Analysis of Direct Costs of Outpatient Arthroscopic Rotator Cuff Repair

Two studies directly estimated the costs of arthroscopic rotator cuff repair. Hearnden and Tennent¹⁶ calculated the cost of RCS at their UK institution to be £2672, which included cost of operating room consumable materials, medication, and salaries of operating room personnel, including surgeon and anesthesiologist. Using online currency conversion from 2008 exchange rates and adjusting for inflation gave a corresponding US cost of $5449.63.¹⁷ Vitale and colleagues¹⁸ prospectively calculated costs of arthroscopic rotator cuff repair over a 1-year period using a cost-to-charge ratio from tabulated inpatient charges, procedure charges, and physician fees and payments abstracted from medical records, hospital billing, and administrative databases. Mean total cost for this cycle was $10,605.20, which included several costs (physical therapy, radiologist fees) not included in the present study. These studies, though more comprehensive than prior work, did not capture the entire cycle of surgical care.

Our study was designed to provide initial data on the direct costs of arthroscopic repair of the rotator cuff for the entire process cycle. Our overall cost estimate of $5904.21 differs significantly from prior work—not unexpected given the completely different cost methodology used.

Our study had several limitations. First, it was a single-surgeon evaluation, and a number of operating room variables (eg, use of adjunct instrumentation such as radiofrequency probes, differences in draping preferences) as well as surgeon volume in performing rotator cuff repairs might have substantially affected the reproducibility and generalizability of our data. Similarly, the large number of adjunctive procedures (eg, subacromial decompression, labral débridement) performed in conjunction with the rotator cuff repairs added operative time and therefore increased overall cost. Double-row repairs added operative time and increased the cost of consumable materials as well. Differences in surgeon preference for suture anchors may also be important, as anchors are a major cost driver and can vary significantly between vendors and institutions. Tear-related variables (eg, tear size, tear chronicity, degree of fatty cuff degeneration) were not controlled for and might have significantly affected operative time and associated cost. Resident involvement in the surgical procedure and anesthesia process in an academic setting prolongs surgical time and thus directly impacts costs.

In addition, we used the patient’s time in the operating room as a proxy for actual surgical time, as this was the only reliable and reproducible data point available in our electronic medical record. As such, an unquantifiable amount of surgeon time may have been overallocated to our cost estimate for time spent inducing anesthesia, positioning, helping take the patient off the operating table, and so on. However, as typical surgeon practice is to be involved in these tasks in the operating room, the possible overestimate of surgeon cost is likely minimal.

Our salary data for the TDABC algorithm were based on national averages for work hours and gross income for physicians and on hospital-based wage structure and may not be generalizable to other institutions. There may also be regional differences in work hours and salaries, which in turn would factor into a different per-minute cost for surgeon and anesthesiologist, depending on the exact geographic area where the surgery is performed. Costs may be higher at institutions that use certified nurse anesthetists rather than resident physicians because of the salary differences between these practitioners.

Moreover, the time that patients spend in the holding area—waiting to go into surgery and, after surgery, waiting for their ride home, for their prescriptions to be ready, and so forth—is an important variable to consider from a cost standpoint. However, as this time varied significantly and involved minimal contact with hospital personnel, we excluded its associated costs from our analysis. Similarly, and as already noted, hospital overhead and other indirect costs were excluded from analysis as well.

Conclusion

Using the TDABC algorithm, we found a direct economic cost of $5904.21 for RCS at our academic outpatient surgical center, with anchor cost the main cost driver. Judicious use of consumable resources is a key focus for cost containment in arthroscopic shoulder surgery, particularly with respect to implantable suture anchors. However, in the setting of more complex tears that require multiple anchors in a double-row repair construct, our pilot data may be useful to hospitals and surgery centers negotiating procedural reimbursement for the increased cost of complex repairs. Use of the TDABC algorithm for RCS and other procedures may also help in identifying opportunities to deliver more cost-effective health care.