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Wang KY, Kishan A, Abboud JA, Verma NN, Srikumaran U. Balloon Spacer Implant is an "Intermediate Value" Innovation Relative to Partial Repair for Full-Thickness Massive Rotator Cuff Repairs: A Cost-Utility Analysis. Arthroscopy 2024:S0749-8063(24)00458-4. [PMID: 38925232 DOI: 10.1016/j.arthro.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/28/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE The purpose of this study was to evaluate the cost-utility of a Balloon Spacer implant relative to partial repair (PR) for the surgical treatment of full-thickness massive rotator cuff tears (MRCT). METHODS A decision-analytic model comparing Balloon Spacer versus PR was developed using data from a prospective, randomized, single-blinded, multi-center controlled trial of 184 randomized patients. Our model was constructed based on the various event pathways a patient could have after the procedure. The probability that each patient progressed to a given outcome and the quality-adjusted life years (QALY) associated with each outcome were derived from the clinical trial data. Incremental cost utility ratio (ICUR) and incremental net monetary benefit (INMB) were calculated based on a probabilistic sensitivity analysis using Monte Carlo simulations of 1,000 hypothetical patients progressing through the decision-analytic model. One-way sensitivity and threshold analyses were performed by varying cost, event probability, and QALY estimates. RESULTS Balloon Spacer had an ICUR of $106,851 (95% CI, $96,317 to $119,143) relative to PR for surgical treatment of MRCT. Across all patients, Balloon Spacer was associated with greater 2-year QALY gain compared to PR (0.20 ± 0.02 for Balloon Spacer versus 0.18 ± 0.02 for PR), but with substantially higher total 2-year cost ($9,701 ± $939 for Balloon Spacer versus $6,315 ± $627 for PR). PR was associated with a positive INMB of $1,802 (95% CI, $1,653 to $1,951) over Balloon Spacer at the $50,000/QALY willingness-to-pay (WTP) threshold. CONCLUSIONS Compared to PR, Balloon Spacer is an "intermediate value" innovation for treatment of MRCT over a 2-year postoperative period with an ICUR value that falls within the $50,000 to $150,000 WTP threshold.
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Affiliation(s)
- Kevin Y Wang
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Orthopaedic Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Arman Kishan
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph A Abboud
- Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush Medical College, Chicago, IL
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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Tiao J, Rosenberg AM, Hoang T, Zaidat B, Wang K, Gladstone JD, Anthony SG. Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures for Isolated Arthroscopic Rotator Cuff Repair, but Patient Out-of-Pocket Expenditures Are Increasing at a Faster Rate Than Total Healthcare Utilization Reimbursement From Payers. Arthroscopy 2024; 40:1727-1736.e1. [PMID: 38949274 DOI: 10.1016/j.arthro.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 07/02/2024]
Abstract
PURPOSE To categorize and trend annual out-of-pocket expenditures for arthroscopic rotator cuff repair (RCR) patients relative to total healthcare utilization (THU) reimbursement and compare drivers of patient out-of-pocket expenditures (POPE) in a granular fashion via analyses by insurance type and surgical setting. METHODS Patients who underwent outpatient arthroscopic RCR in the United States from 2013 to 2018 were identified from the IBM MarketScan Database. Primary outcome variables were total POPE and THU reimbursement, which were calculated for all claims in the 9-month perioperative period. Trends in outcome variables over time and differences across insurance types were analyzed. Multivariable analysis was performed to investigate drivers of POPE. RESULTS A total of 52,330 arthroscopic RCR patients were identified. Between 2013 and 2018, median POPE increased by 47.5% ($917 to $1,353), and median THU increased by 9.3% ($11,964 to $13,076). Patients with high deductible insurance plans paid $1,910 toward their THU, 52.5% more than patients with preferred provider plans ($1,253, P = .001) and 280.5% more than patients with managed care plans ($502, P = .001). All components of POPE increased over the study period, with the largest observed increase being POPE for the immediate procedure (P = .001). On multivariable analysis, out-of-network facility, out-of-network surgeon, and high-deductible insurance most significantly increased POPE. CONCLUSIONS POPE for arthroscopic RCR increased at a higher rate than THU over the study period, demonstrating that patients are paying an increasing proportion of RCR costs. A large percentage of this increase comes from increasing POPE for the immediate procedure. Out-of-network facility status increased POPE 3 times more than out-of-network surgeon status, and future cost-optimization strategies should focus on facility-specific reimbursements in particular. Last, ambulatory surgery centers (ASCs) significantly reduced POPE, so performing arthroscopic RCRs at ASCs is beneficial to cost-minimization efforts. CLINICAL RELEVANCE This study highlights that although payers have increased reimbursement for RCR, patient out-of-pocket expenditures have increased at a much higher rate. Furthermore, this study elucidates trends in and drivers of patient out-of-pocket payments for RCR, providing evidence for development of cost-optimization strategies and counseling of patients undergoing RCR.
