Editorial Commentary: Improved Operating Room Efficiency Is the Best Way to Control Orthopaedic Costs.

Current procedural terminology codes and assigned relative value units associated with arthroscopic hip surgery lag behind other joints in accurately describing, and often undervaluing, what surgery entails. Hip arthroscopy is expensive, and, to address inequity, procedural cost drivers require review. Consumable implants and operating room (OR) time drive the costs associated with the procedure. Hospitals, healthcare payors, patients, and surgeons all benefit from increasing OR efficiency and reducing equipment cost. However, the patient loses if financial strategy supersedes care delivery, and it is wrong to cut necessary use of consumables to save money. Fewer anchors is not the answer (yet we should use reusable, nonimplantable supplies when feasible). The greater opportunity to lower costs is improved OR efficiency, requiring a team approach with buy-in from perioperative, anesthesia, surgical staff, and administrators. OR time is a consistent driver of cost across every type of orthopaedic surgery. Studies evaluating strategies for OR efficiency in hip arthroscopy will benefit the field. By leading this effort, surgeons could be best positioned to address inadequate relative value units.

In-Hospital Complications following Arthrotomy versus Arthroscopy for Septic Knee Arthritis: A Cohort-Matched Comparison.

There is a paucity of literature comparing the relative merits of open arthrotomy versus arthroscopy for the surgical treatment of septic knee arthritis. The primary goal of this study is to compare the risk of perioperative complications between these two surgical techniques. To this end, 560 patients treated for septic arthritis of the native knee with arthroscopy were statistically matched 1:1 with 560 patients treated with open arthrotomy. The outcome measures included major complications, minor complications, mortality, inpatient hospital charges, and length of stay (LOS). Major complications were defined as myocardial infarction, cardiac arrest, stroke, deep vein thrombosis, pulmonary embolism, pneumonia, postoperative shock, unplanned ventilation, deep surgical site infection, wound dehiscence, infected postoperative seroma, hospital acquired urinary tract infection, and retained surgical item. Minor complications included phlebitis and thrombophlebitis, postprocedural emphysema, minor surgical site infection, peripheral nerve complication, and intraoperative hemorrhage. Mortality data were extracted from the database using the Uniform Bill patient disposition. Complications were analyzed using univariate and multivariate logistic regression models, whereas mean costs and LOS were compared using the Kruskal-Wallis H-test. Major complications occurred in 3.8% of the patients in the arthroscopy cohort and 5.4% of the patients in the arthrotomy cohort (p = 0.20). Too few patients in our sample died to report based on National (Nationwide) Impatient Sample (NIS) minimum reporting standards. Rates of minor complications were similar for the arthroscopy and arthrotomy cohorts (12.5 vs. 13.9%; p = 0.48). Multivariate analysis did not reveal any greater risk of minor or major complication between the two procedures. Inpatient hospital cost was similar for arthroscopy ( = $15,917; standard deviation [SD] = 14,424) and arthrotomy ( = $16,020; SD = 18,665; p = 0.42). LOS was also similar for both arthrotomy (6.78 days, SD = 6.75) and arthroscopy (6.24 days, SD = 5.95; p = 0.23). Patients undergoing arthroscopic treatment of septic arthritis of the knee showed no difference in relative risk of perioperative complications, LOS, or hospital cost compared with patients who underwent open arthrotomy.

Cost of Arthroscopic Rotator Cuff Repairs Is Primarily Driven by Procedure-Level Factors: A Single-Institution Analysis of an Ambulatory Surgery Center.

PURPOSE: To identify intraoperative drivers of cost associated with arthroscopic rotator cuff repairs (RCRs) through analysis of an institutional database. METHODS: This was a single-institution retrospective review of arthroscopic RCRs performed at an ambulatory surgical center between November 2016 and July 2019. Patient-level factors analyzed included age, sex, insurance type (private, Medicare, Medicaid, self-pay, and other government), American Society of Anesthesiologists grade (I, II, III, and missing), and Charlson comorbidity index (0, 1, 2, and ≥3). Procedure-level factors included use of biologics (decellularized dermal allograft or bioinductive healing implant), anesthesia type (regional block, monitored anesthesia care, or general), number of anchors and sutures, additional procedures (biceps tenodesis, distal clavicle resection, subacromial decompression), and operative time. Multivariate linear regression analysis was used to identify factors significantly associated with higher or lower charges. RESULTS: A total of 712 arthroscopic RCRs were included. The risk-adjusted operative charges were $19,728 (95% confidence interval $16,543 to $22,913). The above factors predicted nearly 65% of the variability in operative charges. The only patient-level factor significantly associated with lower charges was female sex (- $1,339; P = .002). Procedure-level factors significantly associated with higher charges were use of biologics (+ $17,791; P < .001), concurrent open biceps tenodesis (+ $4,027; P < .001), distal clavicle resection (+ $2,266; P = .039), use of regional block (+ $1,256; P = .004), number of anchors (+ $2,245/anchor; P < .001), and increasing operative time ($26/min). Other factors had no significant association. CONCLUSIONS: Procedural factors are the most significant drivers of operative cost in arthroscopic RCRs, such as quantity and type of implants; additional procedures such as biceps tenodesis and distal clavicle resection; and perioperative conditions such as type of anesthesia and total operating room time. Overall, patient-level factors were not shown to correlate well with operative costs, other than lower charges with female sex. LEVEL OF EVIDENCE: IV, economic study.

