Dr. Andrea Spiker:
Welcome everyone to the Arthroscopy Association's Arthroscopy Journal podcast. I'm Dr. Andrea Spiker from the University of Wisconsin, and today I am joined by Dr. Thomas Wuerz of the Boston Bone and Joint Institute affiliated with the New England Baptist Hospital in Boston, Massachusetts, where he is the director of the Hip Preservation Program.
Dr. Wuerz was the senior author of the article titled Time-Driven Activity-Based Costing Analysis, Identifies Use of Consumables and Operating Room Time As Factors Associated With Increased Cost of Outpatient Primary Hip Arthroscopic Labral Repair, which was published in the May 2024 edition of Arthroscopy Journal. Dr. Wuerz's co-authors were Edward Allen, Madison Sakheim, Kuhan Mahendraraj, Sophie Nemec, Shane Nho, and Chad Mather.
Welcome Dr. Wuerz, and thanks so much for joining us.
Dr. Thomas Wuerz:
Hi Andrea. Thank you first of all for inviting me. When you asked me recently at a dinner the fellows course we were teaching together with some of our friends and colleagues, I actually thought you were joking to have me here, so thank you for doing this. It's exciting to present our work and also want to thank AANA for having me as well.
Dr. Andrea Spiker:
I was very excited to find your paper and to find a reason to invite you on the podcast. And yes, this is typically the hardest part is just finding a time for us to connect to record this, so thank you so much.
Dr. Thomas Wuerz:
So yeah, also want thank my co-authors, particularly Eddie and Madison did most of the hard lifting here, a great team. So thanks for putting this together, both at med school and residency. Currently recovering from an awesome AANA meeting in Boston. So I've learned that hometown meetings are a different beast, so I can tell you it was quite a recovery.
But I want to take this as a shout-out as well to Rachel Frank and John Tokish for putting together an awesome meeting. And also again, thank you to you, Andrea, and Robbie Westermann for an excellent hip session. It was really great fun, learned a lot, and it's always great to meet some good friends and have some good sessions together.
Dr. Andrea Spiker:
So let's dive into your paper. Once again, thanks again for coming onto the podcast. It's great to have you here. And let's start by just having you tell us more about you and your practice.
Dr. Thomas Wuerz:
Yeah, so I'm at Boston Bone Joint Institute and we're affiliated with New England Baptist Hospital and we have a great sports fellowship as well, awesome growing practice. One of my partners actually is Alan Curtis, our current AANA president, and one of the former presidents, John Richmond, he's retired now from surgical practice, but a great mentor and friend of mine.
So shout-out to my awesome partners, growing practice, and also to all the great hip arthroscopy and the hip preservation surgeons in Boston, New England. So as you can tell, I'm primarily doing hip arthroscopy, so this is where the paper is coming from based on my experience and I thought some of the things I wanted to look into and highlight more.
Dr. Andrea Spiker:
Well, great. So tell us a little bit about what you thought was lacking in cost analysis research regarding hip arthroscopy surgery and why it was that you investigated this so that we could know more.
Dr. Thomas Wuerz:
Yeah, great question. So for me, I thought, well, hip arthroscopy actually reimburses pretty well. I also thought looking at the stuff we have in the OR, it's pretty capital intense. So you have a lot of equipment, traction tables, fluoroscopy. Setup takes time in general. It's more than putting together a quick knee scope. There's a lot more that goes on to even get started to do a surgery.
I was also at the time when we were starting to look at this operating at different surgery centers, physician owned and hospital owned, and I realized their differences in how things flow and I figured that might have an impact as well on how things cost in the end. So I want to get a better sense of the cost drivers. There's a lot of emphasis in our society and healthcare costs and how do we increase value, value being better outcomes and less costs for our patients. So I thought maybe look at that and see what the modifiable factors are here.
And on a more personal and very practical reason, one of my awesome partners, Andy Jawa, he had published on this method as well and had introduced me to the Avant-garde database. So when they started at Boston, Harvard Business School and I figured, oh, I live in Boston, just down the road from them. We had a couple of meetings and I looked into it and I thought this could be very, very interesting to look at from a slightly different perspective when we're looking at cost and ultimately, value for our patients.
