High-Volume and Privately Owned Ambulatory Surgical Centers Reduce Costs in Achilles Tendon Repair

Association of endovascular thrombectomy volume and outcomes in acute ischemic stroke: A National Inpatient Sample Study

BACKGROUND

Previous studies suggest a positive relationship between higher hospital endovascular thrombectomy (EVT) volume and improved outcomes. We investigated this association using the National Inpatient Sample (NIS) database from 2016 to 2020.

METHODS

A cross-sectional analysis of the NIS examined the relationship between hospital EVT volume and outcomes. Data on clinical and demographic variables were collected. Outcomes included favorable functional outcome (discharge home without assistance), inpatient mortality, and intracerebral hemorrhage (ICH). Hospitals in the top quintile of annual EVT volume were classified as high-volume centers. We conducted univariate, multivariate, nearest neighbor matched analysis, and an exploratory analysis to identify annual EVT volume cutoffs.

RESULTS

Among 114,640 patients with EVT, 24,415 (21.3%) were treated at high-volume centers. High-volume centers had higher rates of favorable functional outcomes in univariate (odds ratio (OR) 1.20, p < 0.001), multivariate (adjusted OR (aOR) 1.19, p = 0.003), and matched analysis (OR 1.14, p = 0.028). Before matching, inpatient mortality was lower in high-volume centers (OR 0.83, p < 0.001), but this difference was not significant in univariate and matched analyses. No differences in ICH were observed. Functional benefit was noted at ≥ 50 EVTs annually, with centers performing  ≥ 175 EVTs showing significantly higher benefits (aOR 1.42, p = 0.002).

CONCLUSIONS

Increased hospital EVT volume is associated with modestly improved functional outcomes in patients with acute ischemic stroke. Functional improvements are evident at ≥ 50 EVTs annually and increase with higher case volumes, without associated increases in inpatient mortality or ICH.

Risk Factors of Emergency Department Utilization After Outpatient Surgery for Sports-Related Injuries

INTRODUCTION

The purpose of this study was to identify the most common reasons for and risk factors associated with postoperative emergency department (ED) utilization after orthopaedic procedures for sports-related injuries.

METHODS

Using the 2014 to 2016 New York and Florida State Databases from the Healthcare Cost and Utilization Project, outpatient procedures for sports-related injuries were identified. Patient records were tracked across care settings within each state to determine the rate and reasons of postoperative ED utilization within 90 days after the index surgery. Multiple logistic regression models were used to identify risk factors associated with ED visits at 0 to 7 days, 8 to 30 days, 31 to 90 days postoperatively.

RESULTS

A total of 28,192 surgery visits for sports-related injuries were identified, with knee arthroscopy with partial meniscectomy (18.48%) and arthroscopic anterior cruciate ligament reconstruction (17.04%) as the two most common procedures treating sports injuries. The overall postoperative ED utilization rates were 1.6% (0 to 7 days postoperative), 1.3% (8 to 30 days) and 2.1% (31 to 90 days). The main cause of ED visits was markedly different during each postoperative period: mainly musculoskeletal pain (36.3%) during 0 to 7 days, either musculoskeletal pain (17%) or injury (16.6%) during 8 to 30 days, and injury (24.2%) during 31 to 90 days. Sports with the highest ED utilization in descending order were basketball, football, ice/snow sports, walking/running, cycling, and soccer. Relative to open procedures, arthroscopic procedures were 0.71 times as likely to result in a postoperative ED visit. Independent predictors of ED utilization up to 90 days postoperatively included renal failure, chronic pulmonary disease, psychosis, diabetes, and alcohol abuse.

DISCUSSION

Rate of ED utilization after outpatient surgery for sports-related injuries is low (<2.2%), with postoperative musculoskeletal pain and reinjury as the two most common causes, highlighting the importance of postoperative pain management and injury prevention. Arthroscopic procedures showed markedly lower ED utilization compared with open surgery, although not indicative of overall superiority.

LEVEL OF EVIDENCE

III, Retrospective Cohort Study.

Evaluation of Costs Associated With Acute Achilles Tendon Repair

Background

Increasing attention is being paid to the costs associated with various orthopaedic surgeries. Here, we studied the factors that influence costs associated with surgically treated acute Achilles tendon tears.

Methods

We retrospectively identified patients with surgically repaired acute Achilles tendon tears, excluding insertional ruptures or chronic tendon issues. Using the Value Driven Outcome (VDO) tool from our institution, we assessed total direct costs as well as facility costs. Briefly, the VDO tool includes an item-level database that can capture detailed cost data-costs are then reported as relative mean data. Cost variables were adjusted to 2022 US dollars, and total direct cost was compared with patient characteristics using gamma regressions to report cost ratios with 95% CIs.