A Comprehensive Analysis of Medicare Reimbursement to Physicians for Common Arthroscopic Procedures: Adjusted Reimbursement Has Fallen Nearly 30% From 2000 to 2019.

PURPOSE: To analyze and objectively measure the trends in inflation-adjusted Medicare reimbursement rates for the 20 most commonly performed orthopaedic arthroscopic surgical procedures from 2000 to 2019. METHODS: The Centers for Medicare & Medicaid Services website was used to find the top 20 most commonly performed arthroscopic procedures using the Public Use File data file for calendar year 2017. By use of the Physician Fee Schedule Look-Up Tool, national reimbursement averages were calculated from 2000-2019 and data were analyzed. Averages were adjusted for inflation using the Consumer Price Index. Current Procedural Terminology codes that did not exist in 2000 were unable to be analyzed in this study. RESULTS: When adjusted for inflation, Medicare reimbursement for the 20 most commonly performed arthroscopic procedures from 2000-2019 has decreased substantially (-29.81%). The mean Medicare reimbursement to physicians was $906 in 2000 and $632 in 2019. During this same period, the annual change in the adjusted mean reimbursement rate for all included arthroscopic procedures was -1.8% whereas the average compound annual growth rate was -1.9%. CONCLUSIONS: This study shows that when adjusted for inflation, Medicare reimbursement to physicians has decreased by nearly 30% during the past 20 years for the most common arthroscopic procedures. CLINICAL RELEVANCE: This analysis will give orthopaedic surgeons and hospital administrators a better understanding of the financial trends surrounding one of the fastest-growing techniques in surgery. Additionally, these financial-trend data will be increasingly important as the population in the United States continues to age and new payment models are introduced.

The Cost of Outpatient Arthroscopic Rotator Cuff Repairs: Hospital Reimbursement Is on the Rise While Surgeon Payments Remain Unchanged.

PURPOSE: To better understand the relative increases in rotator cuff charges and to analyze national and regional trends between hospital, anesthesiologist, and surgeon charges and reimbursements for contemporary rotator cuff repairs (RCRs) performed in the United States. METHODS: A representative Medicare sample was used to capture hospital, surgeon, and anesthesiologist charges and payments for outpatient RCR from 2005 to 2014. The charges and reimbursements were calculated using Current Procedural Terminology codes. Two ratios were calculated to compare surgeon and hospital charges and reimbursements. The charge multiplier (CM) is the ratio of hospital to surgeon charges, and the payment multiplier (PM) is the ratio of hospital to surgeon reimbursements. Trends were evaluated using national and regional charges, reimbursements, Charlson Comorbidity Index, CM, and PM. RESULTS: In total, 12,617 patients were included in this study. Between 2005 and 2014, hospital charges for RCR significantly increased from $4877 to $11,488 (136% increase; P < .0001), anesthesiologist charges increased from $1319 to $2169 (64% increase; P < .0001), and surgeon charges increased from $7528 to $9979 (33% increase; P < .0001). Reimbursements during the same period significantly increased from $3007 to $6696 (123% increase; P < .0001) for hospitals, from $203 to $239 (17% increase; P = .005) for anesthesiologists. Reimbursements for surgeons remained relatively unchanged (from $1821 to $1885, 3% increase; P = .116). Increases in national CM (P = .003) and PM (P < .0001) were both statistically significant. Charlson Comorbidity Index did not change significantly over the period (P = .1178). CONCLUSIONS: Although outpatient RCR charges increased significantly for hospitals, surgeons, and anesthesiologists, hospital reimbursements increased substantially relative to surgeon and anesthesiologist reimbursements despite stable patient complexity. In 2005, hospitals were reimbursed 65% more than surgeons. By 2014, hospitals were reimbursed 255% more than surgeons, indicating that hospitals disproportionally drove increases in charges and reimbursements over this period. LEVEL OF EVIDENCE: Level IV, economic analysis.