Dr. Andrea Spiker:
Fantastic. Well, tell us more about the various ways in which other people have looked at costs of various surgeries in sports medicine and outside of sports medicine, and then why you decided to use this time-driven activity-based costing, which the acronym for which was TDABC in your paper.
Dr. Thomas Wuerz:
Great question as well. My background is a little bit also in health economics, so a lot of the stuff I looked at before cost-effectiveness or cost utility analysis was all about pretty much implant use primarily. There's obviously other things in terms of value and outcomes that get integrated, but in terms of the cost side of things, it's maybe implant or disposable use and capital use.
So as we know over time is very expensive in general, so I want to kind of capture that dimension, the time dimension as well. And so I figured it would be a great way when I heard about this and I first read Andy Jawa's paper and it's like, man, this could be very interesting, particularly for a procedure that tends to take longer and is more capital intense. So I figured maybe we can identify some factors, some of them more obvious, but maybe something new comes up from this.
Dr. Andrea Spiker:
Excellent. Well, let's dive right into some of your findings.
Dr. Thomas Wuerz:
Yes, let's go.
Dr. Andrea Spiker:
All right. So you found in the study that consumables accounted for the main proportion of the cost of the hip arthroscopy with labral repair. So about 61% of all costs were driven by consumables. And then when you broke that down, OR consumables accounted for 40% of that cost, and then implants accounted for 21% of costs.
Then you looked at surgical personnel and you saw that surgical personnel accounted for the second-largest component after consumables, and that was a total of about 29% of the total costs. So was this what you expected to find when you began this research?
Dr. Thomas Wuerz:
Yeah, I would say I roughly expected this, looking at other areas where similar things were done. Particularly for hip scopes, I think we just use, again, a lot of stuff. Anchor certainly is one thing for labral repairs, capsulotomy blades, boot liners, traction pads, capsule stitches, goes on and on. So I figured from the consumables and disposables side, I wasn't really surprised.
The personnel cost was certainly something, the higher percentage of that I was a little bit more surprised about. And I think on the other hand that was also something I thought, "Well, that's also a good thing to see where this might be something where it's a little bit more easily modifiable to some extent."
Also the OR in terms of personnel, it depends on, at least for me, which setting I'm operating in, but we're using intraoperative fluoroscopy. We also have to have a separate radiology tech in lot centers. So that's an additional cost in terms of personnel. And then set up in general, again with all the stuff we have just takes time.
So I think in some respects some of the stuff I was expecting, but again for me, the personnel costs and that side of things is a little bit more than I thought would be.
Dr. Andrea Spiker:
Yeah, and it's interesting, I was just thinking about this as you were discussing, but certainly when you compare hip arthroscopy to a hip replacement, for example, our implants, those anchors that we use, those very, very small anchors cost a lot less than a hip arthroplasty implant, for example. Was this something that you looked at particularly in comparison to arthroplasty or was that not something that you dove into with this particular study?
Dr. Thomas Wuerz:
No, we didn't definitely not do a real side-to-side comparison because we just wanted to focus on, hey, what were the modifiable factors we might ultimately find and what drives the cost for this particular procedure? Because it's also when you start off, and you might touch on this later, but you start off in practice might be hard as you go to your young guy, gal coming out of fellowship, maybe spend some extra time, hopefully I would say we'll get to that, some hip arthroscopy preservation training.
But you get started and it's daunting, right? I mean it's one of the steepest learning curves, and surgery takes a long time. You have to also make a case for yourself and say, "Hey, does this make sense to have me at the surgery center, for example," if you're in a freestanding surgery center, "and how can you manage costs and why the cost drivers?" It's certainly something a lot of freestanding ASCs would be looking at. So I figured that would be something that certainly would be information that could be useful.
Dr. Andrea Spiker:
Yeah, I completely agree. And as somebody who doesn't have much of a background in this, I found this study very interesting for the same reasons you pointed out that just having an understanding of what we're doing on a day-to-day basis, how we might be able to modify that to improve the cost efficiency of the procedure that we're doing is not something we typically think about. But you've brought to light some ways in which we can.
