Is arthroscopic surgery more or less expensive than a comparable open procedure?

 

(Note: In the USA, at least, that’s a loaded question, as prices are obscured by hospitals* and physicians. Also, there is a lot of price discrimination (i.e. different prices charged to different patients). So, for the purposes of answering this question, think about the costs to deliver the care and not what is billed or collected.)


When thinking about the cost of medical procedures, more technologically-sophisticated procedures tend to be more expensive, largely due to equipment costs.


Consider a rotator cuff repair which can be performed either in open fashion or arthroscopically. For an open procedure, beyond the usual skin knife and sutures, the only “consumed” medical equipment is the stitch used to secure the tendon to bone (Figure 1).

 
Figure 1: Open rotator cuff tear repair (diagram modified from Wikipedia). The shoulder is exposed over the acromion; the deltoid is split; and then a suture is passed through the cuff and attached directly to the humeral head.

 

By contrast, an arthroscopic procedure uses one or more disposable cannulas, an arthroscopic shaver to clear synovium for visualization and remove the remnant of the rotator cuff, and some sort of an implant (screw, anchor, etc.) to attach the sutures to the bone. The operating facility must also acquire the arthroscopy equipment and maintain it, which is a further cost that is paid, in part, by every patient who uses it.

 
Figure 2: Arthroscopic rotator cuff tear repair. A disposable cannula (purple) is typically used to pass the instruments through the skin into the shoulder, and a special single-use screwdriver (yellow) holding a permanently implanted anchor (black) is used to attach suture to bone. Shown here an anchor is implanted into the greater tuberosity to fix a supraspinatus tear.

 

At first glance, it seems that arthroscopy would be considerably more expensive. However, arthroscopy does have substantial benefits that ultimately can result in costs saved. An arthroscopic procedure requires less dissection and less disturbance of normal tissue, thus an arthroscopic procedure is generally less painful — and when patients are more comfortable after a procedure, they are often able to be discharged more quickly. Accordingly, arthroscopic cuff repair is often an outpatient procedure, whereas (historically) patients with an open repair required at least one overnight stay in the hospital. Longer lengths of stay generate expenses far exceeding the cost of disposable equipment used in an arthroscopy procedure. 


Pain poses another aspect to this comparison, which is that if arthroscopy is less painful, patients may choose it more frequently. When patients contemplate whether to pursue rotator cuff repair, they consider their current level of pain and dysfunction and balance that against all costs (financial and physical) of a procedure that may alleviate these limitations.


One such cost would be the pain and morbidity of the procedure. If the costs of the procedure were lower, the level of pain and dysfunction necessary for a patient to consider surgery at all would be lower as well.


As such, technological advances that make rotator cuff repair less painful have made rotator cuff repair more appealing to patients, and because the procedure is more appealing, it will be chosen more often; thus, generating more expenses over all even if each individual procedure is less expensive than the corresponding open procedure it supplanted.


This highlights an important paradox: improvements in healthcare delivery might save money per unit of work, but will add to total expenses by augmenting the amount of work done overall.

 

 

* This study, https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1783043reported that hospitals would more often share the price of parking outside their facility than the price of an EKG within it.