Depression and Anxiety Are Associated With Increased Health Care Costs and Opioid Use for Patients With Femoroacetabular Impingement Undergoing Hip Arthroscopy: Analysis of a Claims Database.

PURPOSE: To determine if opioid use and health care costs in the year before and following hip arthroscopy for femoroacetabular impingement (FAI) differ between those with or without depression or anxiety. METHODS: Using the Truven Health Marketscan database, FAI patients who underwent hip arthroscopy between October 2010 and December 2015 were identified (Current Procedural Terminology codes 29914 [femoroplasty], 29915 [acetabuloplasty], and/or 29916 [labral repair]). Patients were excluded if they had incomplete coverage for 1 year either before or following surgery. The number of patients with 1 or more claims related to depression or anxiety during the year before surgery was quantified (International Statistical Classification Diseases and Related Health-9 codes 296, 298, 300, 309, 311). Health care costs in the year before and following hip arthroscopy were compared between those with or without depression or anxiety. We also compared the number of patients in each group who filled a narcotic pain prescription within 180 days before surgery as well as >60 or >90 days after hip arthroscopy. RESULTS: Depression or anxiety claims were seen in 5,208/14,830 patients (35.1%) before surgery. A significantly greater proportion of those with preoperative depression or anxiety filled opioid-related prescriptions in the 6 months before surgery (36.2% vs 25.6%, P < .0001) and both >60 days (31.3% vs 24.7%, P < .0001) and >90 days after surgery (29.5% vs 23.4%, P < .0001). The group with preoperative depression or anxiety had significantly greater health care costs both before ($8,775 vs $5,674, P < .0001) and following surgery ($5,287 vs $3,908, P < .0001). CONCLUSIONS: Both before and following hip arthroscopy, opioid use and health care costs were significantly greater for FAI patients with comorbid depression or anxiety. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic study.

Open Broström-Gould Repair vs Arthroscopic Anatomical Repair of the Anterior Talofibular Ligament for Chronic Lateral Ankle Instability.

BACKGROUND: The comparative studies on open vs arthroscopic anterior talofibular ligament (ATFL) repair are limited. This study aimed to compare the early therapeutic efficacy and cost between the traditional open Broström-Gould repair and all-arthroscopic anatomical repair of the ATFL for chronic lateral ankle instability. METHODS: A total of 27 of patients with chronic lateral ankle instability undergoing repair of the ATFL between January 2013 and June 2015 were retrospectively included with a traditional open surgery (n = 10) group and arthroscopy (n = 17) group. The surgery duration, surgical cost, postoperative complications, and the preoperative/postoperative American Orthopaedic Foot & Ankle Society Score (AOFAS) and Karlsson-Peterson score were compared between groups. RESULTS: Compared to the arthroscopy group, the open surgery group had significantly shorter surgery duration and lower surgical cost. However, there was no significant difference in hospitalization duration between groups. At 3 years after operation, the AOFAS and Karlsson scores were significantly improved in both groups. Nevertheless, there was no significant difference in the AOFAS and Karlsson scores between groups at both preoperative and postoperative assessment. No significant difference was found in the incidence of postoperative complications between the 2 groups. CONCLUSION: These results suggest that open Broström-Gould repair and all-arthroscopic anatomical repair of the ATFL have comparable therapeutic efficacy for chronic lateral ankle instability. The arthroscopic surgery had a smaller incision, while the open Broström-Gould had a shorter surgery duration and lower cost. LEVEL OF EVIDENCE: Level III, comparative study.

Reference-Based Benefits for Colonoscopy and Arthroscopy: Large Differences in Patient Payments Across Procedures but Similar Behavioral Responses.

