Cost Drivers Associated With Anterior Shoulder Stabilization Surgery

Arthroscopic Bankart repair versus nonoperative management for first-time anterior shoulder instability: A cost-effectiveness analysis

Purpose

Arthroscopic Bankart repair (ABR) may be more effective than nonoperative management for patients with anterior shoulder instability following first-time dislocation. The purpose of the study was to determine the most cost-effective treatment strategy by evaluating the incremental cost-effectiveness ratio (ICER) for ABR versus nonoperative treatment.

Methods

This cost-effectiveness study utilized a Markov decision chain and Monte Carlo simulation. Probabilities, health utility values, and outcome data regarding ABR and nonoperative management of first-time shoulder instability derived from level I/II evidence. Costs were tabulated from Centers for Medicaid & Medicare Services. Probabilistic sensitivity analysis was performed using >100,000 repetitions of the Monte Carlo simulation. A willingness-to-pay (WTP) threshold was set at $50,000.

Results

The expected cost for operative management higher than nonoperative management ($32,765 vs $29,343). However, ABR (5.48 quality-adjusted life years (QALYs)) was the more effective treatment strategy compared to nonoperative management (4.61 QALYs). The ICER for ABR was $3943. Probabilistic sensitivity analysis showed that ABR was the most cost-effective strategy in 100% of simulations.

Discussion

ABR is more cost-effective than nonoperative management for first-time anterior shoulder dislocation. The threshold analysis demonstrated that when accounting for WTP, ABR was found to be the more cost-effective strategy.

An Analysis of Shoulder Surgeon Volume on Surgeon Competency, Hospital Costs, and Adverse Events: A Systematic Review

Purpose

The purpose of this systematic review is to assess the impact of shoulder surgeon volume of common shoulder procedures on hospital/surgeon efficiency, adverse events, and hospital costs.

Methods

Four online databases (PubMed, Embase, MEDLINE, and CENTRAL) were searched for literature on the influence of surgeon volume on outcomes for shoulder surgery, from data inception to October 1, 2020. The Methodological Index for Non-Randomized Studies tool was used to assess study quality. Data are presented descriptively.

Results

Twelve studies encompassing 150,898 patients were included in this review. The distribution of surgery type was rotator cuff repair (53.7%; n = 81,066), shoulder arthroplasty (35.7%; n = 53,833), and ORIF (10.6%; n = 15,999). Higher surgeon volume for rotator cuff repairs was associated with lower surgical time, length of stay, costs, and reoperation/readmission rates. For shoulder arthroplasty, higher surgeon volume was associated with lower length of stay, costs, surgical time, non-routine disposition, blood loss, reoperation/readmission, and complications. As for ORIF, higher surgeon volume was associated with lower length of stay, costs, and complications.

Conclusion

A high surgical volume leads to improved results for hospital/surgeon efficiency and reduces adverse events and hospital costs across various orthopaedic procedures. Hospitals and physicians can use this information to develop and adhere to policies and practices that contribute to more efficient and better-quality care for patients.

Level of Evidence

III.

Perioperative costs of local or regional anesthesia versus general anesthesia in the outpatient setting: a systematic review of recent literature

BACKGROUND AND OBJECTIVES

In this systematic review, we carried out an assessment of perioperative costs of local or regional anesthesia versus general anesthesia in the ambulatory setting.

METHODS

A systematic literature search was conducted to find relevant data on costs and cost-effectiveness analyses of anesthesia regimens in outpatients, regardless of the medical procedure they underwent. The hypothesis was that local or regional anesthesia has a lower economic impact on hospital costs in the outpatient setting. The primary outcome was the average total cost of anesthesia calculated on perioperative costs (drugs, staff, resources used).

RESULTS

One-thousand-six-hundred-ninety-eight records were retrieved, and 28 articles including 27,581 patients were selected after reviewing the articles. Data on the average total costs of anesthesia and other secondary outcomes (anesthesia time, recovery time, time to home readiness, hospital stay time, complications) were retrieved. Taken together, these findings indicated that local or regional anesthesia is associated with lower average total hospital costs than general anesthesia when performed in the ambulatory setting. Reductions in operating room time and postanesthesia recovery time and a lower hospital stay time may account for this result.