Dr. Thomas Wuerz:
Compared to, say, other sports surgery, sorry, but I think to knee arthroscopy, that is what do you need? I mean, the table, you need the tower, the pump, all the usual arthroscopy stuff. I mean then you can basically just go depending on what specific knee arthroscopy you're doing though.
When I tell my patients or their family how long the surgery is, and I always tell them, "Listen, there's about 30, 40 minutes of this time in the OR before we actually get started." So good to tell family members when we call them after surgery, so I say, "This is the amount of surgery time I expect, but I have to add 30 to 40 minutes maybe for setup time."
So just that I never have that discussion about setup time really for a knee scope or shoulder scope, so that just makes it different. I think it's a different beast and that's how we maybe again, as I mentioned, need to justify to the OR managers and also when we submit times for the OR, right, say, "Hey, why does this take so long?"
Dr. Andrea Spiker:
Yeah, I agree with you completely. And the amount of setup for hip arthroscopy exceeds pretty much any other case that I do. So I completely agree with you and it's nice to be able to quantify that.
Now, given the findings that we discussed earlier, what do you think we can do to decrease the cost of hip arthroscopy?
Dr. Thomas Wuerz:
Yeah, I know. Based on what I've seen also in going to different centers and obviously the first priority question is yeah, what do you need? And oh, anchors how much they cost, and then there's all these negotiations going on.
So I think on the disposable side, I think there's often still some room for improvement, but I think the biggest room for improvement we see and modifiable as a factor based on the study as well is maybe the time factor as well. So I think with regards to that, I would propose to build a highly focused team. You need to get experience, not only yourself as surgeon, but your assistants, the surgical tech, the scrub tech, the circulator, the anesthesiologist, and also the radiology tech.
I mean, I don't know how you feel, but sometimes you're in the OR and if somebody is just a circulator that might help. Or with the CR as opposed to radiology tech, who knows what they're doing, I mean that can add easily 5, 10 minutes the case.
So you want to make sure you build a good team. So I think what I would recommend, and it's what we talked about some of the fellows courses as well, is when you start off, make sure you get a team that works with you and continues to work with you. So build experience. People become fast so you become efficient, therefore the time factor goes down, so that also obviously includes a great PA or a group of PAs.
If you have trainees, fellows, or residents, try to talk to the fellowship director and say, "Hey, listen, not just have them with me every other week or once in a while, just, hey, maybe have them with me regularly." So then they become a very efficient part of the team and then they also learn more, it becomes more fun.
So with regards to the implants themselves, I think obviously some of the cost is obviously driven by innovation, so we always want to look for newer and better things. That's something we always have to negotiate the prices. So that's something that we as surgeons often can leverage the relationship we have maybe, but also let the managers kind of work on that side.
But you see more and more with ASCs that there's synergies you can leverage. Maybe with some companies also have arthroplasty implants, so maybe across the whole spectrum you can create synergies and discounts that help maybe drive costs for the implant side down.
I think overall we're also seen data come out now that ASCs provide lower cost care with same level, even better level of quality of care in some studies at least. So it's still maybe contentious, but I think this is largely due to all those focus teams and more efficient care.
So I think these are the driving factors, but also, I mean definitely I want to make sure that nobody thinks the message of these paper should be, "Hey, use less anchors or drive down that." We don't want to infringe on the quality of care for our patients.
So I think the things we can easily modify, let's work on efficiencies and maybe think about some reusable instrumentation as well. But overall, I think the surgeon needs to be doing what's right, what feels right for their patients and what's right in their hands.
Dr. Andrea Spiker:
Those are all excellent suggestions. And you've mentioned this now, but as you found in this study, increasing total OR time was associated with an increasing total surgical cost. You and I have both experienced that learning curve with hip arthroscopy. So do you think that surgeons who are earlier in the learning curve therefore might take longer to do a surgery, especially a hip arthroscopy surgery, are a part of the increased cost that we see across the board?