This study examines how reference-based benefits (RBB) affect patient out-of-pocket payments across outpatient procedures. The California Public Employees' Retirement System (CalPERS) implemented RBB asymmetrically for outpatient procedures in 2012, only applying RBB to outpatient procedures performed in a hospital outpatient department (HOPD), and not applying RBB to outpatient procedures performed in a lower cost ambulatory surgery center. Using claims data (2009-2013) on arthroscopy and colonoscopy services, we found that for colonoscopy, CalPERS patients paid an average of 63.9% (p < .01) more for HOPDs than ambulatory surgery centers in 2012. For arthroscopy, no statistically different cost sharing was found on average. However, high-priced HOPDs were 17.3% and 17.9% less likely to be chosen by CalPERS patients in 2012 for colonoscopy and arthroscopy, respectively. These magnitudes increased in 2013 to 25.2% and 24.2% less, respectively. Overall, responsiveness to RBB with regard to the most expensive HOPDs was similar despite varying cost sharing by procedure.

How do the costs of physical therapy and arthroscopic partial meniscectomy compare? A trial-based economic evaluation of two treatments in patients with meniscal tears alongside the ESCAPE study.

OBJECTIVES: To examine whether physical therapy (PT) is cost-effective compared with arthroscopic partial meniscectomy (APM) in patients with a non-obstructive meniscal tear, we performed a full trial-based economic evaluation from a societal perspective. In a secondary analysis-this paper-we examined whether PT is non-inferior to APM. METHODS: We recruited patients aged 45-70 years with a non-obstructive meniscal tear in nine Dutch hospitals. Resource use was measured using web-based questionnaires. Measures of effectiveness included knee function using the International Knee Documentation Committee (IKDC) and quality-adjusted life-years (QALYs). Follow-up was 24 months. Uncertainty was assessed using bootstrapping techniques. The non-inferiority margins for societal costs, the IKDC and QALYs, were €670, 8 points and 0.057 points, respectively. RESULTS: We randomly assigned 321 patients to PT (n=162) or APM (n=159). PT was associated with significantly lower costs after 24 months compared with APM (-€1803; 95% CI -€3008 to -€838). The probability of PT being cost-effective compared with APM was 1.00 at a willingness to pay of €0/unit of effect for the IKDC (knee function) and QALYs (quality of life) and decreased with increasing values of willingness to pay. The probability that PT is non-inferior to APM was 0.97 for all non-inferiority margins for the IKDC and 0.89 for QALYs. CONCLUSIONS: The probability of PT being cost-effective compared with APM was relatively high at reasonable values of willingness to pay for the IKDC and QALYs. Also, PT had a relatively high probability of being non-inferior to APM for both outcomes. This warrants further deimplementation of APM in patients with non-obstructive meniscal tears. TRIAL REGISTRATION NUMBERS: NCT01850719 and NTR3908.

Open versus modified arthroscopic treatment of acute acromioclavicular dislocation using a single tight rope: randomized comparative study of clinical outcome and cost-effectiveness.

PURPOSE: The purpose of this study was to compare clinical outcome and cost-effectiveness between arthroscopic and open repair using TightRope in acromioclavicular joint dislocation III and IV. PATIENTS AND METHODS: Fifty-two patients with acute acromioclavicular joint dislocation type III and IV were included. Patients were randomly allocated to either of 2 groups: Arthroscopic Repair Group (ARG) and Open Repair Group (ORG). Constant-Murley Score (CMS), visual analog scale (VAS) score, and coracoclavicular (CC) distance were measured preoperatively and 3 months, 6 months, 1 year, and 2 years postoperatively. RESULTS: CMS increased from 40.68 for the ARG and 40.70 for the ORG preoperatively to 84.18 and 84.45 after 2 years from operation. VAS score decreased from 60.59 for the ARG and 64.50 for the ORG 1 day after surgery to 18.04 and 17.87 respectively after 6 months. CC distance decreased from 29.27 mm in the ARG and 28.16 mm in the ORG preoperatively to 9.86 mm in the ARG and 10.54 mm in the ORG on postoperative day 1. Rewidening of the CC distance occurred after 6 months (13.27 mm for the ARG and 13.62 mm for the ORG) and 1 year postoperatively (15.77 for the ARG and 15.41 for the ORG) but remained stable at final follow-up. There was a significant difference in surgical time (80.00 minutes in the ARG compared to 52.79 minutes in the ORG) and cost of consumables (US$1729.95 in the ARG compared to US$851.87 in the ORG). CONCLUSION: Open and arthroscopic repair of acute acromioclavicular joint dislocation yielded good clinical results, yet the arthroscopic technique is more expensive and has a longer surgical time.

Cost-effectiveness and satisfaction following arthroscopic rotator cuff repair: does age matter?.