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Affiliation(s)
- Justin Tiao
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Ashley M Rosenberg
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Timothy Hoang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Bashar Zaidat
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Kevin Wang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - James D Gladstone
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Shawn G Anthony
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A..
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Hirakawa Y, Manaka T, Ito Y, Nakazawa K, Iio R, Kubota N, Nakamura H. Comparison of cost, surgical time, and clinical results between arthroscopic transosseous rotator cuff repair with lateral cortical augmentation and arthroscopic transosseous equivalent suture bridge: A propensity score-matched analysis. J Orthop Sci 2024; 29:529-536. [PMID: 36822948 DOI: 10.1016/j.jos.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/15/2023] [Accepted: 02/04/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND To reduce the healthcare burden, the clinical results of arthroscopic rotator cuff repair and the cost of the implants used have recently been focused upon. This study compared implant cost, surgical time, short-term clinical results, and cuff repair integrity 2 years postoperatively between arthroscopic transosseous rotator cuff repair using lateral cortical augmentation (TOA) and arthroscopic transosseous-equivalent suture bridge (TOE). METHODS This study included 220 patients with rotator cuff repairs performed by a single surgeon between December 2013 and December 2018. Overall, 70 TOA and 68 TOE cases met the inclusion criteria. The same surgeon performed the procedures at two different hospitals, and the techniques differed between the facilities. A total of 42 TOA patients were matched with 42 TOE patients. The patients were matched using a propensity score analysis by gender, age, and cuff tear size. The minimum follow-up period was 2 years. Implant cost and surgical time were compared between the two methods. The range of motion, clinical outcomes, and visual analog scale were evaluated. Magnetic resonance imaging was performed to examine cuff repair integrity 2 years postoperatively. RESULTS The follow-up rate was 81% (112/138 patients). Implant cost was significantly lower with TOA ($1,396 vs. $2,165; p < 0.001) than with TOE. The average surgical time in the TOA method was significantly shorter than that in the TOE method (82 vs. 109 min; p = 0.001). At a minimum 2-year follow-up, the mean active elevation, abduction, and clinical outcomes improved with both methods, although no improvements in external and internal rotations were observed with either method. There were no significant differences in the postoperative variables and retear rate (TOA, 12%; TOE, 19%; p = 0.548) between the two methods. CONCLUSIONS TOA and TOE achieved comparable clinical results; however, TOA was more cost-effective and had a shorter surgical time than TOE. LEVEL OF EVIDENCE Level Ⅲ, retrospective matched control study.
