Friday, October 25, 2013

We spend a lot of money in evaluating cuff tears

The costs associated with the evaluation of rotator cuff tears before surgical repair

Rotator cuff repair surgery is the commonest of all shoulder surgeries. These authors have attempted to estimate the costs associated with the 90-day preoperative evaluation using an insurance company database to identify 92,688 patients undergoing rotator cuff repair from 2004 to 2009, including outpatient physician visits, diagnostic imaging studies, injections, physical therapy, laboratory and other preoperative studies, prior surgeries, etc.

A total of $161,993,100 was charged during the preoperative period, for an average of $1,748 per patient. That is a lot of money!

The breakdown included

Diagnostic imaging  $104,510,646 (65%);
injections, $5,145,227 (3%);
outpatient visits, $29,723,751 (18%);
physical therapy, $13,844,270 (8.5%);
preoperative studies, $6,792,245 (4.2%);
and miscellaneous, $1,164,688 (<1%).

The authors suggest that since the majority of the costs are associated with magnetic resonance imaging, MRIs might be reserved for patients in whom the diagnosis cannot be achieved by other modalities.

Comment: Many surgeons obtain MRI's not only to make the diagnosis, but also to assess the magnitude of the tear and the degree of fatty infiltration. Some of this information can be gained from diagnostic sonography at a lower cost. This study showed that the average per case MRI charges were over $1000, an amount comparable to the surgeon's fee for cuff repair.

Often the diagnosis of cuff tear is evident from the history, physical exam and plain radiographs showing upward displacement of the humeral head against the acromion. We've found that the reparability of the cuff can in the great majority of cases be estimated without magnetic resonance imaging, as shown here.

The quantity and quality of the residual tendon in a shoulder with cuff tear is most definitively determined at surgery. When we discuss the surgical option with patients, we inform them that we will perform a cuff repair if good quality tendon can be robustly reattached to its anatomic location and that this repair will need to be protected for 3 to 6 months after surgery. If these conditions are not met, we will perform a smooth and move procedure, after which procedure there is no need for protection. In that it has been repeatedly shown that attempting of large chronic tears often does not re-establish durable integrity of the cuff, we observe that the benefits of rotator cuff surgery can be gained by the smooth and move without the cost or down-time of a repair attempt.

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