CONCLUSIONS

Despite the limitations of this systematic review, mainly the heterogeneity of the studies and the lack of cost-effectiveness analysis, the economic impact of the anesthesia regimes on healthcare costs appears to be relevant and should be further evaluated.

Ambulatory Surgery Centers Significantly Decrease Total Health Care Expenditures in Primary Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. The volume and cost of ACLR procedures are increasing annually, but the drivers of these cost increases are not well described.

PURPOSE

To analyze the modifiable drivers of total health care utilization (THU), immediate procedure reimbursement, and surgeon reimbursement for patients undergoing ACLR using a large national commercial insurance database from 2013 to 2017.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

For this study, the cohort consisted of patients identified in the MarketScan Commercial Claims and Encounters database who underwent outpatient arthroscopic ACLR in the United States from 2013 to 2017. Patients with Current Procedural Terminology code 29888 were included. THU was defined as the sum of any payment related to the ACLR procedure from 90 days preoperatively to 180 days postoperatively. A multivariable model was utilized to describe the patient- and procedure-related drivers of THU, immediate procedure reimbursement, and surgeon reimbursement.

RESULTS

There were 34,862 patients identified. On multivariable analysis, the main driver of THU and immediate procedure reimbursement was an outpatient hospital as the surgical setting (US$6789 increase in THU). The main driver of surgeon reimbursement was an out-of-network surgeon (US$1337 increase). Health maintenance organization as the insurance plan type decreased THU, immediate procedure reimbursement, and surgeon reimbursement (US$955, US$108, and US$38 decrease, respectively, compared with preferred provider organization; P < .05 for all).

CONCLUSION

Performing procedures in more cost-efficient ambulatory surgery centers had the largest effect on decreasing health care expenditures for ACLR. Health maintenance organizations aided in cost-optimization efforts as well, but had a minor effect on surgeon reimbursement. Overall, this study increases transparency into what drives reimbursement and serves as a foundation for how to decrease health care expenditures related to ACLR.

Increased rates of subjective shoulder instability after Bankart repair with remplissage compared to Latarjet surgery

HYPOTHESIS AND BACKGROUND

Controversy exists as to the ideal management of young active patients with subcritical glenoid bone loss and an off-track Hill-Sachs lesion, and the Latarjet and arthroscopic Bankart with remplissage are effective surgical options. The purpose of this study was to compare rates of recurrent instability and reoperation, as well as patient-reported outcome measures, between Latarjet and arthroscopic Bankart repair with remplissage surgery patients. The authors hypothesized that there would be no difference in rates of recurrent instability, reoperation, and postoperative outcomes between patients who underwent Latarjet surgery and patients who underwent Bankart repair with concomitant remplissage postoperatively.

MATERIALS AND METHODS

All patients who underwent primary shoulder stabilization for shoulder instability from 2014 to 2019 were screened. Latarjet and Bankart repair with remplissage patients were included if arthroscopic surgery was performed in response to anterior shoulder instability. Recurrent instability, revision, shoulder range of motion, return to sport (RTS), and patient-reported outcome measures (Oxford Shoulder Instability, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores) were compared between groups.

RESULTS

Overall, 43 Latarjet patients (age: 29.8 ± 12.1 years, 36 males 7 females) and 28 Bankart repair with remplissage patients (age: 28.2 ± 8.8 years, 25 males 3 females) were included with a mean follow-up of 3.3 ± 1.9 years. Patients who underwent Latarjet surgery had larger amounts of bone loss (19% vs. 11%, P < .001), a lower rate of off-track Hill-Sachs lesions (47% vs. 82%, P < .001), and more frequently had a history of chronic shoulder dislocations (88% vs. 43%, P < .001) compared to Bankart repair with remplissage patients. Latarjet patients less frequently reported feeling subjective shoulder instability after surgery (21% vs. 50%, P = .022), which was defined as feeling apprehension or experiencing a shoulder subluxation or dislocation event. There were no differences in rates of postoperative dislocation, revision, reoperation, or RTS, as well as patient-reported outcome scores, between groups (all P > .05).

