Original Research

Orthopedic Implant Waste: Analysis and Quantification

Am J Orthop. 2015 December;44(12):554-560

The steadily increasing demand for orthopedic surgeries and declining rates of reimbursement by Medicare and other insurance providers have led many hospitals to look for ways to control the cost of these surgeries.

We reviewed administrative records for a 1-year period and recorded total number of surgical cases, number of cases in which an implant was wasted, and cost of each wasted implant. We determined cost incurred because of implant waste, percentage of cases that involved waste, percentage of total implant cost wasted, and average cost of waste per case. We then analyzed the data to determine if case volume or years in surgical practice affected amount of implant waste.

Results showed implant waste represents a significant cost for orthopedic procedures within all subspecialties and is an important factor to consider when developing cost-reduction strategies.

PDF Download

References

1. Alhassani A, Chandra A, Chernew ME. The sources of the SGR “hole.” N Engl J Med. 2012;366(4):289-291.

2. Hariri S, Bozic KJ, Lavernia C, Prestipino A, Rubash HE. Medicare physician reimbursement: past, present, and future. J Bone Joint Surg Am. 2007;89(11):2536-2546.

3. Keehan SP, Sisko AM, Truffer CJ, et al. National health spending projections through 2020: economic recovery and reform drive faster spending growth. Health Aff. 2011;30(8):1594-1605.

4. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481.

5. Belatti DA, Phisitkul P. Trends in orthopedics: an analysis of Medicare claims, 2000–2010. Orthopedics. 2013;36(3):e366-e372.

6. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.

7. Lavernia CJ, Hernandez VH, Rossi MD. Payment analysis of total hip replacement. Curr Opin Orthop. 2007;18(5):23-27.

8. Mendenhall S. 2003 hip and knee implant review. Orthop Network News. 2003;14(3):2.

9. Mendenhall S. 2008 hip and knee implant review. Orthop Network News. 2008;19(3):20.

10. Healy WL, Rana AJ, Iorio R. Hospital economics of primary total knee arthroplasty at a teaching hospital. Clin Orthop Relat Res. 2011;469(1):87-94.

11. Mendenhall S. 2007 hip and knee implant review. Orthop Network News. 2007;18(3):16.

12. Iorio R, Davis CM 3rd, Healy WL, Fehring TK, O’Connor MI, York S. Impact of the economic downturn on adult reconstruction surgery: a survey of the American Association of Hip and Knee Surgeons. J Arthroplasty. 2010;25(7):1005-1014.

13. Healy WL, Iorio R, Ko J, Appleby D, Lemos DW. Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthroplasty. J Bone Joint Surg Am. 2002;84(3):348-353.

14. Iorio R, Robb WJ, Healy WL, et al. Orthopaedic surgeon workforce and volume assessment for total hip and knee replacement in the United States: preparing for an epidemic. J Bone Joint Surg Am. 2008;90(7):1598-1605.

15. Rana AJ, Iorio R, Healy WL. Hospital economics of primary THA decreasing reimbursement and increasing cost, 1990 to 2008. Clin Orthop Relat Res. 2011;469(2):355-361.

16. Robinson JC, Pozen A, Tseng S, Bozic KJ. Variability in costs associated with total hip and knee replacement implants. J Bone Joint Surg Am. 2012;94(18):1693-1698.

17. de Steiger RN, Miller LN, Davidson DC, Ryan P, Graves SE. Joint registry approach for identification of outlier prostheses. Acta Orthop. 2013;84(4):348-352.

18. Havelin LI, Fenstad AM, Salomonsson R, et al. The Nordic Arthroplasty Register Association: a unique collaboration between 3 national hip arthroplasty registries with 280,201 THRs. Acta Orthop. 2009;80(4):393-401.

19. Zywiel MG, Ulrich SD, Suda AJ, Duncan JL, McGrath MS, Mont MA. Incidence and cost of intraoperative waste of hip and knee arthroplasty implants. J Arthroplasty. 2010;25(4):558-562.

20. Kim P, Kurokawa R, Itoki K. Technical advancements and utilization of spine surgery—international disparities in trend-dynamics between Japan, Korea, and the USA. Neurol Med Chir. 2010;50(9):853-858.

21. Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine. 2006;31(23):2707-2714.

22. Soroceanu A, Canacari E, Brown E, Robinson A, McGuire KJ. Intraoperative waste in spine surgery: incidence, cost, and effectiveness of an educational program. Spine. 2011;36(19):E1270-E1273.

23. Bosco JA, Alvarado CM, Slover JD, Iorio R, Hutzler LH. Decreasing total joint implant costs and physician specific cost variation through negotiation. J Arthroplasty. 2014;29(4):678-680.