AIMS: The aim of this study was to investigate the influence of age on the cost-effectiveness of arthroscopic rotator cuff repair. PATIENTS AND METHODS: A total of 112 patients were prospectively monitored for two years after arthroscopic rotator cuff repair using the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), the Oxford Shoulder Score (OSS), and the EuroQol five-dimension questionnaire (EQ-5D). Complications and use of healthcare resources were recorded. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). Propensity score-matching was used to compare those aged below and above 65 years of age. Satisfaction was determined using the Net Promoter Score (NPS). Linear regression was used to identify variables that influenced the outcome at two years postoperatively. RESULTS: A total of 92 patients (82.1%) completed the follow-up. Their mean age was 59.5 years (sd 9.7, 41 to 78). There were significant improvements in the mean DASH (preoperative 47.6 vs one-year 15.3; p < 0.001) and OSS scores (26.5 vs 40.5; p < 0.001). Functional improvements were maintained with no significant change between one and two years postoperatively. The mean preoperative EQ-5D was 0.54 increasing to 0.81 at one year (p < 0.001) and maintained at 0.86, two years postoperatively. There was no significant difference between those aged below or above 65 years of age with regards to postoperative shoulder function or EQ-5D gains. Smoking was the only characteristic that significantly adversely influenced the EQ-5D at two years postoperatively (p = 0.005). A total of 87 were promoters and five were passive, giving a mean NPS of 95 (87/92). The total mean cost per patient was £3646.94 and the mean EQ-5D difference at one year was 0.2691, giving a mean ICER of £13 552.36/QALY. At two years, this decreased further to £5694.78/QALY. This was comparable for those aged below or above 65 years of age (£5209.91 vs £5525.67). Smokers had an ICER that was four times more expensive. CONCLUSION: Arthroscopic rotator cuff repair results in excellent patient satisfaction and cost-effectiveness, regardless of age. Cite this article: Bone Joint J 2019;101-B:860-866.

The primary cost drivers of arthroscopic rotator cuff repair surgery: a cost-minimization analysis of 40,618 cases.

BACKGROUND: An estimated 250,000 rotator cuff repair (RCR) surgical procedures are performed every year in the United States. Although arthroscopic RCR has been shown to be a cost-effective operation, little is known about what specific factors affect the overall cost of surgery. This study examines the primary cost drivers of RCR surgery in the United States. METHODS: Univariate analysis was performed to determine the patient- and surgeon-specific variables for a multiple linear regression model investigating the cost of RCR surgery. The 2014 State Ambulatory Surgery and Services Databases were used, yielding 40,618 cases with Current Procedural Terminology code 29827 ("arthroscopic shoulder rotator cuff repair"). RESULTS: The average cost of RCR surgery was $25,353. Patient-specific cost drivers that were significant under multiple linear regression included black race (P < .001), presence of at least 1 comorbidity (P < .001), income quartile (P < .001), male sex (P = .012), and Medicare insurance (P = .035). Surgical factors included operative time (P < .001), use of regional anesthesia (P < .001), quarter of the year (January to March, April to June, July to September, and October to December) (P < .001), concomitant subacromial decompression or distal clavicle excision (P < .001), and number of suture anchors used (P < .001). The largest cost driver was subacromial decompression, adding $4992 when performed alongside the RCR. CONCLUSION: There are several patient-specific variables that can affect the cost of RCR surgery. There are also surgeon-controllable factors that significantly increase cost, most notably subacromial decompression, distal clavicle excision, use of regional anesthesia, and number of suture anchors. Surgeons must consider these factors in an effort to minimize cost, particularly as bundled payments become more common.

Increased rates of knee arthroplasty and cost of patients with meniscal tears treated with arthroscopic partial meniscectomy versus non-operative management.

PURPOSE: The purpose of this study was to determine the cost of arthroscopic partial meniscectomy (APM), one of the most common surgeries performed by orthopaedic surgeons, and the associated rate of progression to knee arthroplasty (KA) compared to patients treated non-operatively after diagnosis of meniscal tear. METHODS: Utilizing data mining software (PearlDiver, Colorado Springs, CO), a national insurance database of approximately 23.5 million orthopaedic patients was queried for patients diagnosed with a meniscal tear. Patients were classified by treatment: non-operative and arthroscopic partial meniscectomy and were followed after initial diagnosis for cost and progression to knee arthroplasty. RESULTS: There were 176,407 subjects in the non-op group and 114,194 subjects in the arthroscopic partial meniscectomy group. Arthroscopic partial meniscectomy generated more cost than non-operative ($3842.57 versus $411.05, P < 0.001). Arthroscopic partial meniscectomy demonstrated greater propensity to need future knee arthroplasty (11.4% at 676 days) than those treated non-operatively (9.5% at 402 days) (P < 0.001). Female patients demonstrated a higher rate of progression to knee arthroplasty in the arthroscopic partial meniscectomy and non-operative groups (P < 0.001). CONCLUSION: Compared to non-operative treatment for meniscal tears, arthroscopic partial meniscectomy is more expensive and does not appear to decrease the rate of progression to knee arthroplasty. Patients undergoing arthroscopic partial meniscectomy yielded on average a delay of only 9 months (274 days) before undergoing knee arthroplasty. Female patients experienced a significantly higher rate of progression to knee arthroplasty. The authors recognize the limitations of this type of study including its retrospective nature, reliance upon accurate coding and billing information, and the inability to determine whether symptoms including mechanical locking played a role in the decision to perform an APM. LEVEL OF EVIDENCE: IV.