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Affiliation(s)
- Yoshihiro Hirakawa
- Ishikiriseiki Hospital, 18-28, Yayoi-town, Higashi-Osaka City 579-8026, Japan
| | - Tomoya Manaka
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka 545-8585, Japan.
| | - Yoichi Ito
- Osaka Shoulder Center, Ito Clinic, 1-10-12, Ueda, Matsubara-city, Osaka, 580-0016 Japan
| | - Katsumasa Nakazawa
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Ryosuke Iio
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Naoya Kubota
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka 545-8585, Japan
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Bernstein DN, Wright CL, Lu A, Kim C, Warner JJP, O'Donnell EA. Surgeon idiosyncrasy is a key driver of cost in arthroscopic rotator cuff repair: a time-driven activity-based costing analysis. J Shoulder Elbow Surg 2023; 32:e616-e623. [PMID: 37311487 DOI: 10.1016/j.jse.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 04/20/2023] [Accepted: 05/06/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Delivering high-value orthopedic care requires optimizing value, defined as health outcomes achieved per dollar spent. Published literature is stippled with inaccurate proxies for cost, including negotiated reimbursement rates, fees paid, or listed prices. Time-driven activity-based costing (TDABC) offers a more robust and accurate approach to calculating cost, including shoulder care. In the present study, we sought to determine the drivers of total cost in arthroscopic rotator cuff repair (aRCR) using TDABC. METHODS Consecutive patients undergoing aRCR at multiple sites associated with a large urban health care system between January 2019 and September 2021 were identified. Total cost was determined using TDABC methodology. The episode of care was defined by 3 phases: preoperative, intraoperative, and postoperative care. Patient, procedure, rotator cuff tear morphology, and surgeon characteristics were collected. Bivariate analysis was performed across all characteristics between high-cost (top decile) and all other aRCRs. Multivariable linear regression was used to identify the key cost drivers. RESULTS In total, 625 aRCRs performed by 24 orthopedic surgeons and 572 aRCRs performed by 13 orthopedic surgeons were included in the bivariate and multivariable linear regression analyses, respectively. By TDABC analysis, total aRCR cost varied 6-fold (5.9×) from least to most costly. Intraoperative costs accounted for 91% of average total cost, followed by preoperative costs and postoperative costs (6% and 3%, respectively). Biologic adjuncts (regression coefficient [RC] 0.54, 95% confidence interval [CI] 0.49-0.58, P < .001) and surgeon idiosyncrasy (RC of highest-cost surgeon 0.50, 95% CI 0.26-0.73, P < .001) were the major cost drivers in aRCR. Patient age, comorbidities, number of rotator cuff tendons torn, and revision surgery were not significantly associated with total cost. The amount of tendon retraction (RC 0.0012, 95% CI 0.000020-0.0024, P = .046), average Goutallier grade (RC 0.029, 95% CI 0.0086-0.049, P = .005), and the number of anchors used (RC 0.039, 95% CI 0.032-0.046, P < .001) were also significantly associated with cost, but with far smaller effect sizes. DISCUSSION AND CONCLUSION Episode of care costs vary nearly 6-fold in aRCR and are almost exclusively dictated by the intraoperative phase. Tear morphology and repair technique contribute to cost, although the largest cost drivers of aRCR are the use of biologic adjuncts and surgeon idiosyncrasy, defined as something a surgeon does or does not do that impacts total cost and is not controlled for in the current analysis. Future work should seek to better delineate what these surgeon idiosyncrasies may represent.
