Cost and Cost Driver Analysis of Anterior Cruciate Ligament Reconstruction Using Time-Driven Activity-Based Costing: Bone-Tendon-Bone Autograft Versus Hamstring Autograft

Overview

Journal JB JS Open Access

Date 2022 Oct 17

PMID 36245951

Authors

Fernando A Huyke-Hernandez

Breana Siljander

Ilexa Flagstad

Arthur Only

Harsh R Parikh

Marc Tompkins

Bradley Nelson

Christopher Kweon

Brian Cunningham

Affiliations

Soon will be listed here.

Abstract

Methods: Data were collected from electronic medical records for primary ACLR from the institutional patient-reported outcome registry between 2009 and 2016 in 1 ambulatory surgery center. Patients receiving allograft, revision ACLR, or concomitant meniscal repair or ligament reconstruction were excluded. The total cost of care was determined using TDABC. Multivariate regression analysis was conducted between ACLR cost and group characteristics.

Results: A total of 328 patients were included; 211 (64.3%) received BTB autograft and 117 (35.7%) received hamstring autograft. The mean cost was $2,865.01 ± $263.45 (95% confidence interval: $2,829.26, $2,900.77) for BTB ACLR versus $3,377.44 ± $320.12 ($3,318.82, $3,436.05) for hamstring ACLR (p < 0.001). Operative time was 103.1 ± 25.1 (99.7, 106.5) minutes for BTB ACLR versus 113.1 ± 27.9 (108.0, 118.2) minutes for hamstring ACLR (p = 0.001). The total implant cost was $270.32 ± $97.08 ($257.15, $283.50) for BTB ACLR versus $587.36 ± $108.78 ($567.44, $607.28) for hamstring ACLR (p < 0.001). Hamstring graft (p = 0.006) and suspensory fixation on the femoral side (p = 0.011) were associated with increased costs.

Conclusions: The mean cost of care and operative time for BTB autograft ACLR are less than those for hamstring autograft ACLR. Operative time, implant choice, and graft choice were identified as modifiable cost drivers that can empower surgeons to manage primary ACLR costs while maximizing the value of the procedure.

Level Of Evidence: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

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References

Parikh H, OHara N, Levy J, Cunningham B . Value Denominator: The Fundamentals of Costing for Orthopaedic Surgeons. J Orthop Trauma. 2019; 33 Suppl 7:S56-S61. DOI: 10.1097/BOT.0000000000001617. View

Wise K, Parikh H, Okelana B, Only A, Reams M, Harrison A . Measurement of value in rotator cuff repair: patient-level value analysis for the 1-year episode of care. J Shoulder Elbow Surg. 2021; 31(1):72-80. DOI: 10.1016/j.jse.2021.07.004. View

Barrera Oro F, Sikka R, Wolters B, Graver R, Boyd J, Nelson B . Autograft versus allograft: an economic cost comparison of anterior cruciate ligament reconstruction. Arthroscopy. 2011; 27(9):1219-25. DOI: 10.1016/j.arthro.2011.04.008. View

Bokshan S, Mehta S, DeFroda S, Owens B . What Are the Primary Cost Drivers of Anterior Cruciate Ligament Reconstruction in the United States? A Cost-Minimization Analysis of 14,713 Patients. Arthroscopy. 2019; 35(5):1576-1581. DOI: 10.1016/j.arthro.2018.12.013. View

Mather 3rd R, Koenig L, Kocher M, Dall T, Gallo P, Scott D . Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am. 2013; 95(19):1751-9. PMC: 3779900. DOI: 10.2106/JBJS.L.01705. View

Karns M, Jones D, Todd D, Maak T, Aoki S, Burks R . Patient- and Procedure-Specific Variables Driving Total Direct Costs of Outpatient Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med. 2018; 6(8):2325967118788543. PMC: 6080082. DOI: 10.1177/2325967118788543. View