Prior Hip Arthroscopy Increases Risk for Perioperative Total Hip Arthroplasty Complications: A Matched-Controlled Study.

BACKGROUND: Arthroscopic hip surgery is becoming increasingly popular for the treatment of femoroacetabular impingement and labral tears. Reports of outcomes of hip arthroscopy converted to total hip arthroplasty (THA) have been limited by small sample sizes. The purpose of this study was to investigate the impact of prior hip arthroscopy on THA complications. METHODS: We queried our institutional database from January 2005 and December 2017 and identified 95 hip arthroscopy conversion THAs. A control cohort of 95 primary THA patients was matched by age, gender, and American Society of Anesthesiologists score. Patients were excluded if they had undergone open surgery on the ipsilateral hip. Intraoperative complications, estimated blood loss, operative time, postoperative complications, and need for revision were analyzed. Two separate analyses were performed. The first being intraoperative and immediate postoperative complications through 90-day follow-up and a second separate subanalysis of long-term outcomes on patients with minimum 2-year follow-up. RESULTS: Average time from hip arthroscopy to THA was 29 months (range 2-153). Compared with primary THA controls, conversion patients had longer OR times (122 vs 103 minutes, P = .003). Conversion patients had a higher risk of any intraoperative complication (P = .043) and any postoperative complication (P = .007), with a higher rate of wound complications seen in conversion patients. There was not an increased risk of transfusion (P = .360), infection (P = 1.000), or periprosthetic fracture between groups (P = .150). When comparing THA approaches independent of primary or conversion surgery, there was no difference in intraoperative or postoperative complications (P = .500 and P = .790, respectively). CONCLUSION: Conversion of prior hip arthroscopy to THA, compared with primary THA, resulted in increased surgical times and increased intraoperative and postoperative complications. Patients should be counseled about the potential increased risks associated with conversion THA after prior hip arthroscopy.

Cost-Effectiveness Analysis of Needle Arthroscopy Versus Magnetic Resonance Imaging in the Diagnosis and Treatment of Meniscal Tears of the Knee.

PURPOSE: To determine whether needle arthroscopy (NA) compared with magnetic resonance imaging (MRI) in the diagnosis and treatment of meniscal tears is cost-effective when evaluated over a 2-year period via patient-reported outcomes. The hypothesis is that improved diagnostic accuracy with NA would lead to less costly care and similar outcomes. METHODS: A Markov model/decision tree analysis was performed using TreeAge Pro 2017 software. Patients were evaluated for degenerative and traumatic damage to the lateral/medial meniscus. Assumed sensitivities and specificities were derived from the medical literature. The direct costs for care were derived from the 2017 Medicare fee schedule and from private payer reimbursement rates. Costs for care included procedures performed for false-positive findings and for care for false-negative findings. Effectiveness was examined using the global knee injury and osteoarthritis outcome score (KOOS). Patients were evaluated over 2 years for costs and outcomes, including complications. Dominance and incremental cost-effectiveness were evaluated, and 1- to 2-way sensitivity analysis was performed to determine those variables that had the greatest effect. The consolidated economics evaluation and reporting standards checklist for reporting economic evaluations was used. RESULTS: NA was less costly and had similar KOOS versus MRI for both the medial/lateral meniscus with private pay. Costs were less for both Medicare and private pay for medial meniscus, $780 to $1,862, and lateral meniscus, $314 to $1,256, respectively. CONCLUSIONS: Based on the reported MRI incidence of false positives with the medial meniscus and false negatives with the lateral meniscus and based on assumed standards of care, more costly care is provided when using MRI compared with NA. Outcomes were similar with NA compared with MRI. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

Cost-effectiveness analysis of a placebo-controlled randomized trial evaluating the effectiveness of arthroscopic subacromial decompression in patients with subacromial shoulder pain.