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Affiliation(s)
- David N Bernstein
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Casey L Wright
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Amy Lu
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christine Kim
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jon J P Warner
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Evan A O'Donnell
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Meyer DC, Bachmann E, Darwiche S, Moehl A, von Rechenberg B, Gerber C, Snedeker JG. Rotator Cuff Repair and Overlay Augmentation by Direct Interlocking of a Nonwoven Polyethylene Terephthalate Patch Into the Tendon: Evaluation in an Ovine Model. Am J Sports Med 2023; 51:3235-3242. [PMID: 37681526 DOI: 10.1177/03635465231189802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Arthroscopic repair of large rotator cuff tendon tears is associated with high rates of retear. Construct failure often occurs at the suture-tendon interface. Patch augmentation can improve mechanical strength and healing at this interface. PURPOSE To introduce a novel technique for suture-free attachment of an overlaid patch and evaluate its biomechanical strength and biological performance. STUDY DESIGN Descriptive and controlled laboratory studies. METHODS An established ovine model of partial infraspinatus tendon resection and immediate repair was used. After a nonwoven polyethylene terephthalate patch was overlaid to the resected tendon, a barbed microblade was used to draw fibers of the patch directly into the underlying tissue. In vivo histological assessment of healing was performed at 6 and 13 weeks after implantation. Ex vivo models were used to characterize primary repair strength of the suture-free patch fixation to tendon. Additional ex vivo testing assessed the potential of the technique for patch overlay augmentation of suture-based repair. RESULTS The in vivo study revealed no macroscopic evidence of adverse tissue reactions to the interlocked patch fibers. Histological testing indicated a normal host healing response with minimal fibrosis. Uniform and aligned tissue ingrowth to the core of the patch was observed from both the tendon and the bone interfaces to the patch. There was no evident retraction of the infraspinatus muscle, lengthening of the tendon, or tendon gap formation over 13 weeks. Ex vivo testing revealed that direct patch interlocking yielded tendon purchase equivalent to a Mason-Allen suture (150 ± 58 vs 154 ± 49 N, respectively; P = .25). In an overlay configuration, fiber interlocked patch augmentation increased Mason-Allen suture retention strength by 88% (from 221 ± 43 N to 417 ± 86 N; P < .01) with no detectable difference in repair stiffness. CONCLUSION Testing in an ovine model of rotator cuff tendon repair suggested that surgical interlocking of a nonwoven medical textile can provide effective biomechanical performance, support functional tissue ingrowth, and help avoid musculotendinous retraction after surgical tendon repair. CLINICAL RELEVANCE The novel technique may facilitate patch augmentation of rotator cuff repairs.
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Affiliation(s)
- Dominik C Meyer
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Elias Bachmann
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
- ZuriMED Technologies AG, Zurich, Switzerland
| | - Salim Darwiche
- Musculoskeletal Research Unit, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
| | | | - Brigitte von Rechenberg
- Musculoskeletal Research Unit, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
| | - Christian Gerber
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jess G Snedeker
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
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Allaart LJH, Lech J, Macken AA, Kling A, Lafosse L, Lafosse T, van den Bekerom MPJ, Buijze GA. Biomodulating healing after arthroscopic rotator cuff repair: the protocol of a randomised proof of concept trial (BIOHACK). BMJ Open 2023; 13:e071078. [PMID: 37586862 PMCID: PMC10432644 DOI: 10.1136/bmjopen-2022-071078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/13/2023] [Indexed: 08/18/2023] Open
Abstract
PURPOSE/INTRODUCTION Over the last decades, there has been increasing interest in biological stimulation or bioaugmentation after rotator cuff repair. So far, there is no consensus on the appropriate composition of biologicals or which patients would benefit most, and moreover, these biologicals are often expensive. However, there are other, non-pharmacological strategies that are also believed to achieve biological stimulation. This randomised controlled trial evaluates the possible cumulative effect of pragmatic application of cryobiomodulation, photobiomodulation and electrobiomodulation-collectively called biomodulation-on the bone-to-tendon healing process after rotator cuff repair. METHODS In this randomised, controlled proof of concept study, 146 patients undergoing arthroscopic repair of a full thickness posterosuperior or anterosuperior rotator cuff tear will be 1:1 randomly assigned to either a control group or to the additional biomodulation protocol group. The adjuvant biomodulation protocol consists of seven self-applicable therapies and will be administered during the first 6 weeks after surgery. Primary outcome will be healing of the rotator cuff as evaluated by the Sugaya classification on MRI at 1-year postoperatively. ETHICS AND DISSEMINATION This study has been accepted by the National Ethical Review Board CPP Sud-Est IV in France and has been registered at Clinicaltrials.gov. The results of this study will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04618484.
