Results
We identified 28 shoulders in 26 patients (mean age, 54.5 years) who met the inclusion criteria. Of these 28 shoulders, 18 (64.3%) had an isolated supraspinatus tear, 8 (28.6%) had combined supraspinatus and infraspinatus tears, 1 (3.6%) had combined supraspinatus and subscapularis tears, and 1 (3.6%) had an isolated infraspinatus tear. Demographic data are listed in Table 1.
All patients received an interscalene nerve block in the preoperative area before being brought into the operating room. In our analysis, we included nerve block supply costs and the anesthesiologist’s mean time placing the nerve block.
In all cases, primary rotator cuff repair was performed with suture anchors (Parcus Medical) with the patient in the lateral decubitus position. In 13 (46%) of the 28 shoulders, this repair was described as “complex,” requiring double-row technique. Subacromial decompression and bursectomy were performed in addition to the rotator cuff repair. Labral débridement was performed in 23 patients, synovectomy in 10, biceps tenodesis with anchor (Smith & Nephew) in 1, and biceps tenotomy in 1. Mean time in operating room was 148 minutes; mean time in postoperative recovery unit was 105 minutes.
Directly observing the care cycle, hospital volunteers found that patients spent a mean of 15 minutes with the receptionist when they arrived in the outpatient surgical center, 25 minutes with nurses for check-in in the preoperative holding area, and 10 minutes with the anesthesiology resident and 15 minutes with the orthopedic surgery resident for preoperative evaluation and paperwork. Mean nerve block time was 20 minutes. Mean electrocardiogram (ECG) time (12 patients) was 15 minutes. The surgical technician spent a mean time of 20 minutes setting up the operating room before the patient was brought in and 15 minutes cleaning up after the patient was transferred to the recovery room. Costs of postoperative care in the recovery room were based on a 2:1 patient-to-nurse ratio, as is the standard practice in our outpatient surgery center.
Using the times mentioned and our hospital’s salary data—including standard hospital benefits rates of 33.5% for nonphysicians and 17.65% for physicians—we determined, using the TDABC algorithm, a direct cost of $5904.21 for this process cycle, excluding hospital overhead and indirect costs. Table 2 provides the overall cost breakdown. Compared with the direct economic cost, the mean hospital charge to insurers for the procedure was $31,459.35. Mean reimbursement from insurers was $9679.08.
Overall attending and resident physician costs were $1077.75, which consisted of $623.66 for the surgeon and $454.09 for the anesthesiologist (included placement of nerve block and administration of anesthesia during surgery). Preoperative bloodwork was obtained in 23 cases, adding a mean cost of $111.04 after adjusting for standard hospital markup. Preoperative ECG was performed in 12 cases, for an added mean cost of $7.30 based on the TDABC algorithm.
We also broke down costs by care cycle phase. The preoperative phase, excluding the preoperative laboratory studies and ECGs (not performed in all cases), cost $134.34 (2.3% of total costs); the operative phase cost $5718.01 (96.8% of total costs); and the postoperative phase cost $51.86 (0.9% of total costs). Within the operative phase, the cost of consumables (specifically, suture anchors) was the main cost driver. Mean anchor cost per case was $3432.67. “Complex” tears involving a double-row repair averaged $4570.25 in anchor cost per patient, as compared with $2522.60 in anchor costs for simple repairs.
Discussion
US health care costs continue to increase unsustainably, with rising pressure on hospitals and providers to deliver the highest value for each health care dollar. The present study is the first to calculate (using the TDABC algorithm) the direct economic cost ($5904.21) of the entire RCS care cycle at a university-based outpatient surgery center. Rent, utility costs, administrative costs, overhead, and other indirect costs at the surgery center were not included in this cost analysis, as they would be incurred irrespective of type of surgery performed. As such, our data isolate the procedure-specific costs of rotator cuff repair in order to provide a more meaningful comparison for other institutions, where indirect costs may be different.
In the literature, rigorous economic analysis of shoulder pathology is sparse. Kuye and colleagues12 systematically reviewed economic evaluations in shoulder surgery for the period 1980–2010 and noted more than 50% of the papers were published between 2005 and 2010.12 They also noted the poor quality of these studies and concluded more rigorous economic evaluations are needed to help justify the rising costs of shoulder-related treatments.
Several studies have directly evaluated costs associated with RCS. Cordasco and colleagues13 detailed the success of open rotator cuff repair as an outpatient procedure—noting its 43% cost savings ($4300 for outpatient vs $7500 for inpatient) and high patient satisfaction—using hospital charge data for operating room time, supplies, instruments, and postoperative slings. Churchill and Ghorai14 evaluated costs of mini-open and arthroscopic rotator cuff repairs in a statewide database and estimated the arthroscopic repair cost at $8985, compared with $7841 for the mini-open repair. They used reported hospital charge data, which were not itemized and did not include physician professional fees. Adla and colleagues,15 in a similar analysis of open versus arthroscopic cuff repair, estimated direct material costs of $1609.50 (arthroscopic) and $360.75 (open); these figures were converted from 2005 UK currency using the exchange rate cited in their paper. Salaries of surgeon, anesthesiologist, and other operating room personnel were said to be included in the operating room cost, but the authors’ paper did not include these data.