Title : Identifying variations in cost of care for knotted versus knotless bankart repair using time-driven activity-based costing (TDABC)
Abstract:
Purpose: To use time-driven activity-based costing (TDABC) methodology to assess variations in cost between knotted, knotless, and hybrid arthroscopic Bankart repair.
Methods: A retrospective analysis of cost data for all arthroscopic Bankart repairs (CPT code 29806) performed from January 2021—May 2023 using TDABC methodology. Concomitant procedures, SLAP and RCR (CPT 29807 and 29827), and remplissage were taken into consideration when evaluating the procedures. Patients who underwent additional procedures not related to shoulder stabilization were excluded. Cost accounting data and patient demographics were collected by a third-party organization (Avant-garde health). Total cost was indexed and broken down into supply (implant, consumables, and medication) and personnel costs for analyses. Operative notes were reviewed to determine Bankart repair technique including type of anchor, number of anchors used, remplissage, and patient positioning. Surgeon experience was inferred from years of practice, number of fellowships, and whether a sports medicine fellowship was completed. Cohorts were grouped by surgical technique: knotted versus knotless versus hybrid repair. Chi squared and ANOVA tests were performed to test relationships where appropriate. Linear regression modeling tested for associations with indexed total cost.
Results: 130 patients and 9 surgeons were identified that met the inclusion criteria. Of these, 61 patients underwent isolated Bankart repair. Univariate analysis showed no significant difference in total cost between knotless, knot-tying, and hybrid repairs (1.48 ± 0.23 vs 1.41 ± 0.22 vs 1.46 ± 0.17; p=0.577). Knotless repairs had the lowest total OR time (108.37 ± 17.68 vs 125.13 ± 23.73 vs 127.72 ± 22.50; p=0.007), incision to closure time (63.47 ± 20.64 vs 81.46 ± 21.12 vs 79.33 ± 17.20; p=0.011), total personnel cost (1.49 ± 0.16 vs 1.68 ± 0.22 vs 1.68 ± 0.19; p=0.013), and surgical personnel cost (1.81 ± 0.30 vs 2.08 ± 0.37 vs 2.11 ± 0.34; p=0.013) when compared to knot-tying and hybrid Bankart repairs, respectively. Knotless repairs had the highest total supply cost (2.22 ± 0.52 vs 1.80 ± 0.39 vs 1.93 ± 0.30; p=0.006) and implant cost (3.31 ± 1.04 vs 2.49 ± 0.84 vs 2.74 ± 0.62; p=0.010) comparatively. Multivariate linear regression modelling indicated use of knotless anchors (β=0.200; p<0.001), increasing number of anchors used (β=0.072; p=0.010), and increasing incision to closure time (β=0.007; p<0.001) were independent predictors of increased total cost. Surgeon experience (β=-0.122; p=0.007) was predictive of decreasing total cost. When accounting for concomitant procedures, knotless repairs were associated with higher total cost than knotless and hybrid repairs (1.81 ± 0.38 vs 1.48 ± 0.23 vs 1.66 ± 0.25; p<0.001).
Conclusion: There were no significant differences in total cost for isolated Bankart repairs between the three repair techniques. However, there were significant differences between cost parameters. Knotless repairs had faster, more time efficient repairs, which may have led to reduced OR times and personnel costs, thus balancing out the higher cost of these implants. When combined with other concomitant procedures, knotless repairs were associated with a significantly higher cost. Further studies are needed to correlate clinical outcomes.
Level of Evidence: Level IV; Economic Analysis
What will the audience learn from your presentation?
- While using Time-Driven Activity-Based Costing (TDABC) to assess cost at a granular level, this study found no significant difference in total cost for isolated Bankart repairs between knotless, knot-tying, and hybrid repair techniques.
- Repairs utilizing knotless anchors had shorter OR times and lower personnel costs, while simultaneously having higher supply and implant costs.
- Utilization of knotless anchors allowed for faster, more time efficient repairs, which may have led to reduced OR times and personnel costs, thus balancing out the higher cost of the implants.
- When examining repairs with concomitant stabilization procedures (SLAP, RCR, remplissage), knotless repairs were associated with higher costs.
- Given the increased scrutiny of healthcare costs, it is important to establish methodology to better estimate and understand drivers of surgical cost of Bankart repair. Future studies linking TDABC costs to patient outcomes following arthroscopic Bankart repair are necessary to determine cost-effectiveness and maximize patient value.