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Affiliation(s)
- Laurens Jan Houterman Allaart
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
- Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Shoulder and Elbow Unit, Joint Research, Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands
| | - James Lech
- Radiology, Universiteit van Amsterdam, Amsterdam, The Netherlands
- Department of Physics and Astronomy, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Arno Alexander Macken
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Agathe Kling
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
| | - Laurent Lafosse
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
| | - Thibault Lafosse
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
| | - Michel P J van den Bekerom
- Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Shoulder and Elbow Unit, Joint Research, Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands
| | - Geert Alexander Buijze
- Division of Orthopaedics and Trauma Surgery, Clinique Générale Annecy, Annecy, France
- Department of Orthopedic Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Department of Orthopedic Surgery, Montpellier University Medical Center, Lapeyronie Hospital, University of Montpellier, Montpellier, France
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Sahoo S, Derwin KA, Jin Y, Imrey PB, Ricchetti ET, Entezari V, Iannotti JP, Spindler KP, Ho JC. One-year patient-reported outcomes following primary arthroscopic rotator cuff repair vary little by surgeon. JSES Int 2023; 7:568-573. [PMID: 37426918 PMCID: PMC10328782 DOI: 10.1016/j.jseint.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
Background This study's purpose was to investigate the extent to which differences among operating surgeons may influence 1-year patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair (RCR) surgery, after controlling for general and disease-specific patient factors. We hypothesized that surgeon would be additionally associated with 1-year PROMs, specifically the baseline to 1-year improvement in Penn Shoulder Score (PSS). Methods We used mixed multivariable statistical modeling to assess the influence of surgeon (and alternatively surgical case volume) on 1-year PSS improvement in patients undergoing RCR at a single health system in 2018, controlling for eight patient- and six disease-specific preoperative factors as possible confounders. Contributions of predictors to explaining variation in 1-year PSS improvement were measured and compared using Akaike's Information Criterion. Results 518 cases performed by 28 surgeons met inclusion criteria, with median (quartiles) baseline PSS of 41.9 (31.9, 53.9) and 1-year PSS improvement of 42 (29.1, 55.3) points. Contrary to expectation, surgeon and surgical case volume were neither statistically significantly nor clinically meaningfully associated with 1-year PSS improvement. Baseline PSS and mental health status (VR-12 MCS) were the dominant and only statistically significant predictors of 1-year PSS improvement, with lower baseline PSS and higher VR-12 MCS predicting larger 1-year PSS improvement. Conclusion Patients generally reported excellent 1-year outcomes following primary RCR. This study did not find evidence that the individual surgeon or surgeon case volume influences 1-year PROMs, independently of case-mix factors, following primary RCR in a large employed hospital system.
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Affiliation(s)
- Sambit Sahoo
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kathleen A. Derwin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yuxuan Jin
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Peter B. Imrey
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Eric T. Ricchetti
- Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Vahid Entezari
- Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Kurt P. Spindler
- Department of Orthopaedic Surgery, Cleveland Clinic, Weston, FL, USA
| | - Jason C. Ho
- Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA
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Intrasubstance Patellar Tendon Repair with the Addition of a Bio-inductive Implant. Arthrosc Tech 2022; 12:e11-e15. [PMID: 36814985 PMCID: PMC9939420 DOI: 10.1016/j.eats.2022.08.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/25/2022] [Indexed: 12/24/2022] Open
Abstract
Intrasubstance patellar tendon ruptures are an uncommon injury that can have devastating long-term effects for patients. Operative intervention to repair the ruptured tendon is the gold standard treatment for these injuries and can be performed using a variety of techniques. Unlike the more common patellar tendon ruptures at the level of the patella, repairs of intrasubstance ruptures are often challenging because of the poor quality of the remaining tendon fibers. Tendon repair with augmentation via bio-inductive implants has gained popularity in upper extremity literature, as it has demonstrated improved tendon strength and patient outcomes. However, there remains a sparsity of reports regarding tendon augmentation in the lower extremity literature. Here, we describe repair of an intrasubstance patellar tendon rupture using a modified SpeedBridge repair and augmentation with a bio-inductive implant.