Mather 3rd R, Hettrich C, Dunn W, Cole B, Bach Jr B, Huston L . Cost-Effectiveness Analysis of Early Reconstruction Versus Rehabilitation and Delayed Reconstruction for Anterior Cruciate Ligament Tears. Am J Sports Med. 2014; 42(7):1583-91. PMC: 4222991. DOI: 10.1177/0363546514530866. View

Greis P, Koch B, Adams B . Tibialis anterior or posterior allograft anterior cruciate ligament reconstruction versus hamstring autograft reconstruction: an economic analysis in a hospital-based outpatient setting. Arthroscopy. 2012; 28(11):1695-701. DOI: 10.1016/j.arthro.2012.04.144. View

Cooper M, Kaeding C . Comparison of the hospital cost of autograft versus allograft soft-tissue anterior cruciate ligament reconstructions. Arthroscopy. 2010; 26(11):1478-82. DOI: 10.1016/j.arthro.2010.04.004. View

10.

Noyes F, Butler D, Grood E, Zernicke R, Hefzy M . Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am. 1984; 66(3):344-52. View

11.

Arnold M, Calcei J, Vogel N, Magnussen R, Clatworthy M, Spalding T . ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades. Knee Surg Sports Traumatol Arthrosc. 2021; 29(11):3871-3876. DOI: 10.1007/s00167-021-06443-9. View

12.

Carducci M, Gasbarro G, Menendez M, Mahendraraj K, Mattingly D, Talmo C . Variation in the Cost of Care for Different Types of Joint Arthroplasty. J Bone Joint Surg Am. 2019; 102(5):404-409. DOI: 10.2106/JBJS.19.00164. View

13.

Koehler D, Balakrishnan R, Lawler E, Shah A . Endoscopic Versus Open Carpal Tunnel Release: A Detailed Analysis Using Time-Driven Activity-Based Costing at an Academic Medical Center. J Hand Surg Am. 2018; 44(1):62.e1-62.e9. DOI: 10.1016/j.jhsa.2018.04.023. View

14.

West T, Balas E, West D . Contrasting RCC, RVU, and ABC for managed care decisions. A case study compares three widely used costing methods and finds one superior. Healthc Financ Manage. 1996; 50(8):54-61. View

15.

Herzog M, Marshall S, Lund J, Pate V, Mack C, Spang J . Incidence of Anterior Cruciate Ligament Reconstruction Among Adolescent Females in the United States, 2002 Through 2014. JAMA Pediatr. 2017; 171(8):808-810. PMC: 6583877. DOI: 10.1001/jamapediatrics.2017.0740. View

16.

Palsis J, Brehmer T, Pellegrini V, Drew J, Sachs B . The Cost of Joint Replacement: Comparing Two Approaches to Evaluating Costs of Total Hip and Knee Arthroplasty. J Bone Joint Surg Am. 2018; 100(4):326-333. DOI: 10.2106/JBJS.17.00161. View

17.

Herzog M, Marshall S, Lund J, Pate V, Spang J . Cost of Outpatient Arthroscopic Anterior Cruciate Ligament Reconstruction Among Commercially Insured Patients in the United States, 2005-2013. Orthop J Sports Med. 2017; 5(1):2325967116684776. PMC: 5302102. DOI: 10.1177/2325967116684776. View

18.

Genuario J, Faucett S, Boublik M, Schlegel T . A cost-effectiveness analysis comparing 3 anterior cruciate ligament graft types: bone-patellar tendon-bone autograft, hamstring autograft, and allograft. Am J Sports Med. 2011; 40(2):307-14. DOI: 10.1177/0363546511426088. View

19.

Kaplan R, Witkowski M, Abbott M, Guzman A, Higgins L, Meara J . Using time-driven activity-based costing to identify value improvement opportunities in healthcare. J Healthc Manag. 2015; 59(6):399-412. View

20.

Forssblad M, Valentin A, Engstrom B, Werner S . ACL reconstruction: patellar tendon versus hamstring grafts--economical aspects. Knee Surg Sports Traumatol Arthrosc. 2006; 14(6):536-41. DOI: 10.1007/s00167-006-0064-3. View