24. Zywiel MG, Delanois RE, McGrath MS, Ulrich SD, Duncan JL, Mont MA. Intraoperative waste of trauma implants: a cost burden to hospitals worth addressing? J Orthop Trauma. 2009;23(10):710-715.

25. Ast MP, Mayman DJ, Su EP, Gonzalez Della Valle AM, Parks ML, Haas SB. The reduction of implant-related errors and waste in total knee arthroplasty using a novel, computer based, e.Label and Compatibility system. J Arthroplasty. 2014;29(1):132-136.

The cost of health care in the United States is increasing at an unsustainable rate.^1-3To decrease or even reverse this trend, we must decrease the cost of care without adversely affecting quality. Porter⁴ defined value as the quality of care divided by its cost. The economics of total joint arthroplasty (TJA) has received a great deal of attention because of both increasing demand and increasing cost.^5-9About 33% of all orthopedic surgeries and the majority of TJAs are paid for by Medicare.⁹ In recent years, the rate of reimbursement for orthopedic cases has steadily declined while the cost of implants has increased.^3,10,11Given the significant cost of implants, health care providers in some subspecialties have focused on implant costs as a potential area for cost reduction.¹² For example, in TJA this has proved effective in reducing the overall cost, as has decreasing length of stay after surgery.^8,10,13-16

With little evidence suggesting any specific orthopedic implant has outcomes superior to those of others, with the exception of select poorly performing outliers, we must increase value of care by lowering the cost when considering these devices.^17,18In addition, some experts have suggested that intraoperative waste is a significant factor in TJA cost, and it does contribute to the average implant cost for a TJA case.^6,19Using data collected from 72 institutions, Zywiel and colleagues¹⁹ estimated the annual cost of wasted hip and knee arthroplasty implants to be more than $36 million in the United States.

However, considering the aging US population, TJA is not the only orthopedic surgery with increased demand. An estimated 600,000 spine surgeries are performed each year in the United States.²⁰ Between 1992 and 2003, Medicare spending for lumbar spinal fusion increased 500%.²¹ In addition, in a 15-month observational study of incidence of intraoperative waste in spine surgery, Soroceanu and colleagues²² reported waste occurring in 20% of spine procedures.

Although these studies have described implant waste in TJA and spine surgeries, little has been published on the cost of wasted implants in a center performing the full range of orthopedic procedures. In this article, we detail the implant waste costs incurred by surgeons for all orthopedic subspecialties at a single orthopedic specialty hospital over a 1-year period. Our study goals were to identify types of implants wasted, and incidence and cost of implant waste, for all total hip arthroplasties (THAs), total knee arthroplasties (TKAs), and lumbar spinal fusions performed at the hospital and to determine whether case volume or years in surgical practice affect the rate or cost of implants wasted.

Methods

We performed a retrospective economic analysis of 1 year of administrative implant data from our institution. Collected data were quantified and analyzed for factors that might explain any variance in implant waste among surgeons. We were granted exempt institutional review board status, as no patient information was involved in this study.

We reviewed the administrative implant data for the 12-month period beginning June 2012 and ending May 2013. For that period, number of cases in which an implant was used and number of cases in which an implant was wasted were recorded. For each instance of waste, type and cost of the wasted implant were entered into the administrative database. In addition, overall cost of implants for the year and cost of wasted implants were determined. Data were available for 81 surgeons across 8 orthopedic divisions (subspecialties). From this information, we determined percentage of cases in which waste occurred, percentage of total implant cost wasted, average cost of waste per case, and most commonly wasted implants. All 3 variables were also calculated for THAs, TKAs, and lumbar spinal fusion procedures.

Statistical Analysis

The data were analyzed to determine if surgeon case volume or years in surgical practice affected implant waste. All analyses were performed at department, division (subspecialty), and surgeon levels. Case volume was analyzed in 3 groups: top 25%, middle 50%, and lower 25%. Number of years in surgical practice was analyzed in 3 groups: fewer than 10 years, 10 to 19 years, and 20 years or more. Normality assumption of variables was tested using the Shapiro-Wilk test (P < .05). For between-group differences, 1-way analysis of variance and the Tukey honestly significant difference post hoc test were performed for variables with a normal distribution, and the Kruskal-Wallis and Mann-Whitney tests were performed for variables without a normal distribution.

For the subspecialty-level analyses, only the Adult Reconstruction, Sports Medicine, and Spine divisions were analyzed for the effects of volume, and only the Sports Medicine and Spine divisions were analyzed for the effect of surgical experience, as surgeon numbers were insufficient for adequate grouping(s).