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Lu Y, Labott JR, Salmons Iv HI, Gross BD, Barlow JD, Sanchez-Sotelo J, Camp CL. Identifying modifiable and nonmodifiable cost drivers of ambulatory rotator cuff repair: a machine learning analysis. J Shoulder Elbow Surg 2022; 31:2262-2273. [PMID: 35562029 DOI: 10.1016/j.jse.2022.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/25/2022] [Accepted: 04/09/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Implementing novel tools that identify contributors to the cost of orthopedic procedures can help hospitals maximize efficiency, minimize waste, improve surgical decision-making, and practice value-based care. The purpose of this study was to develop and internally validate a machine learning algorithm to identify key drivers of total charges after ambulatory arthroscopic rotator cuff repair and compare its performance with a state-of-the-art statistical learning model. METHODS A retrospective review of the New York State Ambulatory Surgery and Services Database was performed to identify patients who underwent elective outpatient rotator cuff repair (RCR) from 2015 to 2016. Initial models were constructed using patient characteristics (age, gender, insurance status, patient income, Elixhauser Comorbidity Index) as well as intraoperative variables (concomitant procedures and services, operative time). These were subsequently entered into 5 separate machine learning algorithms and a generalized additive model using natural splines. Global variable importance and partial dependence curves were constructed to identify the greatest contributors to cost. RESULTS A total of 33,976 patients undergoing ambulatory RCR were included. Median total charges after ambulatory RCR were $16,017 (interquartile range: $11,009-$22,510). The ensemble model outperformed the generalized additive model and demonstrated the best performance on internal validation (root mean squared error: $7112, 95% confidence interval: 7036-7188; logarithmic root mean squared error: 0.354, 95% confidence interval: 0.336-0.373, R2: 0.53), and identified major drivers of total charges after RCR as increasing operating room time, patient income level, number of anchors used, use of local infiltration anesthesia/peripheral nerve blocks, non-White race/ethnicity, and concurrent distal clavicle excision. The model was integrated into a web-based open-access application capable of providing individual predictions and explanations on a case-by-case basis. CONCLUSION This study developed an ensemble supervised machine learning algorithm that outperformed a sophisticated statistical learning model in predicting total charges after ambulatory RCR. Important contributors to total charges included operating room time, duration of care, number of anchors used, type of anesthesia, concomitant distal clavicle excision, community characteristics, and patient demographic factors. Generation of a patient-specific payment schedule based on the Agency for Healthcare Research and Quality risk of mortality highlighted the financial risk assumed by physicians in flat episodic reimbursement schedules given variable patient comorbidities and the importance of an accurate prediction algorithm to appropriately reward high-value care at low costs.
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Affiliation(s)
- Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joshua R Labott
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Time-Driven Activity-Based Costing Accurately Determines Bundle Cost for Rotator Cuff Repair. Arthroscopy 2022; 38:2370-2377. [PMID: 35189303 DOI: 10.1016/j.arthro.2022.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/05/2022] [Accepted: 02/06/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to determine the cost of the episode of care for primary rotator cuff repair (RCR) from day of surgery to 90 days postoperatively using the time-driven activity-based costing (TDABC) method. The secondary purpose of this study was to identify the main drivers of cost for both phases of care. METHODS This retrospective case series study used the TDABC method to determine the bundled cost of care for an RCR. First, a process map of the RCR episode of care was constructed in order to determine drivers of fixed (i.e., rent, power), direct variable (i.e., healthcare personnel), and indirect costs (i.e., marketing, building maintenance). The study was performed at a Midwestern tertiary care medical system, and patients were included in the study if they underwent an RCR from January 2018 to January 2019 with at least 90 days of postoperative follow-up. In this article, all costs were included, but we did not account for fees to provider and professional groups. RESULTS The TDABC method calculated a cost of $10,569 for a bundled RCR, with 76% arising from the operative phase and 24% from the postoperative phase. The main driver of cost within the operative phase was the direct fixed costs, which accounted for 35% of the cost in this phase, and the largest contributor to cost within this category was the cost of implants, which accounted for 55%. In the postoperative phase of care, physical therapy visits were the greatest contributor to cost at 59%. CONCLUSION In a bundled cost of care for RCR, the largest cost driver occurs on the day of surgery for direct fixed costs, in particular, the implant. Physical therapy represents over half of the costs of the episode of care. Better understanding the specific cost of care for RCR will facilitate optimization with appropriately designed payment models and policies that safeguard the interests of the patient, physician, and payer. LEVEL OF EVIDENCE IV, therapeutic case series.
