Case Report

In-Office Diagnostic Needle Arthroscopy: Understanding the Potential Value for the US Healthcare System

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In-office diagnostic needle arthroscopy is a cost-effective and reproducible procedure with potential cost and quality-of-life benefits for commercial payers and patients. Significant value was realized in this 200-patient retrospective review. Minimum savings of $418 and $554.62 were realized for noncontrast knee and shoulder magnetic resonance imaging (MRI) scans, respectively, in independent MRI facilities. Those savings more than doubled in hospital-based facilities: $961.08 and $1097.62, respectively, for knee and shoulder noncontrast MRI scans.


 

References

Take-Home Points

  • In-office diagnostic needle arthroscopy is a minimally invasive, rapid method for identification of intra-articular joint pathology.
  • Cost savings of a significant value can be realized to both the patient and healthcare system via small-bore needle arthroscopy as opposed to MRI.
  • Diagnostic needle arthroscopy can lead to quicker identification of pathology than MRI.
  • Diagnostic needle arthroscopy can reduce the number of undue "formal" surgical diagnostic arthroscopies.
  • Standardization of image quality of small bore arthroscopy may pose benefits to the variable quality of MRI.

Patient satisfaction and healthcare costs have taken a leading role in today’s health care market. Patient satisfaction, often categorized as the "patient experience," can be measured on numerous levels, such as access to healthcare professionals and diagnostic testing, wait time for appointments, and timely test results. Furthermore, patients’ having a full understanding of their pathology and treatment options may correlate with their overall satisfaction. Some metrics are subjective, but procedure costs are objective.

The algorithm for treating patients who present with knee or shoulder pathology to an orthopedic office involves taking a thorough history, performing a physical examination, and, in many cases, obtaining diagnostic imaging. After arriving at a diagnosis, the physician plans the patient’s treatment. In most cases in which magnetic resonance imaging (MRI) is required, the process can take 2 to 3 weeks. 1

Surgical knee arthroscopy is one of the most common procedures in the United States. 2,3 Worldwide, more than 2 million knee arthroscopies are performed yearly. 4 For most procedures, the decision to treat is based on physical examination findings, and the diagnosis is confirmed with MRI. MRI has 86% sensitivity and 91% specificity for diagnosing ligamentous and meniscal tears. 5 However, regular use of MRI has led to increased healthcare expenditures and a larger financial burden for patients, which can delay diagnosis. 6

Since 2000, MRI use in the United States has risen significantly—by 10% over a 10-year period. 7 According to a 2013 population analysis, 107 in 1000 US inhabitants had an MRI yearly. 8

MRI costs vary widely because of several factors, including state/regional consideration, scanning in a hospital or an independent facility, and use of contrast and arthrography. In a 2017 study of the variation in noncontrast MRI costs at 71 hospitals and 26 independent facilities in Iowa, Westermann and colleagues 9 found that, excluding radiologist interpretation fees, the mean MRI technical component cost to consumers was US $1874 (SD, $694; range, $500-$4000).

Patient factors may preclude use of MRI ( Table).

Table.
In addition, patients with recent or previous surgery on the joint in question may have less than definitive findings on subsequent MRI. 10 Conversely, there are limited situations in which in-office diagnostic arthroscopy is inferior to traditional MRI or magnetic resonance arthrography (MRA) for intra-articular pathology.

Small-bore needle arthroscopy is a cost-effective alternative diagnostic tool with efficacy and accuracy similar to those of MRI and standard arthroscopy for intra-articular pathologies. 6,11 The procedure is performed with a disposable handpiece equipped with an internal light source and optics; this handpiece attaches to a reusable tablet for ease of transportation and visualization ( Figure 1 ).

Figure 1.
The technical aspects of the procedure are described in the literature. 12 Diagnostic needle arthroscopy with a local anesthetic gives physicians real-time dynamic visualization of anatomy in the office setting—reducing time from injury to intervention by as much as 2 to 3 weeks over traditional MRI. 1

In 2014, Voigt and colleagues 6 reported a significant net healthcare system cost saving with use of a small-needle arthroscope for diagnostic testing. The saving was estimated at $115 million to $177 million for simple isolation of medial meniscus pathology—or, more specifically, for appropriate care after more accurate visualization with the diagnostic needle arthroscope coupled with a decrease in false positives compared with MRI use. Other factors include the economic impact of the patient’s lost work hours, often associated with the time off needed for the MRI and for the follow-up visit for review of results.

Methods

We retrospectively reviewed the patient charts for 200 in-office knee and shoulder diagnostic needle arthroscopies performed by 5 surgeons over a 12-month period and examined the costs. Medicare, Medicaid, worker’s compensation, self-pay, and motor vehicle cases were excluded to provide uniformity across commercial insurance payers. Only the reimbursement amounts for Current Procedural Terminology codes 29870 (diagnostic knee arthroscopy) and 29805 (diagnostic shoulder arthroscopy) were examined. Geographical differences in commercial payer reimbursements were considered. The 5 surgeons who submitted data for this study practice in

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