Dr. Thomas Wuerz:
For this study would not, that wouldn't be the case because it was just one, my, surgeon's experience, but overall I think absolutely yes. So when I look at sometimes when you see revisions and coming from different places where you look at the operative report, and if it's reported and documented, but sometimes you see fraction times 60, 90, 120 minutes, very long fraction times overall.
So I think there is, in my mind, it's obviously on one hand a reflection of the complexity of case very frequently, but sometimes it could be also a reflection of maybe there's room for improvement in regards to efficiency. And that ultimately if you have longer time, I mean traction time is one component obviously of the OR time overall, but for me it's an indicator that's a long OR time in general.
So I think one thing is that surgeons who start out would need to explain that to their partners in the surgery centers, the learning curve in order to provide good care. There's a long, steep learning curve, but I think it also emphasizes the fact that you should build a team early on, try to build it, build efficiencies with what I mentioned, anesthesia with scrub techs, everybody working together and not just every time somebody different with you. So then you can kind of dial in all the different aspects of the procedure getting set up.
One idea and what I've done as well we try to focus on is I try to have rooms, I have two rooms to focus on laterality, right? So if I have a bunch of lefts and rights, keep them in one room if we can. So it's not that we have to change the OR setup every time, which adds another 10-15 minutes in terms of turnover.
And then also I think there's innovation. So if you do a combined hip arthroscopy with PAO, like you do a fair amount, Andrea, right?
Dr. Andrea Spiker:
Mm-mm.
Dr. Thomas Wuerz:
Using a table allows you to do both at the same table, so without having to have long turnover time repositioning. So there's all these different aspects of OR time, total OR time that you can modify. And I think as you start off, you want to be, I think, personally the shout-out to focus on hip arthroscopy and hip preservation, the more you focus on this, the more you have the scope to improve efficiencies.
Dr. Andrea Spiker:
Yeah, excellent points.
Now, what about patient factors that might be associated with an increased OR time? So for example, somebody who has a very large cam lesion at the femoral head-neck junction, that might add time because the femoroplasty will take longer. What other patient factors have you identified that knowing as you go into that surgery you might end up needing a little bit more time for that procedure?
Dr. Thomas Wuerz:
Yeah, excellent question. I mean, I think the large cam, this is something whenever I book my surgeries and there's a large cam, I see them in pelvis AP and say more than mid-70s, somewhere there is a lateral and then a large number, a large alpha angle, I always book 30 to 45 minutes, depending on how large it is, of extra time. So that's already indicated for me. It's like, okay, I already need more time.
Obviously revisions, you never know what's going to happen. There's a higher risk of maybe having to do labral reconstruction or capsule reconstruction, so always add time for that. These are time factors. If there's over coverage, I'm worried about distraction. So do I even get distraction? Do I need to go outside in?
If there's a coxa profunda, these are factors where I say, "Okay, well, we need probably more time." And if I have findings, I see a os acetabuli, a rim fragment, that's when my sensors go up and say, "Well, maybe I need a labral reconstruction, or how do I address that piece of bone? Do I have to get it out? Do I have to fixate it?" Also, more time, right?
These are factors where I think preoperatively you can say, "Well, if these come up..." And also loose bodies, man, that's a black box where you never know. It could be pretty quick, but it could take forever. You need extra portals and things.
So I think these are some of the identifiable factors beforehand where you can say, "Well, we need more time." The level of complexity would go up. And I think as we discussed as well, we need to think about how do we properly get reimbursed to this in the end. I mean, that's the other side of the equation, right?
Do we have codes reflective of higher levels of complexity? Apart from some modifiers, probably not really. We hear different things from different colleagues. But overall, I think that's the other side of the equation as well. This difficult work can be time-consuming, so make sure that that works out for the patient but also reflects the high level of complexity.
Dr. Andrea Spiker:
Yeah, I agree. We need more advocacy for the field of hip arthroscopy to appropriately reflect the amount of effort and time that is going into these procedures. Tom, do you want to take that on?
Dr. Thomas Wuerz:
Yeah. I think there's an editorial to this article as well by Elizabeth Scott. Actually trained with me as well before. She points out, we should not shortchange our patients using less anchors, but we need to increase efficiency. I think she also pointed out CPT codes. Maybe that reflects some higher level of complexity. That's certainly something we should look for.
