An estimated 250,000 rotator cuff repair (RCR) surgical procedures are performed every year in the United States, making it the most common shoulder surgery.
These authors investigated the factors affecting the charges for primary arthroscopic cuff repair surgery in six states (Florida, Kentucky, Iowa, Maryland, Nevada and New York) using the 2014 State Ambulatory Surgery and Services Databases.
The average charges for RCR surgery were $25,353. Patient factors that were significantly associated with higher charges included older age, Hispanic race, presence of at least one comorbidity, higher income, male sex, and Medicare insurance. Surgical factors significantly associated with higher charges included longer operative time, use of regional anesthesia (added $4424), surgery during the last quarter of the year, surgery in Florida, concomitant subacromial decompression (added $4992), concomitant distal clavicle excision (added $3424), and number of suture anchors used (each added $1249).
Comment: The value of a treatment is the benefit to the patient divided by the total cost of the treatment. As the authors point out, the actual costs can be difficult to access, so that "charges" are often used as a proxy. This study points out that decisions made by the surgeon are likely to increase the charges for cuff repair: use of regional anesthesia, concomitant subacromial decompression, distal clavicle excision, and number of suture anchors used. It is important to know, but presently unknown, if these discretionary "add ons" result in any increased benefit to the patient.
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The average charges for RCR surgery were $25,353. Patient factors that were significantly associated with higher charges included older age, Hispanic race, presence of at least one comorbidity, higher income, male sex, and Medicare insurance. Surgical factors significantly associated with higher charges included longer operative time, use of regional anesthesia (added $4424), surgery during the last quarter of the year, surgery in Florida, concomitant subacromial decompression (added $4992), concomitant distal clavicle excision (added $3424), and number of suture anchors used (each added $1249).
Comment: The value of a treatment is the benefit to the patient divided by the total cost of the treatment. As the authors point out, the actual costs can be difficult to access, so that "charges" are often used as a proxy. This study points out that decisions made by the surgeon are likely to increase the charges for cuff repair: use of regional anesthesia, concomitant subacromial decompression, distal clavicle excision, and number of suture anchors used. It is important to know, but presently unknown, if these discretionary "add ons" result in any increased benefit to the patient.
Benefit can be quantified by a measurement of interest to the patient before and after treatment: strength, motion, comfort, quality of life. While any metric (ASES, Constant, UCLA, SANE, VAS pain) will work, we most often use the Simple Shoulder Test (SST), 12 "yes" or "no" patient self-assessment questions that are easily understood by the patient:
Is your shoulder comfortable with your arm at rest by your side?
Does your shoulder allow you to sleep comfortably?
Can you reach the small of your back to tuck in your shirt?
Can you place your hand behind your head with the elbow straight out to the side?
Can you place a coin on a shelf at the level of your shoulder?
Can you lift one pound to the level of your shoulder?
Can you lift eight pounds to the level of your shoulder?
Can you carry 20 pounds at your side?
Can you toss a softball underhand 20 yards?
Can you throw a softball overhand 20 yards?
Can you wash the back of your opposite shoulder?
Can you do your work full-time?
Using the SST, the benefit of the treatment is the number of these functions that can be performed at a designated time after treatment minus the number of these functions that could be performed before treatment.
Total cost can include a number of key elements:
Preoperative imaging (MRI, CT scan)
Surgeon professional fees
Anesthesiologist professional fees (surgery, postoperative brachial plexus block)
Operating room (time, drugs)
Implant costs (suture anchors)
Additional procedures (acromioplasty, distal clavicle excision)
Additional procedures (acromioplasty, distal clavicle excision)
Recovery room (time, drugs)
Hospital stay (time, drugs)
Brace/sling
Postoperative physical therapy
Post discharge care
Recovery time (time to get back to normal activities)
Complications (stiffness, persistent pain, infection)
Revision surgery
Comment: We can see that the determination of value should be critical to our decision making.
This straightforward approach enables important comparisons of different treatments. For example, in that non-operative treatment can be effective for many cuff tears, how much more patient benefit is needed to justify the $25,000 charges for surgery as well as the prolonged time after surgery during which patients are unable to use their shoulder?
How should we think about the value of rotator cuff repair to the patient with the rotator cuff tear shown below?
If the preoperative comfort and function is high (SST of 10, 11, or 12) it is unlikely that a rotator cuff repair will lead to a benefit (i.e. it is unlikely that the postoperative SST will be much of an improvement over the preoperative value).
If we are considering attempting a repair, we need to understand the likely benefit (improvement in SST) and costs with different approaches. We can ask if a repair involving the expense of multiple suture anchors is likely to yield a better benefit than a transosseous repair using no suture anchors.
We suggest that a thoughtful analysis is needed to understand the value of the many proposed approaches to the management of different types of rotator cuff tears.
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