Paper #24 - Factors influencing direct clinical costs of outpatient arthroscopic rotator cuff repair surgery

Abstract

Background: Understanding the cost of healthcare delivered is critical to understanding the overall value provided. Billing charges are often confused with the cost of delivering care and are often inaccurate estimates of the actual costs incurred. Overall, there is limited information on the “true cost” of care delivered or direct clinical care costs. Very limited information exists as to what variables affect the direct clinical care costs of rotator cuff repair surgery. The purpose of this study was to determine the direct clinical care cost of outpatient arthroscopic rotator cuff repair surgery utilizing a unique Value-Driven Outcomes (VDO) tool which was designed to identify and track direct costs of all aspects of clinical care; and to identify various patient and treatment-related variables affecting cost. Methods: Arthroscopic rotator cuff repairs performed at an outpatient academic medical center by three surgeons were included in the analysis from 3/2014 to 6/2015. Cost data was derived for all cases during this period using the VDO tool developed and validated at our institution. Cost data included overall total cost, and was further broken down to identify facility utilization costs, indirect costs, medication costs, supply costs and other ancillary costs. Patient and surgical data collected included attending surgeon, smoking status, BMI, ASA health status, tear severity (partial thickness versus full thickness), repair construct (single row versus double row), if a subscapularis repair was performed, if a subacromial decompression was performed, if a distal clavicle excision was performed, if a biceps tenodesis was performed, the overall numbers of anchors utilized per case, anteroposterior size of the tear (mm), tear retraction (mm) and supraspinatus and infraspinatus muscle quality (Goutallier grade). Univariate and multivariate regressions were performed to determine the affect of various factors on cost. P < .05 was considered statistically significant. Results: 170 arthroscopic rotator cuff repairs were performed during the study period. There were 17 active smokers. 31 patients were considered to have severe systemic disease based upon their ASA classification. 138 full thickness tears and 32 partial thickness tears were repaired. A single row repair was performed on 128 patients and double-row repair on 42 patients. The average total number of anchors used per case overall was 3. The average tear size was 21 mm. The average tear retraction was 18 mm.The average Goutallier grade for the supraspinatus and infraspinatus were 0.9 and 0.4 respectively. Subscapularis repair and subacromial decompression were performed in 37 cases and 106 cases respectively. Distal clavicle excision was performed in 19 cases. A biceps tenodesis was performed in 66 cases and a tenotomy in 26 cases. In the univariate analysis, higher overall total cost was correlated with the presence of subscapularis repair being performed (P < .0001), a bicep tenodesis being performed (P = .043) and a greater total number of anchors used per case (P < .0001). Multivariate analysis results showed continued significant correlations between higher total cost and the presence of a subscapularis repair being performed (P = .015) and total number of anchors utilized (P < .0001). Smoking status, attending surgeon, BMI, ASA classifications, partial versus full-thickness tear, single row vs double row construct, the addition of a subacromial decompression or distal clavicle excision, tear size and retraction and muscle quality were not significantly associated with total cost. (P > .05) Discussion: Direct clinical care costs associated with arthroscopic rotator cuff repair are related to the overall number of suture anchors utilized and the addition of concomitant procedures (biceps tenodesis, subscapularis repair). Implementation of strategies to reduce overall costs should focus on reducing overall anchor quantity and/or potentially using alternative surgical techniques that may result in equivalent clinical results (biceps tenotomy vs. tenodesis; debridement of partial thickness upper border subscapularis tears vs. repair).