping all activities involved in a care pathway, quantifying the time and resources required for each activity, multiplying the quantity of each resource by its per-unit cost, and summing the products.
The primary outcome of the study was normalized patient value, which was calculated by dividing 2-year postoperative International Hip Outcome Tool 33 (iHOT-33) scores by time-driven activity-based costs and multiplying by a correction coefficient to normalize the data to a mean of 100 (to protect the confidentiality of hospital cost data).
Pre- and Intraoperative Patient Characteristics
The research team reviewed data on 161 patients. The cohort was 53% male, had a mean age of 36 years, and had a mean body mass index of 26 kg/m2. Preoperatively, 57% of hips were classified as Tönnis grade 1 (the rest were grade 0) and the mean iHOT-33 score was 40.1 out of a maximum of 100 points. Previous contralateral surgery was on record for 7.5% of patients.
Forty-eight percent of patients underwent acetabuloplasty, 44% underwent both a acetabuloplasty and femoroplasty, 5% underwent only a femoroplasty, and 3% did not require any type of osteoplasty. Most patients, 88%, underwent labral augmentation while 8% had a simple repair and 4% had debridement. 64% of patients had cartilage defects treated with microfracture or bone marrow aspirate concentrate augmentation.
Primary Outcome
The value of hip arthroscopy per patient ranged from 25.4 to 216.4 (mean, 100), with 3.0-fold variation between patients in the 10th and 90th percentiles.
In multivariate analyses, variables that independently explained variation in value were:
- Acetabuloplasty or femoroplasty
- Labral repair
- Treatment of cartilage defects
- Worse preoperative iHOT-33 score
- Preoperative Tönnis grade 1
- Previous contralateral hip arthroscopy
Counseling Patients
The finding that the more labor-intensive arthroscopy procedures were of reduced value suggests they don’t improve outcomes at a rate concordant with the increase in costs. However, there is a growing body of outcomes-based research that suggests these procedures may still be of great benefit for symptom improvement.
This illustrates that many insights derived from value-based analyses should be interpreted as descriptive, not prescriptive. For example, a patient requiring combined femoroacetabular decompression may achieve lower value than a patient receiving isolated acetabuloplasty, and expectations should be set accordingly. However, it is also true that the former patient would achieve much lower value if they were mistakenly treated with only acetabuloplasty.
It is plausible, if not likely, that follow-up longer than 2 years is required to appreciate the value of improvements conferred by more labor-intensive procedures. In any event, surgeons treat patients, not statistics, and clinical care should continue to be guided by patient education and shared decision-making.
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