Results

Our cohort consisted of 224 patients with Achilles tendon tears surgically repaired by one of 4 fellowship-trained orthopaedic foot and ankle surgeons. There were no differences in demographics, total direct costs, or facility costs based on surgical positioning (prone n = 156, supine n = 68). Open repairs (n = 215), compared with percutaneous techniques (n = 9) that used commercially available instrumentation, had 37% less total direct costs (P < .001, 95% CI 0.55-0.72). Compared with surgery at a main academic hospital (n = 15), procedures at an ambulatory care center (n = 207) had 19% lower total direct costs (P = .040, 95% CI 0.66-0.99) and 41% lower facility costs (P < .001, 95% CI 0.5-0.7).

Conclusion

Improving cost-effective orthopaedic care remains an increasingly important goal. Patient positioning for Achilles tendon repair does not appear to have meaningful impacts on cost. When clinically appropriate, considering surgery location at an ambulatory center appears to reduce surgical costs.

Level of Evidence

Level III, retrospective comparative study.

Surgical Setting in Achilles Tendon Repair: How Does It Relate to Costs and Complications?

Background

Primary Achilles tendon repair (ATR) can be performed in ambulatory surgery centers (ASCs) or hospitals. We compared costs and complication rates of ATR performed in these settings.

Methods

We retrospectively queried the electronic medical record of our academic health system and identified 97 adults who underwent primary ATR from 2015 to 2021. Variables were compared between patients treated at ASCs vs those treated in hospitals. We compared continuous variables with Wilcoxon rank-sum tests and categorical variables with χ2 tests. We used an α of 0.05. Multivariable logistic regression was performed to determine associations between surgical setting and costs. Linear regression was performed between each charge subtype and total cost to identify which charge subtypes were most associated with total cost.

Results

Patients who underwent ATR in hospitals had a higher rate of unanticipated postoperative hospital admission (13%) than those treated in ASCs (0%) (P = .01). We found no differences with regard to postoperative complications, emergency department visits, readmission, rerupture, reoperation/revision, or death. Patients treated in hospitals had a higher mean (±SD) implant cost ($664 ± $810) than those treated in ASCs ($175 ± $585) (P < .01). We found no differences between settings with regard to total cost, supply costs, operating room charges, or anesthesia charges. Higher implant cost was associated with hospital setting (odds ratio = 16 [95% CI: 1.7-157]) and body mass index > 25 (odds ratio = 1.2 [95% CI: 1.0-1.5]). Operating room costs were strongly correlated with total costs (R2 = .94).

Conclusion

The overall cost and complication rate of ATRs were not significantly different between ASCs and hospitals. ATRs performed in hospitals had higher implant costs and higher rates of postoperative admission than those performed in ASCs.

Level of Evidence

Level III, retrospective comparative study.

Increased Total Cost and Lack of Diagnostic Utility for Emergency Department Visits After ACL Injury

Background:

Patients are commonly evaluated at the emergency department (ED) with acute anterior cruciate ligament (ACL) tears, but providers without orthopaedics training may struggle to correctly diagnose these injuries.

Hypothesis:

It was hypothesized that few patients would be diagnosed with an ACL tear while in the ED and that these patients would be of lower socioeconomic status and more likely to have public insurance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The 2017 State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) from the state of Florida were utilized in this study. Cases with Current Procedural Terminology code 29888 (arthroscopically aided ACL reconstruction [ACLR]) were selected from the SASD, and data from the SEDD were matched to patients who had an ED visit for a knee injury within 120 days before ACLR. Chi-square analysis was used to test for differences in patient and surgical variables between the ED visit and nonvisit patient groups. A generalized linear model was created to model the effect of ED visit on total cost for an ACL injury.

Results:

While controlling for differences in patient characteristics and concomitant procedure usage, a visit to the ED added $4587 in total cost (P < .001). The ED visit cohort contained a greater proportion of patients with Medicaid (20.2% vs 9.1%), patients who were Black (18.4% vs 10.3%), and patients in the lowest income quartile (34.4% vs 25.0%) (P < .001 for all). In the ED visit cohort, 14.4% of patients received an allograft versus 10.1% in the non-ED visit cohort (P = .001) despite having a similar mean age. An ACL sprain was diagnosed in only 29 of the 645 (4.5%) patients who visited the ED.

Conclusion:

Utilizing the ED for care after an ACL injury was expensive, averaging a $4587 increase in total cost associated with ACLR. However, patients rarely left with a definitive diagnosis, with only 4.5% of patients who underwent ACLR being correctly diagnosed with an ACL tear in the ED. This additional cost was levied disproportionately on patients of low socioeconomic status and patients with Medicaid.