CONCLUSION

Despite differences in osseous defects, Latarjet and Bankart repair with remplissage patients had similar rates of clinical, patient-reported, and RTS outcomes at a mean of 3.3 years postoperatively. Latarjet surgery patients may be less likely to experience subjective shoulder instability postoperatively than patients who undergo Bankart repair with concomitant remplissage.

Implementation of Machine Learning to Predict Cost of Care Associated with Ambulatory Single-Level Lumbar Decompression

BACKGROUND

With the emergence of the concept of value-based care, efficient resource allocation has become an increasingly prominent factor in surgical decision-making. Validated machine learning (ML) models for cost prediction in outpatient spine surgery are limited. As such, we developed and internally validated a supervised ML algorithm to reliably identify cost drivers associated with ambulatory single-level lumbar decompression surgery.

METHODS

A retrospective review of the New York State Ambulatory Surgical Database was performed to identify patients who underwent single-level lumbar decompression from 2014 to 2015. Patients with a length of stay of >0 were excluded. Using pre- and intraoperative parameters (features) derived from the New York State Ambulatory Surgical Database, an optimal supervised ML model was ultimately developed and internally validated after 5 candidate models were rigorously tested, trained, and compared for predictive performance related to total charges. The best performing model was then evaluated by testing its performance on identifying relationships between features of interest and cost prediction. Finally, the best performing algorithm was entered into an open-access web application.

RESULTS

A total of 8402 patients were included. The gradient-boosted ensemble model demonstrated the best performance assessed via internal validation. Major cost drivers included anesthesia type, operating room time, race, patient income and insurance status, community type, worker's compensation status, and comorbidity index.

CONCLUSIONS

The gradient-boosted ensemble model predicted total charges and associated cost drivers associated with ambulatory single-level lumbar decompression using a large, statewide database with excellent performance. External validation of this algorithm in future studies may guide practical application of this clinical tool.

Influence of medical comorbidity and surgical indication on total elbow arthroplasty cost of care

BACKGROUND

Movement toward providing value-based musculoskeletal care requires understanding the cost associated with surgical care as well as the drivers of these costs. The aim of this study was to investigate the effect of common medical comorbidities and specific total elbow arthroplasty (TEA) indications on reimbursement costs throughout the 90-day TEA episode of care. The secondary aim was to identify the drivers of these costs.

METHODS

Administrative health claims for patients who underwent orthopedic intervention between 2010 and 2020 were queried using specific disease classification and procedural terminology codes from a commercially available national database of 53 million patients. Patients with commercial insurance were divided into various cohorts determined by different surgical indications and medical comorbidities. The reimbursement costs of the surgical encounter, 89-day postoperative period, and total 90-day period in each cohort were evaluated. The cost drivers for the 89-day postoperative period were also determined. Analyses were performed using descriptive statistics and the Kruskal-Wallis test for comparison.

RESULTS

A total of 378 patients who underwent TEA were identified. The mean reimbursement cost of the surgical encounter ($13,393 ± $8314) did not differ significantly based on patient factors. The mean reimbursement cost of the 89-day postoperative period ($4232 ± $2343) differed significantly when stratified by surgical indication (P < .0001) or by medical comorbidity (P < .0001). The indication of rheumatoid arthritis ($4864 ± $1136) and the comorbidity of chronic kidney disease ($5873 ± $1165) had the most expensive postoperative period. In addition, the total 90-day reimbursement cost ($16,982 ± $4132) differed significantly when stratified by surgical indication (P = .00083) or by medical comorbidity (P < .0001), with the indication of acute fracture ($18,870 ± $3971) and the comorbidity of chronic pulmonary disease ($19,194 ± $3829) showing the highest total 90-day cost. Inpatient costs related to readmissions represented 38% of the total reimbursement cost. The overall readmission rate was 5.0%, and the mean readmission cost was $16,296.