AIMS: The aims of this study were to compare the use of resources, costs, and quality of life outcomes associated with subacromial decompression, arthroscopy only (placebo surgery), and no treatment for subacromial pain in the United Kingdom National Health Service (NHS), and to estimate their cost-effectiveness. PATIENTS AND METHODS: The use of resources, costs, and quality-adjusted life-years (QALYs) were assessed in the trial at six months and one year. Results were extrapolated to two years after randomization. Differences between treatment arms, based on the intention-to-treat principle, were adjusted for covariates and missing data were handled using multiple imputation. Incremental cost-effectiveness ratios were calculated, with uncertainty around the values estimated using bootstrapping. RESULTS: Cumulative mean QALYs/mean costs of health care service use and surgery per patient from baseline to 12 months were estimated as 0.640 (standard error (se) 0.024)/£3147 (se 166) in the decompression arm, 0.656 (se 0.020)/£2830 (se 183) in the arthroscopy only arm and 0.522 (se 0.029)/£1451 (se 151) in the no treatment arm. Statistically significant differences in cumulative QALYs and costs were found at six and 12 months for the decompression versus no treatment comparison only. The probabilities of decompression being cost-effective compared with no treatment at a willingness-to-pay threshold of £20 000 per QALY were close to 0% at six months and approximately 50% at one year, with this probability potentially increasing for the extrapolation to two years. DISCUSSION: The evidence for cost-effectiveness at 12 months was inconclusive. Decompression could be cost-effective in the longer-term, but results of this analysis are sensitive to the assumptions made about how costs and QALYs are extrapolated beyond the follow-up of the trial.

Low-Cost Self-Made Arthroscopic Training Camera Is Equally as Effective as Commercial Camera: A Comparison Study.

PURPOSE: To assess the effectiveness of a low-cost self-made arthroscopic camera (LAC) in basic arthroscopic skills training compared with a commercial arthroscopic camera (CAC). METHODS: One hundred fifty-three orthopaedic residents were recruited and randomly assigned to either the LAC or CAC. They were allocated 2 practice sessions, with 20 minutes each, to practice 4 given arthroscopic tasks: task 1, transferring objects; task 2, stacking objects; task 3, probing numbers; and task 4, stretching rubber bands. The time taken for participants to complete the given tasks was recorded in 3 separate tests; before practice, immediately after practice, and after a period of 3 months. A comparison of the time taken between both groups to complete the given tasks in each test was measured as the primary outcome. RESULTS: Significant improvements in time completion were seen in the post-practice test for both groups in all given arthroscopic tasks, each with P < .001. However, there was no significant difference between the groups for task 1 (P = .743), task 2 (P = .940), task 3 (P = .932), task 4 (P = .929), and total (P = .944). The outcomes of the tests (before practice, after practice, and at 3 months) according to repeated measures analysis of variance did not differ significantly between the groups in task 1 (P = .475), task 2 (P = .558), task 3 (P = .850), task 4 (P = .965), and total (P = .865). CONCLUSIONS: The LAC is equally as effective as the CAC in basic arthroscopic skills training with the advantage of being cost-effective. CLINICAL RELEVANCE: In view of the scarcity in commercial arthroscopic devices for trainees, this low-cost device, which trainees can personally own and use, may provide a less expensive and easily available way for trainees to improve their arthroscopic skills. This might also cultivate more interest in arthroscopic surgery among junior surgeons.

Meniscus Root Repair vs Meniscectomy or Nonoperative Management to Prevent Knee Osteoarthritis After Medial Meniscus Root Tears: Clinical and Economic Effectiveness.