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Jackson GR, Bedi A, Denard PJ. Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates. Arthroscopy 2022; 38:2342-2347. [PMID: 34767956 DOI: 10.1016/j.arthro.2021.10.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 02/02/2023]
Abstract
We provide our algorithm for tissue augmentation of rotator cuff repairs based on the current available evidence regarding rotator cuff healing. A variety of factors are associated with healing following rotator cuff repair. Increasing tear size and retraction as well as severe fatty degeneration have been associated with worsening rates of tendon healing. Given the correlation between tendon healing and postoperative outcomes, it is important to identify patients at high risk for failure and to modify their treatment accordingly to minimize the risk of early biomechanical failure and maximize the potential for structural healing. One approach that may be used to improve healing is tissue augmentation. Tissue augmentation is the use of tissue patches and scaffolds to provide rotator cuff reinforcement. Surgical management for rotator cuff tears (RCTs) continues to be a challenging task in orthopaedic surgery today. Appropriate treatment measures require an in depth understanding and consideration of the patient's prognostic factors such as age, fatty infiltration of the rotator cuff muscles, bone mineral density, rotator cuff retraction, anteroposterior tear size, work activity, and degenerative changes of the joint. Using these factors within the Rotator Cuff Healing Index, we can determine a patient's surgical treatment that will yield the maximum healing rate. For nonarthritic RCTs, joint-preserving strategies should be first-line treatment options. For young, active patients with a reparable RCT and minimal fatty infiltration, a complete repair can be effective. For young patients with irreparable RCTs, superior capsular reconstructions, and tendon transfers are viable options. For elderly patients with low work activity, an irreparable RCT and significant fatty infiltration, a partial repair with or without graft augmentation can be attempted if minimal to no arthritic changes are seen. LEVEL OF EVIDENCE: Level V, expert opinion.
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Affiliation(s)
- Garrett R Jackson
- American University of the Caribbean School of Medicine, Sint Maarten
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
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Sanders B. The Transosseous Cerclage In Situ Technique for Biceps Tenodesis. Arthrosc Tech 2022; 11:e1247-e1250. [PMID: 35936865 PMCID: PMC9353272 DOI: 10.1016/j.eats.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/03/2022] [Indexed: 02/03/2023] Open
Abstract
There are many techniques described for biceps tenodesis that vary by fixation type, location, and open or arthroscopic method. Clinical outcomes are similar regardless of repair technique; therefore, the cost and time of procedures are increasingly points of improvement to practice value-based medicine and deliver cost-effective care. The technique described in this article builds on previous arthroscopic transosseous technical knowledge to yield a cost-effective and efficient clinical method to perform biceps tenodesis in the suprapectoral location without the cost and complications of an implant. In addition, this technique provides 4 methods of tenodesis in series, which serves to decrease the risk of mechanical failure and leverages the robust method of suture cerclage for capture of the biceps.
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Affiliation(s)
- Brett Sanders
- Address correspondence to Brett Sanders, M.D., Center for Sports Medicine and Orthopaedics, 2415 McCallie Ave, Chattanooga, TN 37404, U.S.A.
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Solomon DJ. Editorial Commentary: Cost Associated With Arthroscopic Rotator Cuff Repair Can Be Largely Controlled by the Surgeon. Arthroscopy 2021; 37:1084-1085. [PMID: 33812513 DOI: 10.1016/j.arthro.2020.12.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 02/02/2023]
Abstract
Surgeons must rely on cost and charge data to inform a patient outcome-optimized value-based approach to arthroscopic rotator cuff repairs. Using biologic and regenerative procedures to augment repairs only when necessary and optimizing anchor number are 2 obvious ways surgeons can help control cost of these procedures. Addition of biologics, such as patches and tissue augmentation, nearly doubled the charges for the procedure.
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