CONCLUSION

TEA reimbursements are significantly influenced by surgical indications and medical comorbidities during the postoperative period and the total 90-day episode of care. As the United States transitions to delivering value-based health care, the need for surgeons and policy makers to understand treatment costs associated with different patient-level factors will expand.

Duration of Care and Operative Time Are the Primary Drivers of Total Charges After Ambulatory Hip Arthroscopy: A Machine Learning Analysis

PURPOSE

To develop a machine learning algorithm to predict total charges after ambulatory hip arthroscopy and create a risk-adjusted payment model based on patient comorbidities.

METHODS

A retrospective review of the New York State Ambulatory Surgery and Services database was performed to identify patients who underwent elective hip arthroscopy between 2015 and 2016. Features included in initial models consisted of patient characteristics, medical comorbidities, and procedure-specific variables. Models were generated to predict total charges using 5 algorithms. Model performance was assessed by the root-mean-square error, root-mean-square logarithmic error, and coefficient of determination. Global variable importance and partial dependence curves were constructed to show the impact of each input feature on total charges. For performance benchmarking, the best candidate model was compared with a multivariate linear regression using the same input features.

RESULTS

A total of 5,121 patients were included. The median cost after hip arthroscopy was $19,720 (interquartile range, $12,399-$26,439). The gradient-boosted ensemble model showed the best performance (root-mean-square error, $3,800 [95% confidence interval, $3,700-$3,900]; logarithmic root-mean-square error, 0.249 [95% confidence interval, 0.24-0.26]; R² = 0.73). Major cost drivers included total hours in facility less than 12 or more than 15, longer procedure time, performance of a labral repair, age younger than 30 years, Elixhauser Comorbidity Index (ECI) of 1 or greater, African American race, residence in extreme urban and rural areas, and higher household and neighborhood income.

CONCLUSIONS

The gradient-boosted ensemble model effectively predicted total charges after hip arthroscopy. Few modifiable variables were identified other than anesthesia type; nonmodifiable drivers of total charges included duration of care less than 12 hours or more than 15 hours, operating room time more than 100 minutes, age younger than 30 years, performance of a labral repair, and ECI greater than 0. Stratification of patients based on the ECI highlighted the increased financial risk borne by physicians via flat reimbursement schedules given variable degrees of comorbidities.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Glenoid bony morphology along long diameter is associated with the occurrence of recurrent anterior shoulder dislocation: a case-control study based on three-dimensional CT measurements

PURPOSE

The purpose of our study is to compare the anatomic parameters of proximal humerus, glenoid, and glenohumeral joint between patients with recurrent anterior shoulder dislocation (RASD) and patients without RASD with the assistance of three-dimensional (3D) CT scans.

METHODS

Sixty patients were included in the study and divided into group RASD and group control. 3D-CT models of shoulder joint for each included patient were reconstructed and multiple anatomic parameters were measured.

RESULTS

There were no statistically significant differences between the two groups in morphological parameters of humerus and glenohumeral joints. Long diameter of glenoid was 3.50 ± 0.34 cm for patients in group RASD and 3.31 ± 0.32 cm in group control (p = 0.039). There was a statistically significant difference in the ratio of long to short diameter of glenoid (p < 0.001). Ratio of humeral head height to glenoid long diameter (Hhh/Gld) was 1.02 ± 0.07 in group RASD, significantly lower than 1.09 ± 0.08 in group control (p = 0.001). Longitudinal depth of glenoid was significantly higher in group RASD (p = 0.013).

CONCLUSION

The glenoid morphology along long diameter is closely correlated with the stability of glenohumeral joint, including glenoid long diameter and glenoid longitudinal depth. It is especially noteworthy that the value of Hhh/Gld decreases in patients with RASD. The difference of Hhh/Gld between the two groups reminds us that the correlation of bony structure along long diameter between glenoid and humeral head plays an important role in RASD.