BACKGROUND: Medial meniscus root tears are a common knee injury and can lead to accelerated osteoarthritis, which might ultimately result in a total knee replacement. PURPOSE: To compare meniscus repair, meniscectomy, and nonoperative treatment approaches among middle-aged patients in terms of osteoarthritis development, total knee replacement rates (clinical effectiveness), and cost-effectiveness. STUDY DESIGN: Meta-analysis and cost-effectiveness analysis. METHODS: A systematic literature search was conducted. Progression to osteoarthritis was pooled and meta-analyzed. A Markov model projected strategy-specific costs and disutilities in a cohort of 55-year-old patients presenting with a meniscus root tear without osteoarthritis at baseline. Failure rates of repair and meniscectomy procedures and disutilities associated with osteoarthritis, total knee replacement, and revision total knee replacement were accounted for. Utilities, costs, and event rates were based on literature and public databases. Analyses considered a time frame between 5 years and lifetime and explored the effects of parameter uncertainty. RESULTS: Over 10 years, meniscus repair, meniscectomy, and nonoperative treatment led to 53.0%, 99.3%, and 95.1% rates of osteoarthritis and 33.5%, 51.5%, and 45.5% rates of total knee replacement, respectively. Meta-analysis confirmed lower osteoarthritis and total knee replacement rates for meniscus repair versus meniscectomy and nonoperative treatment. Discounted 10-year costs were $22,590 for meniscus repair, as opposed to $31,528 and $25,006 for meniscectomy and nonoperative treatment, respectively; projected quality-adjusted life years were 6.892, 6.533, and 6.693, respectively, yielding meniscus repair to be an economically dominant strategy. Repair was either cost-effective or dominant when compared with meniscectomy and nonoperative treatment across a broad range of assumptions starting from 5 years after surgery. CONCLUSION: Repair of medial meniscus root tears, as compared with total meniscectomy and nonsurgical treatment, leads to less osteoarthritis and is a cost-saving intervention. While small confirmatory randomized clinical head-to-head trials are warranted, the presented evidence seems to point relatively clearly toward adopting meniscus repair as the preferred initial intervention for medial meniscus root tears.

Comparative cost-effectiveness analysis of the subacromial spacer for irreparable and massive rotator cuff tears.

PURPOSE: There is ongoing debate regarding the optimal surgical treatment of irreparable rotator cuff tears (IRCT). This study aimed to assess within the Italian health care system the cost-effectiveness of subacromial spacer as a treatment modality for patients with IRCT. METHODS: An expected-value decision analysis was created comparing costs and outcomes of patients undergoing arthroscopic subacromial spacer implantation, rotator cuff repair (RCR), total shoulder arthroplasty, and conservative treatment for IRCTs. A broad literature search provided input data to extrapolate and inform treatment success and failure rates, costs, and health utility states for these outcomes. The primary outcome assessed was an incremental cost-effectiveness ratio (ICER) of subacromial spacer implantation versus shoulder arthroplasty, RCR, and conservative treatment. RESULTS: Subacromial spacer is favorable over both arthroscopic partial repair and shoulder arthroplasty since it costs less than both options and increases effectiveness by 0.06 and 0.10 quality-adjusted life years (QALYs), respectively. While conservative treatment is the least costly management strategy, subacromial spacer results in a gain of 0.05 QALYs for the additional cost of 522 €, resulting in an ICER of 10,440 €/QALY gain, which is below the standard willingness to pay ratio of $50,000 USD. Strategies with an ICER of less than 50,000 USD are considered to be cost-effective. CONCLUSIONS: Based on the available evidence and reasonably conservative assumptions, subacromial spacer is likely to provide a safe, effective, and cost-effective option for patients with massive IRCTs. Furthermore, this cost-effectiveness analysis may ultimately serve as a guide for development of health care system and insurer policy as well as clinical practice.

Factors Affecting the Cost and Profitability of Arthroscopic Rotator Cuff Repair.

PURPOSE: To examine the cost metrics and profitability of rotator cuff repairs (RCRs) in a large health care system. METHODS: A retrospective study was performed using value analysis team data from 2 hospitals within a large metropolitan health system from 2010 to 2014. Cost and profit metrics were collected and compared against surgeon volume, surgeon subspecialty training, implant costs, Current Procedural Terminology (CPT) coding, length of stay, and hospital site. RESULTS: A total of 5,899 RCRs were identified with a mean contribution margin of $2,133. Surgical supplies were the largest contributor to direct costs. Hospital site also significantly affected contribution margin ($1,912 at hospital 1 vs $3,129 at hospital 2, P < .001). The number of billed CPT codes was not significantly correlated to contribution margin; however, significant differences were noted in contribution margin and direct cost associated with different CPT code combinations, with arthroscopic RCR with subacromial decompression and distal clavicle excision being the most profitable, at an average contribution margin of $2,147. There was no correlation between surgeon volume and contribution margin or direct cost. CONCLUSIONS: Our overall findings show that improvement in the profitability of arthroscopic RCR for hospital systems is possible, both by examining institutions' direct costs and by providing individual surgeons with cost breakdowns and contribution margin information to improve the profitability of their practice. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.