I think one of the other factors we are looking at currently, a starting point from this study as well, was in-room OR time, how do we improve that? So think about where do you do the anesthesia? I mean is it spinal? Then you could probably do it pre-op. General, obviously in the OR, but also general, you need to have a good team that's dialed in because how many times do you have cases you're done and then you need some time to wake up the patient? So clock is ticking, right?
Again, that goes back to the team, the expert team, and we found in some preliminary data that spinal anesthesia time in OR time is shorter, even if you do the spinal in the OR. And then postoperative, part of the whole chain of things, you have to think about that as an assembly line basically. But pre-op, intra-op, post-op, so in the PACU spinal seems to have shown some benefits as well, not only in use of narcotics, but also in PACU time. So another cost driver for ASC’s use
And I think again, a final thought here, due to the long, steep learning curve, I would advocate for some level of specialization, additional training focusing on hip arthroscopy and preservation to develop that skill set so you're ultimately going to be a more efficient surgeon. Again, irrespective of what you do in training, there is going to be a long and steep learning curve. But I think you can cut off some of that a little bit by focusing your training on that.
I mean, that's why we also see a lot of specialized fellowships, for example. But overall, I mean the earlier we get trainees into looking at hip arthroscopy, I think the better so you can develop that highly focused team. Then you can cut out on time set up in the OR, traction time, turnover time.
And then overall, the more volume we have in this, shown time and time again in outcome studies, higher volume leads to better outcomes and safer procedures for our patients. So I think that's what we ultimately strive for, value, the value proposition, so better outcomes with less OR time and resource use. So I think that would be my shout-out for that, to try to build those highly efficient and focused teams.
Dr. Andrea Spiker:
I completely agree.
Well, as we wrap up here, any final thoughts, anything that you're going to implement in your operating room this week or in the next year to implement what you found in your paper?
Dr. Thomas Wuerz:
Yeah, I think again, highlighting the efficiency. So I think some of the findings in the paper helped me to raise some of the discussions to a different level with some of the different surgery centers and say, "Hey, we need to be efficient. We need a team. I can't just have somebody else in the room every week." So I think that's important as a discussion point to have. So I think that's something that will change my practice hopefully for the next year.
And then I also think the intraoperative imaging, some of the modalities we can use these days, help you to be more efficient, effective, and maybe reducing your cam resection time. So leveraging the imaging and some of the innovations are coming down the pike now as well, might help us to be faster while providing the same level or even better level of care moving forward.
Dr. Andrea Spiker:
Well, that's awesome, Tom. Thank you so much again for joining us.
Dr. Thomas Wuerz:
Thank you for having me. It was great and looking forward to seeing more of this discussion. And hopefully also, okay, would want to shout out for the Hip Preservation society, ISHA, big annual meeting, whoever likes arthroscopy and is interested, October this year in Washington, DC. So AANA’s partner society, ISHA, great meeting, putting together an awesome program. Andrea will be there as well.
Dr. Andrea Spiker:
Yes, I will. I'm looking forward to it. So I agree, everybody should join us at ISHA this October.
Dr. Wuerz's article titled Time-Driven Activity-Based Costing Analysis, Identifies Use of Consumables and Operating Room Time as Factors Associated With Increased Cost of Outpatient Primary Hip Arthroscopic Labral Repair can be found online at www.arthroscopyjournal.org.
This concludes our episode of the Arthroscopy Journal podcast. Thank you for joining us.
The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.
Medical Disclaimer:
The information and opinions discussed herein, including but not limited to text, graphics, images, and other material contained in this podcast and its referenced paper are for informational and educational purposes only. No material in this podcast or its referenced paper is intended to be a substitute for professional medical advice, diagnosis or treatment. Specifically, all content and information in this podcast and its referenced paper does not constitute medical advice. Always seek the advice of your physician and/or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you were exposed to from this podcast or its referenced paper. The information discussed in this podcast and its referenced paper may not apply to every individual and may cause harm.