Abstract
Research Type:
Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies
Introduction/Purpose:
Although advancements in implant design and surgical techniques have been improved over the decades, total ankle arthroplasty (TAA) is still among the most technically demanding joint arthroplasties, requiring significant expertise and operative time. However, the adequacy of its compensation remains unexamined, particularly in comparison to other joint arthroplasties. The fee-for-service model in the U.S. healthcare system is based on work Relative Value Units (wRVUs). wRVUs are assigned to various clinical activities, including surgical procedures, serving as a key metric for physician reimbursement and procedural valuation. While multiple factors influence wRVU assignment, physician effort, time, and technical expertise are the primary determinants. This study evaluates whether TAA is fairly compensated relative to hip, knee, and shoulder arthroplasty using the National Surgical Quality Improvement Program (NSQIP) database.
Methods:
The NSQIP database from 2020 to 2022 was reviewed. Total ankle, knee, hip, and shoulder arthroplasty procedures performed were identified using Current Procedural Terminology (CPT) codes. 1:1 Propensity score matching (PSM) was performed based on age (±1 year) and sex among the groups. The adequacy of TAA compensation was evaluated based on wRVUs, operative time (OT), wRVUs per hour (wRVU/hour), and reimbursement rates ($/hour) compared to other joint arthroplasties. Additionally, the relationship between OT and wRVU/hour for TAA was analyzed. As the non-linear relationship between OT and wRVU/hour was noted, polynomial regression analysis was performed. Furthermore, postoperative complications within 30 days, including mortality, readmission, and reoperation, along with secondary complications such as wound complications, infections, thromboembolic events, and respiratory, renal, or cardiac events were assessed to compare procedural risk profiles among the groups. Analysis of covariance was conducted to adjust for the effect of complication rates on compensation adequacy.
Results:
511 TAA cases were identified, and 1:1 PSM based on age and sex was performed for each joint arthroplasty. Compared to other joint arthroplasties (TKA, THA, TSA), TAA demonstrated a significantly longer OT (135.69 vs 91.66 vs 97.82 vs 96.77 minutes, P<.001) and a significantly lower mean wRVU/hour (7.17 vs 13.84 vs 13.13 vs 15.86, P<.001). These trends were maintained after adjusting for the rates of complication (mortality, readmission, reoperation, wound complications, and thromboembolic events) as well as post-hoc analysis. Additionally, polynomial regression analysis demonstrated a trend of decreasing wRVU/hour with increasing OT in TAA. Clinically, there were no significant differences in morbidity, readmission, reoperation rates, or secondary complications, including wound issues and thromboembolic events, between TAA and other joint arthroplasties.
Conclusion:
Our results indicate that the current wRVU scale does not adequately compensate for TAA, particularly compared to other joint arthroplasty procedures. Despite requiring significantly longer operative time, TAA demonstrated a notably lower wRVU/hour. Additionally, mean wRVU/hour declined as operative time increased in TAA. These findings suggest a potential need for wRVU adjustments to ensure more appropriate compensation for TAA.
Is Total Ankle Arthroplasty Adequately Compensated? A Propensity Score-Matched Comparison of Work Relative Value Units with Other Joint Arthroplasties
